Coping strategies used by undergraduate first-year nursing students during transition from basic to higher education: a qualitative study

An exploratory descriptive qualitative [9] research design was adopted to achieve the aim of this study. Such a research design is best suited for studies in healthcare practice and education, including this one, as it allows for exploration and description of phenomena on aspects of nursing education and practice, including related policies [9].

The study was conducted at a university in South Africa, which has three campuses spread across two provinces. The third campus of this university was not yet accredited to offer the undergraduate nursing qualification at the time of conducting this study. The two campuses where the study was conducted offer an aligned undergraduate curriculum. Although the university strives to offer the same higher education experience to its students across its campuses, the two campuses vary in terms of geographic urbanization: one campus is located in a semi-urban area, while the other is in a predominantly rural area.

The participants were undergraduate first-year nursing students from the two campuses of a university in South Africa. In the context of this study, undergraduate first-year nursing students are those who hold a Grade 12 certificate (university entry exam) and are in their first year of a four-year Bachelor of Nursing program. The researcher’s interest was piqued by literature that has shown that poor resilience is predominant among undergraduate first-year nursing students, especially those arriving at university straight from high school [7]. A non-probability purposive sampling technique was used to select potential participants and form four focus group discussion (FGD) groups from a population of 156 undergraduate first-year nursing students across the two campuses. The process of sampling was conducted with the assistance of a mediator to ensure that potential participants were thoughtfully selected. The participants included males and females aged between 18 and 21 years, the inclusion criterion being bona fide undergraduate first-year nursing students. First-year students in postgraduate qualifications, undergraduate first-year nursing students who are repeating first year and undergraduate nursing students at year levels 2, 3, and 4 were excluded.

Data was collected in August 2023 through online FGDs which were conducted using the Microsoft Teams app guided by an unstructured FGD schedule. The literature recommends that an FGD should comprise between five and twelve participants [10‐13]. Two FGDs were held for each campus, comprising ten and seven participants for campus A, and seven and eight participants for campus B. The choice of FGD as a method was due to its capability of producing data rich in detail through widening the range of responses and activation of forgotten ideas [12]. Data was gathered during students’ free time, mostly after classes when they were mostly in their rooms and using institutional WiFi. For participants who did not stay at either a campus residence or accredited residences with free WiFi, a 1GB data bundle was provided so that they could connect and participate in the online FGD. Participants were requested to keep the cameras of their devices on during data collection, to ensure that all nonverbal cues were captured as field notes. The type of data that were collected were the demographic information of the participants and that relating to their coping mechanisms regarding transition from basic to higher education. In exploratory descriptive research, collecting quantitative materials such as the demographics of participants helps to support the results [9]. However, no identifying information such as names, identity numbers or student numbers were collected. Instead, participants were referred to by numbers, as participant 1, 2, 3 and so forth. Although the FGDs were primarily conducted in English, participants were awarded an opportunity to clarify in their vernacular since English was not their primary language. The FGDs were recorded using the recording option on Microsoft Teams and later transcribed verbatim. The vernacular transcriptions were translated by an expert in language, after which they were checked by a bilingual expert to ensure that they reflected the collected data. Each FGD lasted between 50 and 60 min.

Trustworthiness was ensured through credibility, dependability, confirmability, and transferability [10, 11]. In addition, the authors used other measures of triangulation during data collection, where field notes from the video feed were collected to corroborate the findings. Furthermore, discrepant information that runs counter to the categories identified in this study was also described during the discussion. According to Creswell and Creswell [13], discussion of discrepant information adds to the credibility of the findings, because it is a common occurrence that life perspectives do not always coalesce. Finally, the findings in the form of categories and sub-categories were also confirmed with the participants, to ensure that the findings represented the data that was obtained from them, a method known as member checking.

Data was analyzed following a conventional qualitative content data analysis method, encompassing a detailed analysis of narrative data to generate categories and patterns of these categories [11]. Conventional qualitative content analysis involves segmenting raw data into small units, followed by coding, and naming the units as per the content that they are representing, and finally grouping the generated codes to form categories and sub-categories [11]. To achieve this, data was analyzed independently by both the researcher and the co-coder throughout the data collection process. The second and third authors were available on standby in case there were conflicts regarding consensus on the categories between the researcher and co-coder. However, there were no such conflicts as the researcher and co-coder agreed on the categories and sub-categories. The following steps by Creswell and Creswell [13] in conjunction with Atlas.ti version 23 software were used for data analysis (see Table 1).

The proposed study was defended and approved by the institutional scientific review committee. It was then sent to the institutional ethics review committee to ensure that it met the minimum standards of conducting research with human participants, and it was approved and issued with a unique ethics number (NWU-00053-23-A1). Upon approval by both the scientific and ethics committee, goodwill permission was obtained from the Research Data Gate Keeper Committee (NWU-GK-23-140) of the institution where the study was conducted. Finally, goodwill permission was sourced from the individual deputy directors of the campuses where data was collected. To ensure that participants’ right to autonomy was respected, recruitment was carried out by an independent research assistant because the researcher is a staff member at the selected university. This ensured that recruitment was fair and just, without coercion or undue influence. As a result, participation in the study was entirely voluntary. Participants were allowed at least 14 days to read through the informed consent and decide if they wanted to participate or not. It is no secret that FGDs cannot be 100% confidential, which was one of the key ethical issues [12]. However, to combat this, participants were requested to keep all matters being discussed in the FGD confidential. Furthermore, all research team members were requested to sign a standard institutional confidentiality agreement form to ensure confidentiality throughout.

Data was collected from four FGDs (two from each campus). The demographic characteristics of the participants are indicated in Table 2.

Three categories and sub-categories were identified from data analysis and are presented in Table 3.

Participants expressed that transition from basic to higher education implies transition to independence. This include shifting from traditional teaching modalities to more self-directed and student-centered learning. They explained that unlike in basic education, where their studies were primarily planned for by their parents, the transition to higher education saw them becoming fully responsible for organising their studies. According to the participants, the transition to independence is mainly because during higher education they mainly stay alone and do not have anyone to share responsibilities with, like their parents, siblings, or even helpers. Furthermore, although they felt that the transition from basic to higher education implies a transition to independence, participants alluded to the fact that it is a difficult and challenging process, especially in the first semester.

The following verbatim quotes from participants illustrate this:

“I needed to get comfortable with the fact that I am living on my own and need to look after myself [showing quotation sign] if you want to call it that. And I think that thing that you need to go buy your own food, you need to make your food [laughs], you need to do your washing, you need to keep your apartment clean, things that we kind of [had] done by your parents or just ensured by them, it adds a lot of stress.”

“But when you are in university, you need to focus more on the things like, I need my uniform by tomorrow, I’ve worn it yesterday, I need to wash it, but I have this and this and this classes today.”

Participants expressed that they struggle with time management; lack of time management and increased workload during higher education make it difficult for them to manage their modules and weekly schedules. The participants’ explanation of the demanding schedule was centered around the theoretical demands of the undergraduate nursing degree, its clinical demands, and the need to maintain a social life. They explained that a weekly outline of their schedule would include classes which sometimes stretched up to two hours and 45 min, work-integrated learning placements and tests. They further explained that some classes would end at around 17h45 on Fridays, thus, negatively affecting their concentration span:

“I think a lot of us isn’t coping, like I’m still struggling with my time management. And yeah, the workload.”

“it’s a little bit difficult for me to like to, to, to manage my modules because you find it maybe today or rather tomorrow, we have a test. Friday. Thursday. We have a test.”

Participants elucidated that the teaching style during higher education seems too fast for them compared to that in basic education, which makes adapting to academic demands difficult. In addition to unfamiliar teaching styles, they expressed that one of the challenges that they grapple with is the rich content, which they are expected to grasp within a short space of time. They referred to the content at higher education as complex and always requiring an extra effort, or someone to guide them through the process of learning. According to the participants, learning in higher education is seen as a never-ending cycle which extends beyond the classroom premises:

“The content from, okay, from high school is different from the content from varsity in a way that the varsity one is complex, and you cannot do it by yourself.”

“Let me just say, it was a bit difficult obviously, because of the learning and teaching. Adaptations differ and yeah, so it was like kind of hard for me to adapt.”

Participants described their experience of adapting to clinical demands during the transition from basic to higher education as similar to being thrown in the deep end. This is because adapting to clinical demands had to happen concurrently with trying to adapt to academic demands. They explained that they felt that they were not prepared enough psychologically to deal with cases such as psychiatric patients at outpatient departments, or caring for a dying patient. For some, this would include caring for a large number of sick patients, as this took an emotional toll on them. Furthermore, participants expressed that they experience being looked down on and ill-treated by other healthcare professionals, including students pursuing healthcare professions other than nursing. This makes their adaptation to clinical demands even more difficult. What also stood out was also the existence of stigma attached to male nursing students:

“I felt like I was thrown in the deep end because I was a bit confused as to what to expect from the actual work that we are going to do, and the placements in hospital, and what’s going to be expected from us, while working in a hospital.”

“What we’ve been seeing, it is heavy stuff like seeing a patient pass away or dealing with a mentally ill patient for the first time. It’s not something a normal 18- or 19-year-old person faces.”

Participants expressed that transition from basic to higher education required them to adapt to unfamiliar social systems. They explained that they had challenges such as language barriers and culture shock at the institution of higher learning, which led them to be somewhat preoccupied. Some participants indicated that they had to learn to adapt to city life, since they were from primarily rural small villages with no exposure at all to city life. They further explained that, despite these unfamiliar social systems, they had to form social relations since they were stuck together and had to learn to survive together. Another major finding was that some of the participants were naturally introverts and had to learn how to socialize, as they were required to work in groups when completing some of the activities. Also, participants expressed that they were not sure of the boundaries of seeking help from their lecturers, compared to what they were used to during basic education:

“I found it a little difficult since I graduated last year and came from a small town in the Western Cape. So, there were like really few people and then coming to Campus B, there was this this massive [laughs while talking] amount of people and cultures and different languages…”

“Now there is how many different people that you never met in your life before, its complete strangers, and now you have to not only study together the same thing but deal with these difficult situations of emotional heaviness together with your colleagues and its difficult.”

Participants expressed that they were overwhelmed with clinical and theoretical demands, and often find it difficult to balance the two. According to them, what exacerbates the lack of balance between clinical and theoretical demands is the staggering allocation. Another key element that they highlighted regarding balancing the clinical and theoretical demands was that they often return from clinical services late, at around 21h00, and they would be expected to be in class the following day, or vice versa. They state that this puts a strain on them and does not allow them time to fully prepare for the next day. As a result, participants felt that the pressure from the need to satisfy the clinical and theoretical demands does not allow them enough chance to self-study and revise the content taught in class or at the simulation room. One other key element that they highlighted was that sometimes they witness cases at the clinical sites which are unpleasant, but regardless of that they still need to adhere to the theoretical schedule, which could be a test the next day after such a traumatic event:

“When she says balancing between going to placement and school also, academics. It’s like, Sir, we see a lot of traumatising things at the hospital. Also, at school the pressure is a lot. It’s like it’s kind of difficult to balance those two things, mental health …”

“… for example, this week we wrote, we were just writing today. Yesterday we were working. Tomorrow we are working, and we are writing on Friday. So, it is kind of difficult to catch up with the work, both theory and practical of course.”

Adaptive coping refers to the application of both cognitive and behavioural efforts towards the management of a stressful situation or event [14]. In this study participants used adaptive coping mechanisms to cope with the transition from basic to higher education. According to them the first point was to realize the need to change and accept it. This means that participants acknowledged that they were now in higher education and needed to learn to adapt to it. Those who had attended boarding school expressed that it was not really an adaptation process but an adjustment, since they had been semi-independent at school. A second adaptive coping strategy that they highlighted was the need to breech barriers like language by learning a few words of the language which they struggled with, for purposes of communication among peers and especially with patients. Participants expressed that they also had to draft their own timetables to improve on time management. They also explained that they use platforms like YouTube to boost their understanding of content after lectures and while studying:

“I think also by learning small amounts of words from other languages, it helped, and then just going with the flow [laughs]. Ultimately it helps you in the end, you get comfortable.”

“Honestly, I think just for me personally, I think we just need to realize the change and just accommodate this change and adapt to the change, because I mean it gets different and difficult.”

Appraisal-focused coping is concerned with changing one’s mindset about a stressful situation or one they feel that they cannot cope with, in order to be able to cope with it [14]. The participants expressed that a change of mindset about higher education greatly assisted them to cope with the transition. They explained that they changed their mindset to focus on what other students are doing to be able to prosper in the Bachelor of Nursing degree, and tried to apply that in their lives too. Appraisal-focused coping was also applied, even in the clinical setting where participants expressed that they would sometimes put themselves in patients’ shoes to gain a better understanding of their situation. This assisted them to cope with cases, such as the management of psychiatric patients at clinics or in the outpatients’ department:

“… I found a way to change my mindset, like focus more on knowing what people do in order to achieve and be successful in life, and try to apply that in in my own life, in my own daily living.”

“… making a mind change and realising that It’s not just you. There’s a bigger picture. But yeah, I don’t have a coping mechanism, a coping strategy for that. I just think that is a mindset change that you have to do.”

An emotion-focused coping mechanism was identified as one of the strategies used by undergraduate first-year nursing students to cope with the transition from basic to higher education. An emotion-focused coping mechanism is defined as a process of the individual employing efforts aimed at reducing the stressors that they cannot cope with [14]. The participants expressed that while the main goal is to balance the clinical and theoretical demands, there is also a need to engage in recreational activities that are offered at the higher education institution, to reduce stress. In addition, participants stated that adequate sleep, doing house chores, and periodic exercise also assisted them to lower their stress level and be able to cope better with the transition. Socialising and listening to music were also aspects highlighted under emotion- focused coping strategy:

“I can say try to balance your life, your social life and your academic life. For example, it’s not a matter of you must always be focused on your studies. Try to be part of the recreational activities…”

“And you also need to make time for res and to participate with that, and make sure that you have, and [that you are] actually enjoying it while you are studying.”

Problem-focused coping is a strategy where an individual directly faces a problem or a stressor that is responsible for poor coping [14]. In this study, the participants expressed that one of the potential problems in terms of lack of coping is the accessibility of entertainment. They explained that they had to reduce entertainment time, including time spent on social media, significantly. They indicated that the time that they had initially spent on entertainment and social media was then redirected to studying. In addition, participants expressed that reducing entertainment time also improved their time management, which they previously found challenging. Participants further expressed that they had to learn to plan weeks ahead, so that they could manage the theoretical and clinical demands. Planning a week ahead would include allocating times to study individual modules as per the drafted plan:

“So, what I found that was really helpful is to take a day in a week, for example a Sunday, and just to plan out the next week. So, make sure that you have everything ready for the next week…”

“So, my strategy is to cope with that. I’ve been trying to eliminate my social life, like I’ve been trying to reduce the things that I do socially, like entertainment.”

Social coping is described as seeking support from the community or society to enhance ability to cope with a stressor [14]. Participants expressed that they had to form relations and associate with other students in order to cope with the transition from basic to higher education. They explained that the persons that they formed relationships with matured into becoming study partners and assisted them with interpretation services to patients. The participants stated that social coping was also used to try and understand the experiences of their peers, which they could relate to. They explained that they would normally sit in groups after class and talk about their experiences and how each is navigating the stressors associated with the transition from basic to higher education. In addition, participants explained that they would find humour about their experiences during those group sessions as a way to cope, and not necessarily to make a mockery of the situation:

“… they placed us in hospital mixed ratio, like with when I work with my one friend, she can speak Setswana then the two of us will work together the whole time so that she can speak to the patient when the patient is Setswana, and I can speak to the patient when the patient is Afrikaans.”

“… we used to finish at around half past 11–12 and then we had our community health class starting at 3. So, that hour between our session… we would sit in our nursing group our like clique [showing quotation signs with hands], we would sit and just talk and we would basically make light of our situation.”

Another coping strategy that participants used was seeking help from mentors. The identified mentors were senior undergraduate nursing students, supplementary instructors, and (to a certain extent) student leadership structures. Participants expressed that they coped by seeking advice from their seniors within the Bachelor of Nursing program. They explained that they would periodically ask their seniors how they coped when they were faced with similar adversities and would apply those coping strategies. Furthermore, participants expressed that having some guidance from supplementary instructors assisted them to cope with the academic demands. This is particularly important because in most cases supplementary instructors would be people in the same age group as the students, who they could therefore relate to better, and could maximize learning. Participants indicated that they also sought help from their lecturers and parents in order to cope with the transition from basic to higher education:

“I will normally ask those that have experienced the first year, those that were once first years, how do you cope with this thing on the whole concept of nursing? How do you deal with your life, your personal life and your academic life?”

“What I wanted to say is some of the children, when they encounter situations where nurses are unfair or not treating them right, they do… I don’t know, here at the university they can… I don’t know how to say it in English. They can go give those names, like writing it, write a report and give their names to the faculty.”

Participants suggested that academic support would come in handy in ensuring a smooth transition from basic to higher education. Within academic support the recommendation that they highlighted was the need to have additional study materials, such as recorded lessons and tutorial videos of the content being taught in class. In addition, participants recommended that the time spent in the lecture room should be reduced to allow them to prepare for other classes and even to study further what had been taught in class. Lastly, the participants recommended that assessment schedules should be shared well in advance so that they could have sufficient time to prepare for assessments amid their hectic schedules:

“… if like they would upload maybe like tutorial videos on the content or study unit, that would be much better.”

“… they don’t take too much of our time, so that we can just use half of the day to study then prepare for the practical. Then when we get back from the practical, so that we can also prepare for the next class.”

Participants expressed that there is a need for a contextual orientation program for nursing students that is based on their needs. They explained that the orientation program offered at higher education, which focuses on showing students landmarks of the university, is not that helpful to nursing students. They expressed that having someone to explain the logistics of nursing to undergraduate first-year nursing students during the orientation period could be helpful. They explained that this would help undergraduate first-year nursing students to be prepared for first year of the Bachelor of Nursing program, because they would be aware of the expectations of the program:

“Maybe if the coming first years should at least be orientated on what really happens in nursing. Unlike the orientation that took place, whereby we were shown around the school …”

“I think there should also be better procedures put in place in terms of the navigating your way around campus. It’s a bigger place than high school.”

Participants expressed that there is a need for stress management sessions for undergraduate first-year nursing students, as these would greatly assist the students to debrief about the adversities they face during the transition from basic to higher education. Thus, would improve their ability to cope. They further suggested that the stress management sessions could be done in the form of group counselling, since they all experience similar adversities:

“… think of a stress management because nursing can be stressful. So, teaching stress management techniques like meditating, it can be beneficial.”

“Then another thing that I think might be effective is group counselling sessions that’s specific to nursing and the health care.”

The participants expressed that they could cope better if lecturers or clinical preceptors would check on them from time to time in terms of how they are coping, especially with regard to their clinical experiences. They explained that such support should not only be regarding negative experiences, but also to celebrate milestones in clinical placement. Furthermore, participants suggested that clinical placement should be structured in such a way that it encompasses senior students. They indicated that, clinical preceptors have a large pool of students to supervise and might not always be around. Being placed with senior students gives them a fair amount of confidence, because they know they can always consult them since they are available:

“I think making an effort to ensure that there is another senior on the ward with you, I think that will also help with you feeling secure about what you are doing.”

“… I know that there is a senior member that if anything happens, if there is a situation, because I know it’s not always necessary to call the preceptor because sometimes is just ‘Oh! I’ve seen my first patient die’, or ‘Oh! I just witnessed a terrible situation’ …”

Participants recommended that lecture periods should be reduced to allow time for self-study and for preparation for commitments such as clinical placement. They also suggested that theory and clinical days should be separated to ease navigation between the two competing demands of the Bachelor of Nursing program. They explained that they would recommend that theory time be completely separated from clinical time, a system called a block system, where students attend classes for a certain period and later attend clinical placement for an agreed period. In addition, participants expressed the need for supportive messages on the institutional teaching and learning online platforms. They explained that lecturers should sometimes send out supportive messages using online learning platforms, instead of communications that remind them of their workload all the time.

“The lecture should be reduced; the time should be reduced for us to go study and also the practical.”

“… going to class today, tomorrow we’re going for practical, it’s really draining. Like if maybe they can do … this week it’s classes, then next week its practical, just like that, because it’s really difficult…”

In terms of opportunities to improve communication, participants recommended that undergraduate first-year nursing students should be afforded a compulsory vernacular subject on the language that is common in the community where the university is located. They explained that such a vernacular subject should be an addition to their mother tongue and English, which can enable them to communicate with patients and fellow students with ease. They also suggested the need for social activities, which will pave the way for socialization among students from different cultural and geographic backgrounds. They also recommended that there should be an anonymous channel for students to communication their concerns to lecturers or other students; this would be helpful because some students find it difficult to express themselves:

“I think it will really benefit us to have maybe one semester or even a first year to have a different language that you can learn…”

“So it is much better for you to actually write something that to send in your request anonymously, to say ‘Ma’am, this is what I request’”.

Participants recommended that apart from teaching and learning activities, there should be opportunities to release stress, as a way to cope with the transition from basic to higher education. Opportunities suggested by the participants were a sports day for nursing students, being afforded an opportunity to enjoy recess, and periodic team-building events where they can meet with nursing students from other universities. They expressed that these opportunities would allow them to socialize and strengthen their coping mechanisms:

“I don’t know if it’s late or what, like maybe like a trip somewhere, like for a weekend. Get to meet like professional nurses. Like so that we can meet with other first-year nurses from maybe other universities, so that we meet and talk, some motivation.”

“There should be a sports day for nursing students where they go and play basketball and netball, football.”

The participants showed the need for viable coping strategies owing to the challenges they face during the transition from basic to higher education. They argued that the orientation period that is meant to smooth their transition from basic to higher education is not content-specific to the needs of undergraduate first-year nursing students. This was in contradiction with Rossato et al., [2]whose findings indicated that welcoming activities help students to adapt to the nursing course in their first year. The findings revealed six strategies that the participants use to cope with the transition from basic to higher education: adaptive coping strategies, appraisal-focused coping strategies, emotion-focused coping strategies, problem-focused coping strategies, social coping strategies, and seeking help from mentors. In their study, Andrew et al. [16] stressed that high-quality mentoring and breaks in between theory and clinical placement improves students’ ability to cope with the transition to higher education. Furthermore, a study conducted by Monisha et al. [17] reported that good psychological and behavioural coping strategies are essential in improving the transition from basic to higher education, thus confirming the findings of the current study. However, a study conducted by Bodys-Cupak et al. [4] found that in addition to the coping strategies identified in this study, some students use destructive coping strategies such as the use of psychoactive substances. In this study issues related to psychoactive substances were not mentioned among the coping strategies.

The findings support a call for contextual structured support for undergraduate first- year nursing students that will help to smooth their transition from basic to higher education. It is argued that the coping strategies mentioned here should be incorporated into the orientation program to improve the resilience of undergraduate first-year nursing students during their transition from basic to higher education.

The findings of this study showed that there is a need to strengthen academic support and informational support by means of contextual orientation programs, psychological support, and support from mentors, to improve undergraduate nursing students’ transition from basic to higher education. In addition to the aforementioned recommendations, participants indicated that there is also a need for external support by alleviating the nursing program so that they can also be integrated into the university activities. They explained that the current structure of the program is very busy and does not allow them adequate time to plan their academic activities, let alone be able to socialize. Consistent with the recommendations in this study, Andrew et al. [16] found that undergraduate first-year nursing students who have additional mentorship and informational support in online resources transition better to higher education from basic education.