Stress, Challenges and Expectations Efforts to Improve Nursing Students' Resilience During Clinical Practice Education

: Nursing students often face problems in the form of stress and challenges when carrying out clinical nursing practice; it can worsen the quality of service in the clinic. Resilience is suspected to improve individuals in carrying out self-management well so that the process of adapting to problems can be carried out adaptively. It is essential to know the resilience of nursing students and the expected efforts so that they can overcome problems in the optimal service setting. This study explores stress, challenges, or efforts to increase resilience in nursing students in clinical practice education. According to the inclusion criteria, sixteen nursing students were involved in this qualitative study using this phenomenological approach. The process of data analysis using the Collaizi method was carried out, starting from reading the data repeatedly, forming categories to formulating themes. Triangulation efforts were carried out by involving three student supervising nurses to ensure the suitability of the information that had been obtained from student nurses. This study resulted in three themes: difficulties during clinical education challenges when carrying out clinical education and expectations for efforts to increase student resilience. It was concluded that there was a correlation between stress, challenge, and strength of nursing students and the interdependence between the three components. It is necessary to prepare nursing students' resilience before undergoing clinical practice by utilizing the potential supported by technological advances so that students can manage themselves well in dealing with various complicated problems in the clinical practice learning setting.


Introduction
The Covid 19 pandemic that began to spread in Indonesia in March 2021 had a real broad impact, including the implementation of clinical practice for nursing students. Concern about the nature of the transmission of Covid 19 has resulted in the performance of health protocols, including limiting interactions, using masks, and maintaining distance (Drozdikova-Zaripova et al., 2021). The severity of the threat of transmission and the treatment process that is still undergoing revision efforts have limited the implementation of clinical learning (Nolan & Owen, 2021;Ozsaban et al., 2019). These consequences have a significant effect on the clinical practice learning line for nursing students, causing stress. The occurrence of stress among nursing students has been identified to cause complex problems (Singal et al., 2020). Increased stress can reduce physical health conditions due to decreased body immunity, in addition to affecting mental health. Psychological impacts when a pandemic occurs and is felt are post-traumatic stress disorder (post-traumatic stress disorder), confusion, anxiety, frustration, fear of affection, insomnia, and feeling powerless. Some challenges are felt by nursing students as well. A series of competency achievements must be met by students. Despite being in a Covid-19 pandemic condition, the competency targets that must be achieved 5193 remain the same as conditions when there was no pandemic. Challenges arise when the pandemic forms attitudes in students to be able to provide care to patients with all conditions. Stressors faced by nursing students in the form of problems and challenges cause them to be able to adapt to remain able to survive. Resilience will make a person able to adapt to dealing with various stressors. However, there are differences in the strength of each individual, depending on many components. Students' success in achieving clinical practice targets is influenced by, among others, resilience. Resilience training is known to have an impact on the ability of nursing students to cope with stressors in clinical settings. Support from academics and clinics contributes to increasing the resilience of prospective nurses.
It is imperative to do a study on the problems, challenges, and resilience of nursing students in the context of clinical learning, and the three concepts are suspected to be correlated, but research exploring the implementation of these three concepts is minimal. Several recommendations can be made based on this exploratory study to increase resilience in overcoming stressors of nursing students in carrying out clinical practice to prepare better before they provide nursing services after they finish their education.

Method
This study involved sixteen nursing students from three educational institutions. Each institution was represented by five participants who had completed practice in the same clinic and received an assessment, male and female, were in the same semester in their final academic year and expressed their willingness to be involved as a participant. Determination of participants using purposive sampling technique so that researchers obtain information according to the objectives to be achieved. The number of participants was determined based on data saturation. Researchers conducted indepth interviews with participants at the participants' homes, using voice recorders and field notes. The indepth interview process is conducted for 60-90 minutes, with as many as 2-3 in-depth interviews. Before data collection, participants obtained an informed consent explanation to understand that their participation was critical and ensure that the information submitted would only be used for research purposes, would not affect academic achievement, and would be kept confidential. Questions asked to include: what was the most challenging condition experienced during clinical practice?; what are your efforts to survive in difficult situations during clinical practice; and what kind of support do you expect when clinical practice?
Before the research started, the in-depth interview guide was tested to determine the suitability of the questions with the information to be obtained and an understanding of the formulation of in-depth interview questions. The results of the recorded interviews were recorded as interview transcripts, then analyzed to form categories and themes. For the purposes of triangulation of data to ensure the trustworthiness of the research results, the researcher interviewed three clinical supervisors as parties who directly interacted in student clinical practice. Based on the information provided by the clinical supervisor, the researcher can confirm the suitability of the student information with the facts at the clinic. The research, which was conducted from October 2021-January 2022, has obtained permission from the Health Research Ethics Committee of the Palembang Health Polytechnic in 2021.

Result
The following is the demographic data of the participants of this qualitative research as seen in Table  1.  Interview quotes Theme Category The rules in the clinic must limit the interaction of nursing students with their patients (nurse A) Clinical regulations only allow supervisors from the clinic (P2) The lack of clinical guidance process Only clinical supervisors become instructors when studying at the clinic (P7) We are often asked to learn from seniors who are not our mentors (P2) Sometimes we ask the patient in the room to teach students (nurse B). I am often asked to lend tools from another room for the benefit of the patient (P8) Limited provision of facilities Yesterday I was asked to borrow an oxygen cylinder to help the patient breathe (P10) The tools in the room are often not enough to borrow from each other (P13) Indeed, if the case is a lot of tools so they take turns, the student lends it to another room (nurse A) Patients who are treated a lot can actually make us more trained (P8) The increasing number of patients Challenges when carrying out clinical education The pandemic period makes us have to serve more (P4) An unexpected number of hospitalized patients (P9) In the past few days, cases are increasing rapidly, often unexpectedly (nurse C) We have many skills to master (P5) Demand for competency achievement Sometimes we doubt whether we can achieve the skills that must be obtained in the clinic (12) We must be able to treat all patients, physically and psychologically (P14) Indeed, with many students' abilities during clinical practice, it isn't easy to manage time to guide students (nurse B) If in the clinic, there should be someone who accompanies students while practicing (P11) Maximum support needs Hope for efforts to increase student resilience We are rarely noticed because the supervisor seems very busy (P13) If we were given input, the direction would be very happy (P1) We need encouragement to get us more excited (P16) We really know that students need our help (nurse B) We should have been taught while caring for a patient (P13) Comprehensive education If only we weren't left too soon while helping the patient during the injection (P3) Not all supervisors had time to provide guidance; they were very busy with their work (P9) Actually, really want to ask so that we are accompanied and given an explanation when learning to care for patients (P7) We admit that sometimes we don't have time to accompany nursing students because we are busy (nurse C) We want that, after practice there is a mentor approach (P5) Reflection is a must If only the supervisor asked how we felt after clinical practice (P9) We will be happy if we can share our opinion after undergoing clinical practice (P12) After students finish clinical practice, we evaluate it from the post-test only (nurse A)

Discussion
Based on the research results, three main themes have been formulated, including difficulties during clinical education, challenges during clinical education, and I; to strengthen resilience. The three themes are interconnected, starting from the initial stage, namely the difficulties of nursing students who can be considered a component of stressors and the challenges they face. Meanwhile, efforts to strengthen resilience are positioned as a component of copying or adaptation to problems.
Nursing students who undergo clinical practice episodes face complex problems (Grande et al., 2021;Singal et al., 2020). In this case, the limitations of interacting with patients (Yilmaz, 2017), the lack of acceptance of clinical guidance, and the lack of fulfillment of the provision of facilities are stressors in the form of difficulties students face from various academic institutions (Clark, 2003). Although the participants came from different educational institutions, the stressors experienced were the same in clinical learning. The ability of participants to perceive the problem is very dependent on their characteristics of the participants. Female participants generally perceive issues more deeply than men (Douglas et al., 2014;Magovcevic & Addis, 2005). The experience factor has the opportunity to understand the severity of the problem Yilmaz (2017), so even though women are more sensitive to exploring issues, the experience forged by rich experiences can make women able to face problems.
The challenges of nursing students during clinical learning are in the form of increasing the number of patients and demands for achieving learning competencies (Abidah et al., 2020;Grande et al., 2021;Lee et al., 2021;Nashwan et al., 2021). Actually, the increase in the number of patients will go hand in hand with the variety of patient cases. Challenges are defined as things or objects that inspire determination to improve problem-solving skills. In this study, participants were motivated to achieve learning competencies even though participants faced stressors that were not simple (Peñacoba et al., 2021). The increasing number of patients to be treated and the clinical learning competencies that must be achieved, if viewed in a positive angle, will be able to encourage students to make it a challenge that must be conquered. However, the ability to overcome every problem and challenge is highly dependent on individual resilience and several other factors.
Resilience is a positive adaptation in dealing with stress and trauma (Sun et al., 2020). As a mindset that allows individuals to seek new experiences and to see life as a work that is progressing, resilience can increase a person's capacity to stay in good shape and have productive solutions when dealing with difficulties or trauma, which allows for stress in his life (Ozsaban), (Turan and Kaya, 2019). Several references explain that resilience is also seen as a measure of the success of coping abilities in dealing with stress (Opoku et al., 2020;Terry & Peck, 2020). Resilience is closely related to persistence, strength and optimism (Süss & Ehlert, 2020). In addition, the ability to regulate emotions is also a determining factor in one's resilience competence (Gjersoe & Havard, 2017;Peñacoba et al., 2021;Serrano et al., 2021). The factors that influence resilience consist of four factors: individual, family, community, and risk factors (Cusinato et al., 2020;Dantzer et al., 2018;Gerino et al., 2017;Ménard et al., 2017).
Participants who were 21 or 22 years old had one of the characteristics of still looking for identity, did not have much experience, and the majority did not live with their families. They must adjust to the new environment even during clinical practice education. The non-optimal process of guidance, direction and support from supervisors is a separate stressor for students (Mediarti et al., 2021;Patras et al., 2021;Ulenaers et al., 2021). In addition, the demands for full service by the clinic are increasingly aggravating the burden on students and the pandemic condition, which suddenly changes all service patterns, approaches, and structures so that they require immediate adjustments (Adorjan et al., 2021;Opoku et al., 2020). The disaster factor in the form of the COVID-19 pandemic is a risk factor in the resilience of nursing student practice (Leigh et al., 2020;Ulenaers et al., 2021).
In this study, some hopes of nursing students to increase their resilience are through the provision of support by clinical supervisors, optimization of the educational process, and reflection activities. Participants faced various stressors with being able to survive during clinical practice.
It is necessary to arrange clinical practice preparation from the academic stage when a disaster occurs so that nursing students can better prepare themselves psychologically to deal with sudden changes in the situation. It is essential to strive for resilience training to be followed by students so that their ability to deal with stress can increase so that they can continue to treat patients with maximum quality amid the heavy burden they are experiencing. Practicing student resilience means trying to shape students' personalities to be at the stage of self-acceptance, appreciate themselves and the environment, have good intentions, act positively, have spiritual experiences, and feel calm. Utilizing technology to increase student resilience is a wise solution because it is not limited by space and time.

Conclusion
Clinical practice learning in a pandemic situation occurs in a very complex setting so it can trigger stress in nursing students. Resilience is needed for nursing students to prepare themselves physically and psychologically to survive through good selfmanagement.
Providing maximum support, comprehensive education, and reflection at the end of each activity are efforts that can be made to increase the resilience of nursing students while undergoing clinical practice.