Assessing Stressors and Coping Mechanisms of International Nursing Students in the Country of Georgia

International nursing students in the country of Georgia face many stressors beyond native Georgians in the same context. These students who have chosen to move to a new country where they do not speak the language, have different food and climate and even look very differently than the local population have developed different coping mechanisms that are both effective and not effective. This descriptive study provides a basic assessment of stressors and coping mechanisms currently being experienced by this international community.

Studying at university is a rite of passage for many young adults.It forces a transition from dependency to independence by challenging them academically and promoting autonomy as the student moves out from under their parent's authority.It is common knowledge that university students are required to work hard to succeed to achieve their diploma as well as grow as individual adults.In many instances, students move from their parent's home and direct care to another city, a dorm, or another country.Students must learn to cook, clean, manage money while developing new social groups and being engaged in a higher standard of achievement.
Students studying outside of their native country and culture are faced with many challenges that those who study within their own culture are not faced with for the most part.These stressors include language barriers, different climate, different food, living with nonfamily members, and often without a family support system in country (Amos &Lordly, 2014;Hamboyan & Bryan, 1995).Students may also experience homesickness that leads to depression, anxiety, and withdrawal behaviors (Kovatz, Kutz, Rubin, Dekel, & Shenkman, 2006;Thurber & Walton, 2012).All of these stressors regardless of expected or not, can lead to loneliness, depression, misunderstanding, mistrust and academic inadequacy and have been documented to affect most university students regardless of the major that they have chosen (Shaikh & Deschamps, 2006, Thurber & Walton, 2012).Students may experience racial discrimination and prejudice that leads to conflict between majority and minority groups and increasing severity of homesickness (Shaikh & Deschamps, 2006;Thurber & Walton, 2012).These different attributes can be explained through the concept of perceived and actual acculturation stress.Acculturation is apparent when a person gives up traits of their own culture of origin when coming in contact repeatedly with another culture.There are varying degrees to this and it is not absolute (Purnell, 2013).Acculturation can lead both to culture stress and shock as well as assimilation, characteristics and gradual adoption of the prevailing culture, and enculturation, natural conscious and unconscious conditioning processes of learning accepted cultural aspects and achieving competence in one's culture through socialization (Purnell, 2013).The ability of one to have minimal culture stress and shock and facilitate a smooth transition to cultural acceptance and enculturation is a delicate process that involves repeated assessment, implementation and evaluation of all those involved (Ruddock & Turner, 2007).
Since the fall of the Soviet Union, a growing trend has occurred for students to travel and study overseas in Eastern European countries especially for the medical professions.Georgia, a former part of the Soviet Union, has a growing international student community, especially in Tbilisi, the capital.This international community is largely made up of Indians, Middle Easterners and West Africans.Georgia's population of close to 4.5 million people is approximately 85% Caucasian ethnicity (native inhabitances of the Caucasus Region).(Gamkrelidze et al, 2014) and therefore is homogenous in appearance and culture and has limited exposure to people from different regions of the world.Minimal exposure leads to limited cultural competency since skilled cultural competency comes from repeated exposure to other cultures (Kumas-Tan, Beagan, Loppie, Macleod, & Frank, 2007).Only a few universities accept international students in Georgia and only one accepts international students for nursing.In addition, to cultural bias and conflict, nursing only recently was declared a profession in Georgia (Wold, Crawford & Jashi, 2013).Nursing up until this time was considered a technical diploma that one could achieve after their first year in medical school (Wold et al., 2013) rather than a separate profession as recognized by many international organizations (International Council of Nurses, 2011).This ignorance has further contributed to the isolation of international nursing students.In Georgia, there are currently 1.6 physicians per 100,000 compared to 1 nurse (per 100,000) (Gamkrelidze et al., 2014).One university in Georgia started the first international Baccalaureate nursing program for the country in 2012.There are currently less than 40 international students from Nigeria and Chile studying nursing in Georgia.
In order to develop a culturally competent community within this university, a general assessment of common stressors as well as coping skills needs to be collected from these students.No literature exists for studying and assessing the international nursing student situation in Georgia.The purpose of this descriptive study is to assess different coping mechanisms and stressors of international nursing students in Georgia.This study will be the first of many used to assess and implement a more culturally competent university environment.

Participants
First and third year nursing students from Nigeria (31 students) and Chile (1 student) were surveyed to assess different possible stressors that they had experienced and coping skill they used while in Georgia.Student ages range from 18 years old to 30 years old.Each of the students received an email as well as verbal reminders to attend of one of two meetings during the first week of November, 2014.These meetings occurred in week nine of a 17week semester that was also the week following midterm exams.Each participant signed a consent waiver allowing their survey to be used.The survey was approved by the Dean of the School of Health Sciences and Public Health.

Procedure
A descriptive survey of 39 questions was developed to assess different stressors and coping skills.Thirty-five questions were measured on a five point Likert scale ranging from least likely/never to most likely/always and covered six different topics (school, health/coping mechanisms, family/support system, culture, spiritual aspects and general stress levels/ perception of current situation) and.The final four questions consisted of two closed and two open questions.Thirty one surveys were distributed.In order to maintain anonymity each survey specifically stated that the participant to not put their name on the survey.In addition, surveys were collected by one student representative at each meeting and then turned collectively for analysis.

Results
Twenty-nine surveys were collected.One survey was not returned and one student did not give consent for their data to be used.Of those participants eight were male, 18 were female and three did not specify gender.The average age of all the participants was 23 years-old.The students' ethnicity was not collected since only one student was not Nigerian.
Results for school topic showed that 55% felt as though they are able to communicate effectively with their teachers regarding questions or problems they had (Figure 1).In addition, 55% of students feel like their lectures and readings for class prepare them for the exams.Only 35% stated that they study three hours or more a day outside of class.Almost 60% felt like the environment provided by the university was conducive to the learning process.
When asked about health habits and coping mechanisms, less than 10% said that they smoked cigarettes/ cigars less than five days a week and less than 15% drink more than two alcoholic beverages in a week.Most of the positive health habits measured were practiced by less than 25% of the population; eat five fruits and vegetables a day (10%), exercising five times or more a week for at least 30 minutes each time (21%), more than seven hours of sleep a night (21%).Students' current health status over the past two months noted having symptoms of cold/ flu (52%), feeling more tired (52%), feelings of hopelessness and despair (41%) and abdominal discomfort (38%).Only 62% said that they mostly or always had enough money to buy food and pay for housing with 41% saying that they mostly or always felt they were able to relax in their living situation.Only 10 percent had financial worries.).Even with all of these health stressors, 57% said that they mostly or always are able to think logically and process potential consequences.
Family and other support systems (such as friends, pets and spiritual habits) were also measured.Only 90% had been in contact with their family that week (93%) and 86% believe that their family is happy with their performance in school.Only two students own or come in contact with pets regularly and 38% said that they had friends and a support system to mostly or always help them deal with stressful situations in Georgia.Over 90% are either indifferent or longing to be home with their family and friends at the time of this survey.Sixty-two percent of the students mostly or always attend a religious service at least once a week and 70% pray at least once a week.
When asked specific questions regarding Georgian regulations and culture, over 50% of students stated they have had some level of visa problems, and that cultural and psychological stressors affect them daily.As many as 59% of the students state that they have felt uncomfortable with strangers calling them names, staring uncomfortably or even an unwelcome touch of something on their person in the past weeks.Less than 50% of the students polled felt mostly or completely in control of their environment with only 59% feeling in control of their life at the moment of the survey.About 50% of the students feel more stressed in November, 2014, than they did in September, 2014 while 60% felt more stressed the week of the survey than the midterm week before (Figure 2).Finally, 59% of students felt happy about the decisions they made in the prior two weeks to the survey according to the Likert scale questions.
Two closed questions were asked regarding if the students had considered harming themselves or others in the last two months and if they would like to talk with someone professionally regarding the stress they are experiencing in Georgia.Only two people stated that they had considered harming themselves or others.Out of 29 people, nine (seven females, one male, and one participant who did not answer the gender question) stated that they would like to talk with a professional and two (one male and one female) stated they were not sure if they wanted to or not.
The two open questions inquired about the top three different stressors in each person's life and top three ways that each person deals with stress (Figure 3).The top stressor identified was school studies/ academic work.This was followed by personal emotional/mental issues that they did not specify and the weather in Georgia.Eight people did not list any stressors.The top three ways that students deal with stress were sleeping, praying, and singing or listening to music respectfully.Only three people identified talking with their family as a stress reliever.Five people did not remark.

Discussion
It is a given that university students will have stress and need to learn to cope in new and changing situations (Kovatz et al. 2006).At this university, this cohort of students is part of a larger group of international students with other majors besides nursing that started in spring, 2014.These are the first international students at this university.These nursing students not only are learning to adapt to a completely different culture, they are being asked to perform where there are no current professional role models in clinical settings at their same educational level.This is the only BSN program in the country that is set to Bologna process standards in the European Union.These students only have one professor who was trained and worked in a developed country.While the other professors are exceptional teachers, they are teaching topics that they may have never seen in practice.These professors are all native Georgians and not native English speakers with one exception and may explain why the percentage of students who are comfortable in communicating with their professors and mentors and why they feel they are adequately prepared for the exams are both not higher than 55%.However since only one third of the students study three hours or more a day, the responsibility for exam preparation cannot be fully placed on professors.
In addition, international students have a higher incidence of physical ailments than previously stated in the literature for other students (Bhandari, 2012).However, nursing students who have been educated on the importance of proper health habits are not applying this knowledge as demonstrated by the less than 25% eating, sleeping and exercising at commonly accepted recommendations.With the added stress in general of being in a different culture, students are in need of making sure that they are actively practicing positive health habits (Chou, Chao, Yang, Yeh, & Lee, 2011).These students come from low smoking and alcoholic intake cultures, which do not add any negative health habits.This could also be due to their religious beliefs regarding these items since over 60 percent participate regularly in a religious congregation.
It is important to note that over 90% are longing to be home with their family as well as communicating regularly with their loved ones and yet over 60% have not either had time or ability to develop a strong support system in Georgia.This could be due to the significant cultural barriers (language, food, weather, etc.) between Nigeria, Chile and Georgia.The lack of a local support system could also be a cause of the high percentage of these students affected by cultural stress daily (Pantelidou & Craig, 2006).Inappropriate behavior by native Georgians, who may have never seen a person that has different hair and skin tone than ethnic Georgians, may also contribute to cultural stress.Culture stress can also lead to the feeling of lack of control both of their personal belongings and on a governmental level regarding visa regulations that has a reputation of limited English and confusing regulations.
At the time of the survey, the majority of students remarked that they were happy with decisions that they had made in the previous two weeks and yet 60% were more stressed the week after midterm exams than they were even a month prior.Four students identified the actual task of taking of midterms themselves as one of the three main stressors.More information is needs to be explored why these stress levels are increasing rather than decreasing after a midterm test.

Limitations
This study was a basic descriptive study used to gather initial information.Each question needs to be reanalyzed in order to decrease confusion and bias.A few questions had multiple points that might have been confusing for the reader.One question had to be thrown out because it was missing the Likert scale and a third question was generally ambiguous.Before this questionnaire can be administered again, there should be revisions to ensure reliability of the answers.
The sample size is also small.Unfortunately this convenience sample is not larger.Other international students with other majors and from other countries exist in Tbilisi and would be invaluable to helping understand international students studying in Georgia as well as where universities can improve their cultural competence.
Finally, this survey did not produce any interventions for some of the data gathered, ie.Harm to self or others.This also did not explain why someone was stressed regarding school or having physical ailments.It will be important to spend more time on each section, and explore more cause and effect reasoning to some of the questions.Focus groups with these nursing students will greatly improve the depth and understanding of exactly which stresses these students have and why.Once those areas are explored more, then interventions via education and culturally sensitive events can be administered.This is the first survey in Georgia for international students with many others to follow.