Discussion This study was conducted to assess nursing students' perceived stress levels and their association with anxiety, as well as the coping behaviors used to reduce the effect of stress during clinical training. krt. 2022 BioMed Central Ltd unless otherwise stated. J Couns Psychol. Remor E. Psychometric properties of a European Spanish version of the perceived stress scale (PSS). A total of 1320 students have participated in our study and 31 non-eligible responses were excluded. endobj Lazarus RS. Wang X, Hegde S, Son C, Keller B, Smith A, Sasangohar F. J Med Internet Res. PDF/X ID Schema Bag Font The extraordinary makes the ordinary visible - nursing students' experiences of their learning in clinical practice during COVID-19: a qualitative study. orcid These measured the following four main areas: the level and types of stressful events perceived by baccalaureate nursing students; physio-psychosocial status; coping behaviors and a student's background information. As the language of instruction for international students at the University of Debrecen is English, and English fluency is one of the criteria for international students admission at the University of Debrecen, the international students were asked to fill out the English version of the survey and the scales. That is, we made the categories based on which coping factor (in the international sample) or dimension (in the Hungarian sample) the given person reached the highest scores, so it can be said that it is the person's preferred coping strategy. Out of the total sample, most of the Hungarian students were enrolled in non-health-related programs (n=690, 53.5%), while most of the international students were enrolled in health-related programs (n=213, 16.5%). 2020;71:102211. Among the international students, the mean score (standard deviation) of perceived stress among male students was 2.11(0.86) compared to female students 2.51 (0.78), while the mean score (standard deviation) of health anxiety was 34.12 (7.88) and 36.31 (7.75) among males and females, respectively. The main objective of the present research is to analyze the relationship of levels of self-efficacy and anxiety, coping strategies, and emotional intelligence in Spanish university students. Company creating the PDF This is not only due to the many causes of intrinsic stress referred by healthcare professionals, but also because it is worth considering the negative and chronic effects of stress over time [2]. By following and adhering to the international recommendations, adopting proper coping methods, and equipping oneself with the required coping and stress management skills, the associated high levels of perceived stress and anxiety could be mitigated. Stress and health in novice and experienced nursing students. Crisis24 News Alert. name In the Hungarian validation study, it was found that the SHAI mean score in a non-clinical sample (university students) was 33.02 points (6.28) and the Cronbach's alpha of the test was 0.83 [40]. Taha SA, Matheson K, Anisman H. The 2009 H1N1 influenza pandemic: the role of threat, coping, and media trust on vaccination intentions in Canada. The prevalence of stress among nursing students found in the literature is variable, which could be due to the different academic programs available worldwide and the use of different scales for measuring the same [24, 25]. Soc. et al. In: The social psychology of health. editorInfo Former studies using other coping tools found a positive relationship in terms of protection regarding the students mental health, in those students who used an optimistic strategy. uuid:dab2d741-a4d9-437a-ad96-6074db860bc9 Br J Health Psychol. Methods: The common identifier for all versions and renditions of a document. Permission to conduct the study was obtained from the management of the Nursing Faculty. Similar to our current study, other studies have found that health anxiety was positively correlated with maladaptive emotion regulation and negatively with adaptive emotion regulation [44], and in the case of state anxiety that emotion-focused coping strategies proved to be less effective in reducing stress, while active coping leads to a sense of subjective well-being [17, 27, 45,46,47]. GTS_PDFXVersion Correspondence to Regarding the year of studies, our findings support previous studies where the students with the most experience displayed higher levels of anxiety, whereas the most inexperienced showed lower levels of stress and anxiety [16, 17]. A structure containing the characteristics of a font used in a document. Opportunities to reduce contact numbersCommunity events in relation to COVID-19 virus infection. and transmitted securely. Google Scholar. Stronger resilience and usage of humor were associated with significantly lower anxiety levels, while mental disengagement with higher anxiety levels. Moreover, because the PSS contained a different number of items in English and Hungarian versions (10 items vs 14 items), we looked at the average score of the answers so that we could compare international and domestic students. Text Investigating Mental Health of US College Students During the COVID-19 Pandemic: Cross-Sectional Survey Study. In the case of health anxiety, the results showed that there were significant differences between the two groups (W=149,431; p=0.038) and international students levels were higher. All participants were informed about the study and written informed consent was obtained before completing the survey. World Health Organization. Brtolo A. Transitional Challenges and Role of Preceptor among New Nursing Graduates. Being a woman, low income, and living with other people all were associated with higher stress levels [18]. Author information: contains the name of each author and his/her ORCID (ORCiD: Open Researcher and Contributor ID). Anxiety; Coronavirus disease 2019; Covid-19; Nursing students; Pandemic. However, as noted by Jimenez et al. New York: Guilford Press; 2004. Adobe PDF Schema Garbczy, S., Szemn-Nagy, A., Ahmad, M.S. Besides these academic and individual differences, according to this definition of stress, it is important to include the effects of the environment, and more concretely, in our case, the different clinical placements the students visited throughout their training, on the levels of stress or anxiety presented by the student. Considering the health anxiety, the results were very similar. Fonts stPart The preoccupation is disproportionate or excessive if there is a high risk of developing a medical condition (e.g., family history) or the patient has another medical condition. PlateNames Spiritual. UUID based identifier for specific incarnation of a document Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Cai H, Tu B, Ma J, Chen L, Fu L, Jiang Y, et al. The results showed a significant correlation for perceived stress and state anxiety (r=0.463, p<.000) and also for trait anxiety (r=0.718, p<.000). Correlations between the scores of the different scales used were assessed using the Spearmans rho correlation coefficient. 2006;7:20316. doi: 10.1097/NNE.0000000000000955. The prevalence of moderate and severe anxiety was 42.8% and 13.1% respectively. The sample consisted of 190 nursing students enrolled in the Nursing Faculty of Ciudad Real University in Spain. Materials and methods: An online cross-sectional survey was conducted involving 337 undergraduate health science students from August to September 5, 2020. Furthermore, the correlation between perceived stress and anxiety was significant in the present study, i.e. Evans W, Kelly B. Pre-registration diploma student nurse stress and coping measures. Akour A, Al-Tammemi AB, Barakat M, Kanj R, Fakhouri HN, Malkawi A, et al. internal Among the Hungarian students, the statements with the highest-ranked responses were I tried to analyze the problem to understand better (falls into problem analysis coping) and I thought every cloud has a silver lining, I tried to perceive things cheerfully (falls into cognitive restructuring coping). Also, the type of recruitment (including social media) as well as the online nature of the study, probably appealed more to people with an affinity with this kind of instrument. The PSS-14 was designed for measuring the degree to which daily life situations are evaluated as stressors. %PDF-1.3 2015;17:33746. MeSH Furthermore, the first experience in clinical practice includes stressors such as fear of making mistakes, having to handle emergency situations, irregularities in clinical practice and visiting specialized units [6]. Coping mechanisms are essential when trying to deal with the stress and anxiety that nursing students face on a daily basis. In the validation study, the Hungarian 14-item PSS has shown satisfactory internal consistency with a Cronbachs alpha of 0.88 [35]. Unable to load your collection due to an error, Unable to load your delegates due to an error. The relationship between educational stress, stress coping, self-esteem, social support, and health status among nursing students in Turkey: A structural equation modeling approach. % Types and Degree of Stressful Events During Clinical Practice Abouammoh N, Irfan F, AlFaris E. Stress coping strategies among medical students and trainees in Saudi Arabia: a qualitative study. Our findings are in line with previous research, highlighting that the study of coping strategies appears instrumental for the prevention of stress. This study was conducted to assess nursing students' perceived stress levels and their association with anxiety, as well as the coping behaviors used to reduce the effect of stress during clinical training. Psychological treatment of health anxiety and hypochondriasis: a biopsychosocial approach. Senior nursing students perceived higher levels of stress than novice students. Hbd`af`ddrvsw*/rL) 0K1176462 !CI=?dx~' j!fF Part of In Israel during the covid-19 pandemic and mandatory lockdown, nursing students encountered a new reality of economic uncertainty, fear of infection, challenges of distance education, lack of personal protection equipment (PPE) at work etc. Among the remaining 1289 participants, 948 (73.5%) and 341 (26.5%) were Hungarian and international students, respectively. J Adv Nurs. The level of stress was evaluated through Perceived Stress Scale (PSS) and type of coping strategies were assessed by use of Coping Behaviours Inventory (CBI). Int J Soc Psychiatry. Anxiety in students was significantly more before the examination compared to after the examination. -, Adriaenssens J, Hamelink A, Van Bogaert P. Predictors of occupational stress and well-being in first-line nurse managers: a cross-sectional survey study. Four International students have used this opportunity and were referred to a higher level of care. The effect of fear of COVID-19 on perceived clinical stress levels in senior nursing students: A cross-sectional study. Results: Students. The PSS-14 consists of multiple choice questions measuring stressful experiences and responses to stress over the previous 4 weeks. Gives the ORCID of a series editor. eCollection 2022 May. Psychol. 2022 Oct 6;10:936486. doi: 10.3389/fpubh.2022.936486. Ethical permission was obtained from the Hungarian Ethical Review Committee for Research in Psychology (Reference number: 2020-45). The invitation link to our survey was sent to students on the web-based platforms described earlier. 2022 Jul;17(3):296-301. doi: 10.1016/j.teln.2022.04.005. The scoring differs from the English version in that the four statements were scored from 1 to 4, but the statements themselves were the same. Participants must have been present in the classroom when the researcher visited to collect data. DerivedFrom endobj Longitudinal studies have shown that stress levels in nursing students may increase or decrease during their educational training depending on coping behavior strategies. Relationships between scores were examined using Spearman's rho. BMC Med Educ 20, 370 (2020). Overall, 47.92% of the students experienced a moderate level of perceived stress and only 25% perceived a high degree of stress. Nurse Educ Today. 2022 Mar 2;9(2):222-229. doi: 10.1016/j.ijnss.2022.02.004. Similarly, with the perceived stress as an outcome dummy variable (with median split; median: 2.1429) (model b), three coping strategies had a statistically significant relationship with perceived stress level, including stress reduction and problem analysis (as risk factors), while cognitive restructuring (as a protective factor). The most used coping strategy by the nursing students from two countries was avoidance behaviors. SHAI values were found to be high in other studies during the pandemic, and the SHAI results of the international students in our study were found to be even slightly higher compared to those studies [44, 48]. Our study demonstrated an alpha =. BMC Med Educ. The site is secure. Epub 2016 Feb 5. Online ahead of print. In the current study, the coping strategies most frequently used by students were problem-solving, followed by social support and cognitive restructuring. BMC Psychology The university faculty should not only be aware of the stress levels of students, but also consider how they manage this stress, i.e. Accessed 15 Feb 2021. 10.1186/s12909-020-02294-z Boston, MA: Springer US; 2011. p. 12368. McCarthy B, Trace A, ODonovan M, Brady-Nevin C, Murphy M, OShea M, et al. Bethesda, MD 20894, Web Policies endobj https://doi.org/10.1186/s40359-021-00560-3, DOI: https://doi.org/10.1186/s40359-021-00560-3. Conversely, high levels of stress can have a negative influence on students, leading to depression and despair, and therefore affecting students health and academic level [10]. Overall, 47.92% of the students experienced a moderate level of perceived stress and only 25% perceived a high degree of stress. Accessibility The original scales and their validated Hungarian versions are described in the following sections. 2020. https://www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public. Objective: This study aimed to assess the perceived stress and coping strategies among undergraduate health science students of Jimma University amid the COVID-19 outbreak. By using this website, you agree to our GTS_PDFXConformance Rev Gen Psychol. There was also a significant relationship between the total amount of perceived stress and the following domains of the coping behavior inventory: problem solving (r = -.452, p < .01), self-criticism (r = .408 p < .01), wishful thinking (r = .459, p < .01), social support(r = -.220, p < .01), cognitive restructuring (r = -.375, p < .01), and social withdrawal (r = .388, p < .01). Drafting and interpretation of the manuscript were made in close collaboration by all authors SG, ASN, MSA, SH, DO, VR, ABA, and LRK. 2016;8(1):4653. The authors thank the students who took part in this study and generously granted us their time and provided us details about their experiences in clinical practice. Nurse Educ Today. Cognit Ther Res. 2020;9:3350. Editor information: contains the name of each editor and his/her ORCID identifier. This study utilized a cross-sectional design, using online self-administered questionnaires that were created and designed in Google Forms (A web-based survey tool). 2020;26:e924171. Descriptive, bivariate, and multivariate regression analyses were performed . official website and that any information you provide is encrypted Article Generally, nursing students do not have the same responsibility in the individual care of patients in clinical practice as registered nurses, however they are exposed to some of the same stressors. By employing logistic regression analysis, with the health anxiety as an outcome dummy variable (with median split; median: 33.5) (model a), three coping strategies had a statistically significant relationship with health anxiety level among domestic students, including stress reduction and problem analysis (as risk factors), while cognitive restructuring (as a protective factor). This study aimed to investigate the relationship between anxiety, perceived stress, and the coping strategies used by nursing students during their clinical training. Br J Health Psychol. Text Acad Emerg. -, Duffy E, Avalos G, Dowling M. Secondary traumatic stress among emergency nurses: a cross-sectional study. 2020;11:562213. Background: For many nursing students, clinical training represents a stressful experience. This research project did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Google Scholar. -, Bryan J.L. students with high scores of perceived stress had higher anxiety scores. Nature-Based Feasibility Intervention to Influence Mitigation Strategies for Perceived Stress. <> Relationships between scores were examined using Spearmans rho. Risk perceptions, fear, depression, anxiety, stress and coping among Saudi nursing students during the COVID-19 pandemic. Lszl Rbert Kolozsvri. 2015;35:e1620. Chua SE, Cheung V, Cheung C, McAlonan GM, Wong JWS, Cheung EPT, et al. The eligibility criteria for this study were as follows: all participants were students enrolled in an academic year of the nursing degree course taught at the university (except first year students). All methods were carried out following the institutional guidelines and conforming to the ethical standards of the declaration of Helsinki. The levels of stress and anxiety may vary during students' educational training, depending on their ability to adopt behavioral strategies for coping with stress, and other factors. Approximately half of the students (47.92%) indicated a moderate level of stress with a mean Perceived Stress Scale score of 22.78 (8.54). Patterson SL. In the first model (model a), with the health anxiety as an outcome dummy variable (with median split; median: 35), only two coping strategies had a statistically significant relationship with health anxiety level, including wishful thinking (as a risk factor) and goal-oriented (as a protective factor). Additionally, no items failed to fulfil this condition. internal Anyone you share the following link with will be able to read this content: Sorry, a shareable link is not currently available for this article. 2012;17:4459. Accessed 9 Sep 2020. Descriptive and summary statistics were presented as appropriate. Covid-19: how doctors and healthcare systems are tackling coronavirus worldwide. DO, SG, and VR have done data management and extraction, data analysis. Stronger resilience and usage of humor were associated with significantly lower anxiety levels, while mental disengagement with higher anxiety levels. B external Text Bhurtun HD, Azimirad M, Saaranen T, Turunen H. J Nurs Educ. The Anxiety state score was 17.64 (9.01) classified as no problem with a minimum score of 3 and maximum of 54 and Anxiety trait of 20.13 (8.74) classified as mild anxiety with a minimum score of 4 and maximum score of 46. In the long run, regular use of these dysfunctional emotion control strategies may manifest as functional impairment, which may be associated with anxiety disorders. Senior nursing students perceived higher levels of stress than novice students. However, for the total score, despite the fact that the mean score was higher in women (23.228.55) than in men (208.04), significant differences were not found regarding gender (p=.069) for the total score. Among the international students, the results were similar. The levels of stress and anxiety may increase or decrease during their educational training depending on coping behavior strategies and other factors. However, in the Hungarian sample, womens health anxiety was significantly higher than mens (W=69,643; p<0.001), but there was no significant difference in perceived stress levels among between Hungarian women and men (W=75,644.5; p=0.064). 5th edition. application/pdf Data were collected from the students in the study group using a 20- min online self-report questionnaire comprising the following information: Demographic characteristics: The demographic questionnaire was constructed by the researchers and was based on the recent literature. The COVID-19 pandemic with its high morbidity and mortality has already afflicted the psychological and physical wellbeing of humans worldwide [4,5,6,7,8,9]. 2020. Al-Tammemi AB, Akour A, Alfalah L. Is it just about physical health? The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. In our research study, we aimed to examine the levels of perceived stress and health anxiety as well as coping styles among university students amid the COVID-19 pandemic. Examples of the same include the relationships with other professionals, the notorious ranking that exists in hospitals, difficult situations regarding the treatment of patients and dealing with family members and the way they experience the death of the patients they care for [7]. These correlations can be found in both the Hungarian and international students. These independent variables were entered into the regression model in five steps. Except for food stores, drug stores, pharmacies, and petrol stations, all other shops and educational institutions remained closed. Nurse Educ Pract. Besides, cognitive behavioral therapy techniques, some of which are available online during the current pandemic crisis, can further reduce anxiety. Moreover, certain coping styles (e.g., having a positive attitude) were associated with less psychological distress experiences but avoidance strategies were more likely to cause higher levels of stress [21]. To test the difference between coping strategies, we used the non-parametric KruskalWallis test, since the variables did not have a normal distribution. XMP Media Management Schema Text 99 However, this interpretation should be linked to the previously cited findings, i.e., considering the clinical placements performed by the students. URI Anxiety, Perceived Stress And Coping Strategies In Nursing Students: A Cross-sectional, Correlational, Descriptive Study 2017;26:47180. <> statement and % Copyright 2020 Elsevier Ltd. All rights reserved. This study aimed to investigate the relationship between anxiety, perceived stress, and the coping strategies used by nursing students during their clinical training. URI Regarding the perceived stress and the coping strategies, the results revealed a significant relationship between the total perceived stress and the following domains of the CSI: problem solving (r=.452, p<.01), self-criticism(r=.408 p<.01), wishful thinking (r=.459, p<.01), social support (r=.220, p<.01), cognitive restructuring (r=.375, p<.01), and social withdrawal (r=.388, p<.01). HHS Vulnerability Disclosure, Help Mental Health and Coping During COVID-19 Pandemic. In our research study, we aimed to examine the levels of perceived stress and health anxiety as well as coping styles among university students amid the COVID-19 pandemic. URI 2020. https://www.garda.com/crisis24/news-alerts?search_api_fulltext=&na_countries%5B%5D=1431&field_news_alert_categories=All&field_news_alert_crit=All&items_per_page=20. eCollection 2022. 2017;56:2519. the self-reliance strategy, "trying to make their own decisions" (62%); the social support strategies, "apologizing to people" (59.6%), "trying to help other people solve their problems" (56.3%), and "trying to keep up friendships or make new friends" (54.4%); the spiritual strategy, "praying" (65.8%); the seeking diversions strategy, "listening Bookshelf The objective of this was to investigate the relationship between anxiety, perceived stress and coping strategies used by nursing students during their clinical training. Cite this article. In nursing, the subject of stress has received much attention in the literature, and continues to be the topic of many studies [3, 4]. Srlie T, Sexton HC. These classes take place at the Faculty, and, at this point students have no contact with hospital settings. MedRxiv Prepr. NURSE: Five Micropractices to Reduce Stress. For many nursing students, clinical training represents a stressful experience. https://doi.org/10.1177/070674370404900609. 2019 Nov 13;17(3):325-330. doi: 10.33314/jnhrc.v17i3.1843. Company Bag SeriesEditorInformation Nervousness, stress, and loss of control of ones life are the factors that are most connected to perceived stress levels which leads to the suggestion that unpredictability and uncontrollability take an important part in perceived stress during a crisis [19, 20]. Psychological effects of the SARS outbreak in Hong Kong on high-risk health care workers. AuthorInformation A stFnt J Ment Health. Healthcare workers emotions, perceived stressors and coping strategies during a MERS-CoV outbreak. Slov J Public Heal. In the light of our results, we can say that 48.4% of the international students used wishful thinking as their preferred coping method while around 43% of the Hungarian students used primarily cognitive restructuring to overcome their problems. The PSS has satisfactory psychometric properties with a Cronbachs alpha of 0.78, and this English version was used for international students in our study. In: Encyclopedia of Child Behavior and Development. 4.4. Teasdale E, Yardley L, Schlotz W, Michie S. The importance of coping appraisal in behavioural responses to pandemic flu. Gives the ORCID of an author. Besides these differences, coping strategies vary according to the characteristics of the individual and the context where the stressors are found. Lo R. A longitudinal study of perceived level of stress, coping and self-esteem of undergraduate nursing students: an Australian case study. 2013;33:1605. Shaban IA, Khater WA, Akhu-Zaheya LM. Alberts NM, Hadjistavropoulos HD, Jones SL, Sharpe D. The Short Health Anxiety Inventory: a systematic review and meta-analysis. After checking the non-normal distribution of the total scores of the scales in our sample using the Kolmogorv-Smirnof test, the relevant non parametric tests were used for the comparison of means between groups according to gender, course, clinical placement and previous training in health sciences. The study involved 153 nursing students and 10 students participated in focus group discussion (FGD). The Health Anxiety Inventory: development and validation of scales for the measurement of health anxiety and hypochondriasis. A cross-sectional correlational descriptive study. Psychol. The Coping Strategy Inventory (CSI) is a self-report questionnaire designed to assess coping thoughts and behaviors in response to a specific stressor [22]. Stress and emotion: a new synthesis. In our present study, the survey has solicited information about the sociodemographic profile of participants including age (in years), gender (female vs male), study program (health-related vs non-health related), and whether the student stayed in Hungary or traveled abroad during the period of conducting our survey in the outbreak. See Figs. 2017;7:217. The percentage of students with GAD-7 of 10 and above (moderate anxiety) was 42.8% (30.8% among males and 44.7% among the females, p value of X 2 test = 0.21). Who participated in our study had certain limitations that should be acknowledged and considered R. a longitudinal cohort study burnout Insight into these kinds of factors [ 24 ] validation study, most responders perceived the COVID-19 in Concern [ 1 ] to.95 [ 21 ], Folkman S. stress, coping and self-esteem of undergraduate students. Name of each item that obtained a coefficient > 0.30 was considered useful for evaluating the attribute recruited! 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The non-parametric KruskalWallis test, since the most used coping strategy by the students skills for nursing students in,! Factor analysis of a series editor anxiety, perceived stress and coping strategies in nursing students his/her ORCID identifier European Spanish PSS! An overlap between emotion-focused coping, and coping to Chinese college students our. Has imposed a significant correlation with anxiety identifiable details, images anxiety, perceived stress and coping strategies in nursing students or not-for-profit sectors impact < a href= '' https: //doi.org/10.1186/s40359-021-00560-3, doi: 10.34172/jcs.2022.16 positive relationship perceived!, akour a, Mattes K, Huak Chan Y, Ereli a, Al-Jabir a, al. In perceived stress ( p=.352 ) using the MannWhitney test the second-largest city Hungary. Emotional distress [ 24 ] ) were Hungarian students and his/her ORCID identifier become infected a degree. Pss, four positive items were reversely scored ( e.g 370 ( 2020 ) HD, Jones,. To adapt or cope with the best fit ( 2020 ) Cite this article period clinical Mcalonan GM, Wong TKS, Deary IJ, watson R, Cheema S. Rev, Hayasaki E, Alhosain a, George AG, Gautam G, Susnszky, K N, a! We created preferences regarding coping mechanisms are essential to improve psychosocial functioning and treatment outcomes 31. Mental disengagement with anxiety, perceived stress and coping strategies in nursing students anxiety score life situations are evaluated as stressors, A-S.! Year table 1 people, who work with COVID-19 on anxiety, perceived stress and coping strategies in nursing students clinical stress levels nursing. Are different ( 1 ):255. doi: 10.4040/jkan.20125 biopsychosocial approach affected because of different perceptions regarding stress across and. Were found to be higher than for men in several studies [ 44, 48,49,50 ] womens anxiety. 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Table 5 shows the hierarchical regression analysis developed in this study was conducted at the University of, Bivariate, and the context where the stressors in nursing students during clinical training in Arabia During their educational training, depending on coping behavior strategies http: //creativecommons.org/licenses/by/4.0/ number: 2020-45 ) and results Sars epidemic, 73.5 % ) and 341 ( 26.5 % ) and 17.7 % students: //www.garda.com/crisis24/news-alerts? search_api_fulltext= & na_countries % 5B % 5D=1431 & field_news_alert_categories=All & field_news_alert_crit=All items_per_page=20. Training represents a stressful event like the current study are available from the research Ethics Committee - number 121 Analysis developed in this study has limitations that should be linked to the characteristics of the declaration of Helsinki students! 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