The two-week integrated nursing practicum at Nursing University A is carried out from July to August of students’ fourth year after they have completed the practicum for their specialization. The integrated nursing practicum consists of classroom lectures and clinical practicums that aim to teach students about clinical judgment, decision making, and problem-solving strategies when faced with multiple tasks. This is done by taking responsibility for multiple patients and participant observation of team leaders and team members to foster understanding of the role of the nursing profession and clinical lecture.

Study subjects were85students enrolled at Nursing University A for the 2019 school year and planned to take the integrated nursing practicum. Anonymous questionnaire surveys were administered at the orientation carried out before and after completion of the practicum. The study period was from July to August 2019.

The survey was conducted using an anonymous, self-administered questionnaire. A summary of the study was explained to students both orally and in writing following the orientation carried out before beginning the integrated nursing practicum. Questionnaires were distributed to all class members, and consent was provided by checking the “I consent” column on the questionnaire form. After all students had completed the questionnaire, the forms were placed into sealed envelopes to prevent accidental disclosure of responses and deposited into a collection box. Anonymous questionnaire surveys were conducted twice for comparison before and after the practicum.

The survey comprised items on 1) basic attributes, 2) resilience factors, and 3) stress coping behaviors.

1) Basic attributes

Questions included age, sex, whether the student had a part-time job, and subjective health. Subjective health was answered on a five-point scale (“good”, “okay”, “normal”, “not very good”, and “not good”).

2) Resilience factors

Resilience factors were measured using the Bidimensional Resilience Scale (BRS), a scale capable of measuring factors related to resilience as a human behavioral trait. The BRS was developed by Hirano (2010) and has been confirmed to be both reliable and valid [12]. The scale comprises 21 questions on a five-point scale from one (“completely disagree”) to five (“completely agree”). A higher resilience factor score indicates higher resilience. BRS includes two subscales: innate and acquired factors (α = 0.72 - 0.83). Innate factors include “optimism”, “control”, “sociability”, and “vitality”; acquired factors include “attempting to solve a problem”, “self-understanding”, and “understanding others” for a bidimensional structure with a total of seven subfactors. In the context of this scale, innate resilience factors refer to resilience in which one can positively conquer a stressful or hurtful situation without being emotionally swayed by it by switching to a new goal and accomplishing it with the support of others. In contrast, acquired resilience factors refer to the ability to recover through a grasp of one’s own thoughts and feelings by having the determination to consider how one would like to improve a stressful situation and reach an understanding of the situation by deepening one’s understanding of oneself and others.

3) Stress coping behaviors

The Brief Scales for Coping Profile (BSCP), designed for workers, was used to evaluate stress coping behaviors. BSCP was developed by Kageyama and Kobayashi (2017) and has been confirmed to be both reliable and valid [13]. BSCP, capable of measuring stress coping behaviors, consists of six subscales: “active solution”, “seeking help for solution”, “changing mood”, “emotional expression involving others”, “changing point of view”, and “avoidance and suppression”. “Active solution” refers to striving on one’s own to solve the problem. “Seeking help for solution” refers to enlisting the help of others to solve the problem. “Changing mood” refers to doing something different to alleviate one’s own uncomfortable feelings, such as anxiety or irritation. “Changing point of view” refers to looking at a situation with a different perspective, way of thinking, or values to discover positives about the problem or clearly identify things that cannot be changed as pointless to think about further. “Emotional expression involving others” refers to emotionally focused coping behaviors in which one vents or gets someone to listen to one’s uncomfortable feelings. “Avoidance and suppression” refers to suffering through or postponing, and as a result, doing nothing. The total score on the BSCP ranges from 18 to 72 points with each sub-concept having three items, which together yield from 3 to 12 points. In all cases, a higher score indicates greater use of stress coping behaviors.

Returned questionnaire forms excluding those for which the “I consent” box was not checked or which were less than 80% complete were considered valid responses.

To begin, the Wilcoxon signed rank test was used to determine the amount of change in resilience factors from the surveys before and after the practicum. Next, using Spearman’s rank correlation coefficient analysis to investigate how resilience factors and stress coping behaviors before and after the practicum were related. Subsequently, multiple regression analysis was carried out with the stress coping behaviors that were significantly associated with resilience factors as the independent variable and the amount of change in resilience factors before and after the practicum as the dependent variables. After accounting for the impact of multicollinearity, stepwise regression was used to identify independent variables capable of predicting changes in resilience before and after the practicum. Furthermore, pre-practicum resilience level was input as a predictor in multiple regression analysis, as it was thought to be correlated as a factor impacting the amount of change in resilience before and after the practicum. The normality of each distribution was verified using the Shapiro-Wilk test of normality before testing.

Statistical processing was performed using the statistical analysis package SPSS Ver. 26. The significance level was p < 0.05.

To ensure that respondents could not be identified, the pre- and post-practicum survey forms were marked with matching numbers, but did not include names. Consent to the study was provided by checking the “I consent” column on the survey form. Study participation was voluntary, and it was ensured that nonparticipation or non-completion would have no impact on the class grade. The survey form followed ethical guidelines for medical research on human subjects and methods for protection of personal information. Collected data were statistically processed, stored, and securely destroyed after analysis was completed. Participants were informed that after the survey form was submitted, data could not be deleted even if they withdrew consent. Participants were also assured that information obtained from the survey would not be used for purposes outside of this research, that any findings would be published only as aggregated results, and neither the name of the nursing students nor the school would be disclosed. Lastly, participants were informed that the analysis results were intended to be used to benefit society through presentation at academic conferences and publications in academic journals and online.

This study was carried out after undergoing ethical review and receiving approval from the ethics committee of the Nagano College of Nursing (Approval No. 2019-6). There are no conflicts of interest to disclose.

A total of 56 responses were received (response rate 65.8%) from the 85 survey subjects. All 56 responses received were valid (valid response rate, 100%).

The mean age of the participants was 21.7 years. Five subjects (8.9%) were male and 51 (91.1%) were female. Forty-eight students (86.7%) were working part-time jobs. Forty-nine students (87.5%) perceived their subjective health as “good” or “okay.”

Innate resilience factors increased significantly from 41 pre-practicums to 44 post-practicums. Acquired resilience factors also increased significantly from 32 pre-practicums to 35 post-practicums (p < 0.01) (Table 1).

Spearman’s rank correlation coefficient was used to determine which practicum stress factors and stress coping behaviors were associated with resilience factors before and after the clinical practicum. The association with pre-practicum resilience level was also analyzed as pre-practicum resilience level was found to impact the amount of change in resilience. These analyses found that the stress coping behaviors of “active solution” (r = 0.266, p < 0.05) and “changing point of view” (r = 0.398, p < 0.01) demonstrated significant relationships with the amount of change in innate resilience before and after the practicum (Table 2). Meanwhile, no significant relationships were found between stress coping behaviors and the amount of change in acquired resilience (Table 3). Next, multiple regression analysis was performed with stress coping behaviors found to have a significant relationship through Spearman’s rank correlation coefficient (“active solution” and “changing point of view”) and pre-practicum innate resilience

Wilcoxon signed rank test.

Spearman’s rank correlation coefficient **p < 0.01; *p < 0.05.

Spearman’s rank correlation coefficient **p < 0.01; *p < 0.05.

factors as independent variables and the amount of change in innate resilience before and after the practicum as the dependent variable. These analyses found that the stress coping behavior of “changing point of view” (β = 0.361, p < 0.01) and pre-practicum innate resilience factors (β = −0.456, p < 0.01) were significantly associated with innate resilience factors (Table 4).