INTRODUCTION:

According to WHO, health is a state of complete physical, mental, and social well- being and not merely the absence of disease or infirmity. Adolescence is the phase of life between childhood and adulthood, from ages 10 to 19. It is a unique stage of human development and an important time for laying the foundations of good health. Adolescents experience rapid physical, cognitive and psychosocial growth making them more prone to stress¹.

The term “stress” as it is currently used was coined by Hans Selye in 1936, who defined it as “the non-specific response of the body to any demand for change”. The situations and pressures that cause stress are known as stressors. We usually think of stressors as being negative, such as an exhausting work schedule or a rockyrelationship. However, anything that puts high demands on you can be stressful. This includes positive events such as getting married, buying a house, going to college, or receiving a promotion. Of course, not all stress is caused by external factors. Stress canalso be internal or self-generated, when you worry excessively about something that may or may not happen, or have irrational, pessimistic thoughts about life².

Based on National Mental Health Association report, the results of the recent studies conducted in London Wolfson Health Sciences Institute show that 46% of male students and 64% of female students suffer from anxiety while 12% of male students and 15% of female students suffer from depression. The counselors in the above-mentioned institute reported an increase in students’ referrals to counseling centers from 2.4 out of 100,000 students in the year 1995 to 9.7 out of 100,000 in the year 2000³.

It is important for the academic to maintain well balanced academic environment for better learning. Academic stressors are related to Institutions studying for university examinations, completion of assignments and seminars, parental pressureand above all large amount of content to master within a limited time. As per the study conducted by National Institute of Mental Health and Neuroscience (NIMHANS) about the growing number of suicides in India among school and college going students, 11% of college students and 7 to 8% of high school students have attempted suicide because of stress. Depression, anxiety, behavioral problems, irritability are few of the many problems reported in students with high academic stress⁴.

Laughter is a complex emotional response to one’s environment, situation, and stimuli. Studied for many years, it was not generally perceived to have any particular healing effect until 1979, when Norman Cousins published As Anatomy of an Illness. Since that time, interest in laughter as a potential therapeutic option has grown, both in popular culture as well as in scientific research⁵.

NEED FOR THE STUDY:

Nursing profession is a disciplined profession involved in the delivery of health to the society also it is helping profession, service oriented to maintain health and well- being of people, an art and science. But the nursing profession comes with stress both mentally and physically because of its fast- paced and emotional nature. Nursing colleges are now recognized as a stressful environment that often exerts a positive effect on the academic performances and psychological well-being of students. The life of a student may be affected by different stressors in both the internal and external environment. Although people from all walks of life experience stress on daily basis, students are more likely to experience stressful situations because of their academic requirements⁶.

Academic sources of stress are examination, long hours of study assignments, grade, lack of free time, lack of timely feedback after their performance, special elements of the academic program like arrangement and conduction of workshop. Clinical sources of stress are like taking care of ill patients, inter personals conflicts with peer group, insecurity about personal clinical competence fear to complete clinical requirement, dealing with uncooperative patients, work load, prolonged standing learning psycho-motor skills e.g.-handling unconscious patients, bed bath and vital signs monitoring have also been associated with high level of stress. The reaction of parents and friends to the results weigh upon the student to create exam stress, lack of interest to study and inability to follow the professor cause disinterest in attending classes⁷.

In the recent years, there is a growing appreciation of the stresses involved in nursing students. Nursing students suffer from high level of stress related to introduction of new study subjects, increased academic assignments and clinical skill training. It is important for nursing educators and students to know the prevalence of academic stressamong nursing students⁸.

A cross sectional descriptive study conducted to assess the perceived stress among nursing students at Maharishi Markandeshwara University, Mullana. The study included 400 of students who were currently studying in the college of nursing. Out of total 400 students, 282 completed and returned the questionnaire. Out of this majority (39.7%) were experiencing high level of stress, 23.7% moderate stress and 28.4% mild stress⁹.

A cross-sectional study conducted to assess the perceived stress and source of stress among undergraduate medical students in Mysore Medical College. Study included 303 samples selected by simple random sampling technique. Data was collected by using Perceived stress scale and Stressor questionnaire was used to assess the source of stress. The study results shows that 51.5% were male and 48.5% were females. The prevalence of mild, moderate and severe stress was 20%, 74% and 6% respectively¹⁰.

Stress is a double-edged sword that can either stimulate and motivate students to peak performance or reduce students to ineffectiveness. Therefore, it is of urgent need to identify stressors among nursing students and manage them appropriately¹¹.

The review of literature of the present study is organized and presented under the following heading:

1. Studies related to assess the incidence and prevalence of academic stress among nursing students

2. Studies related to assess the effectiveness of laughter on academic stress.

1. Studies related to assess the incidence and prevalence of academic stress among nursing students:

A Non-Experimental Exploratory study was carried out to assess the academic stress and coping strategies used among the undergraduate nursing students from selected colleges of Pune city. Data was collected from 60 undergraduate nursing students selected by non- Probability purposive sampling technique. Data was collected using Academic Stress Scale. The descriptive and inferential statistics were used for data analysis. The result of the study revealed that majority of 53.33% of students had moderate stress (99-147), 31.67% of them had slight stress (50-98) and 15% of them had high stress (148-196)¹².

A non-experimental descriptive study was conducted to assess the academic stress among nursing students in Sri Ramachandra Institute of higher education and research. Study included 75 students from III-year B.Sc. nursing students selected by purposive sampling technique. Academic stress scale and questionnaires were used to collect data. Study revealed that majority 58(77.3%) had severe level of academic stress, and 17(22.7%) of them had moderate level of stress in relation to personal inadequacy; regarding fear of failure, majority 64 (85.3%) of them had moderate level of stress and 10 (13.3%) of them had severe stress and only one (1.03%) person had mild level of stress. The present study concludes that majority of the students studying in 3rd year had moderate level of academic stress¹³.

A descriptive study was conducted in the Faculty of Nursing, Alexandria University to assess the academic stress and its contributing factors among 600 baccalaureate nursing students selected by using the equal allocation method. Data structured interview and Perceived Stress Scale (PSS) were used for data collection. Data was analysed using SPSS version 20. The study showed that more than three quarters (79.7%) of the students had high academic stress level and the rest (20.3%) of them had moderate academic stress. The findings of the present study revealed that academic stress is a prevalent problem among nursing students as all nursing students experienced moderate and high stress level¹⁴.

A cross sectional study was conducted regarding the stress among undergraduate nursing students of Lucknow city and determine the risk factors causing stress among 380 B.Sc nursing students selected by simple random sampling method. Data was collected by using semi structured questionnaire and DASS 42 scale. Data was analysed through SPSS, version 23.0. Study findings revealed that 60% of total nursing student from government college were stressed with majority of the students (23.0%) were having moderate stress, 62.0% of students from private nursing college were stressed with majority of the students (27.6%) were having moderate stress and 1.0% had extremely severe stress¹⁷.

A cross sectional study was conducted to assess the psychological morbidity, sources of stress and coping strategies among undergraduate medical students of Manipal college of medical science, Pokhara, Nepal. 525 samples were selected using survey method. A 24-item questionnaire was used to assess sources of stress and their severity. The coping strategies adopted was assessed using brief COPE inventory and psychological morbidity was assessed using general health questionnaire. The study showed that the overall prevalence of psychological stress was 20.9% and was higher among students of basic sciences, Indian nationality and whose parents were medical doctors. The study concluded the most common sources of stress were related to academic and psychosocial concerns¹⁸.

OBJECTIVES:

The following are the objectives of the study:

1. To assess the pre-existing level of academic stress among the nursing students.

2. To evaluate the effectiveness of laughter on academic stress among nursing students.

3. To determine the association between the level of pre-test academic stress scores with their selected demographic variables.

OPERATIONAL DEFINITIONS:

1. Assess: In this study, it refers to the information gathered through rating scale to monitor level of academic stress among nursing students.

2. Effectiveness: In this study, it refers to the expected outcome of videos of laughter and demonstration of laughter techniques on reducing academic stress among nursing students.

3. Stress: In this study, stress is the arousal response to any demand or change experienced by the nursing students within the environment.

4. Laughter: In this study, it refers to the laugh to relieve stress, to improve emotional well- being in order to facilitate improvement in health, as it reduces stress hormones like adrenaline and epinephrine.

ASSUMPTIONS:

Assumptions of the study are:

· Nursing students are at high risk of academic stress.

· Nursing students may have some knowledge regarding the academic stress.

· Nursing students may not have adequate knowledge regarding stress reduction techniques.

· Nursing students are interested to learn laughter techniques.

· After administering laughter, the level of academic stress among nursing students will be reduced.

DELIMITATIONS:

The study is delimitated to:

a) The B.Sc. Nursing students from selected nursing institutions in Mysuru.

b) The age group within 18- 23 years.

PROJECTED OUTCOMES:

The study will help to reduce the academic stress among nursing students with the effective use of laughter techniques by watching laughter videos and demonstration.

HYPOTHESES:

The following hypotheses are formulated for the study.

^H1^:^{There will be a significant difference
between the level of pre-test and post-test academic}stress scores among nursing students.

^H2: ^{There will be significant association
between the levels of pre-test academic stress scores}among nursing students with their selected demographic variable

METHODOLOGY:

RESEARCH APPROACH:

An evaluative approach is used in this study. The main aim of the study was to assess the effectiveness of laughter on academic stress among nursing students in selected nursing institution at Mysuru.

RESEARCH DESIGN:

The investigator used pre-experimental design (one group pre-test & post-test) for this study. There was a manipulation for the subjects without a control group and Randomization.

Description of the pre-experimental study design:

Group	Pre-test	Intervention	Post-test
Study group	O1	X	O2

Notes:

O1 - Level of academic stress before administering video-assisted laughter and demonstration

X - Administration of video-assisted laughter and demonstration

O2 - Level of academic stress after administering video-assisted laughter and demonstration

VARIABLES OF THE STUDY:

The variables of the study were:

a) Independent Variable : Laughter

b) Dependent Variable : Academic stress

c) Selected Demographic Variables : Age, gender, have you attended any stress reduction programme, habits

d) Extraneous Variables : Mass media, peer group, knowledge about laughter

SETTING OF THE STUDY:

Setting is a physical location and condition in which data collection takes place. The present study was conducted in JSS College of Nursing in Mysuru District.

POPULATION OF THE STUDY:

Population is the entire aggregation of cases in which the researcher is interested.”

In the present study, population comprises of B.Sc. Nursing students in selected nursing institutions at Mysuru.

SAMPLE AND SAMPLING:

“A sample is a subset of population selected to participate in a study.”

The sample of present study comprised of first year B.Sc nursing students of JSS College of Nursing, Mysuru aged between 18-23 years. In the present study, 60 nursing students were selected.

SAMPLING TECHNIQUE:

“Sampling is the process of selecting a portion of the population to represent the entire population.”

Non-probability purposive sampling technique was used for the selection of the sample in this study.

SAMPLING CRITERIA:

Inclusion criteria:

a) Who were available during data collection.

b) Age group within 18- 23years.

c) Who were currently studying in 1^st year BSc Nursing.

d) Who were interested to participate in the study

Exclusion criteria:

a) Those who are not willing to participate in the study.

b) Those who were not available during data collection.

DATA COLLECTION TECHNIQUES AND INSTRUMENTS:

Selection and development of data collection tool:

A Modified Perceived Academic Stress Scale was prepared to collect the data to achieve the objectives of the study based on review of literature and consultation with experts. A thorough review of literature from journals, articles, published and unpublished research studies help the researcher to develop the tool.

The data collection tool in the study consisted of two parts.

PART A:

It consists of selected demographic variables of participants.

PART B:

It consists of a Modified Perceived Academic Stress Scale to assess the level of academic stress among nursing students.

DESCRIPTION OF THE TOOL:

Demographic variables:

The demographic variables were used to collect the sample characteristics like age, gender, year of study, have you attended any stress reduction programme and habits.

Modified Perceived Academic Stress Scale to assess the level of academic stress among nursing students:

A Modified Perceived Academic Stress Scale was developed to assess the level of academic stress of nursing students. Extensive literature was reviewed in the area of academic stress. A blue print was prepared with content areas divided under academic, clinical and personal stressors. The stress scale consists of 40 items in total. There were five alternative Reponses from which the participants had to choose and tell one best response. The five responses were strongly agree, agree, neutral, disagree and strongly disagree.

From 40 items, 31 positive statements were scored as, 5 score for strongly agree, 4 score for agree, 3 score for neutral, 2 score for disagree and 1 score for strongly disagree. The remaining 9 statements were considered negative and scored as 5 score for strongly disagree, 4 score for disagree, 3 score for neutral, 2 score for agree and 1 score for strongly agree. The total stress level ranged from 40-200. In order to categorize, the stress level was arbitrarily divided into mild stress (40-100), moderate stress (101-150) and severe stress (151-200).

Content validity:

The modified perceived academic stress scale was submitted to 5 experts from nursing field and were requested to give their opinions and suggestions regarding the items. There was 100% agreement by all experts. However, there were a few suggestions to modify some items and they were incorporated in the final draft.

RELIABILITY:

The coefficient of correlation for modified perceived academic stress scale was 0.993. Hence the tool was found reliable.

PILOT STUDY:

Pilot study is the small-scale trail run, one in preparation of the main study. The setting selected for the pilot study was St. Alphonsa College of Nursing, Mysuru. The study was conducted from 29-11-22 to 06-12-22 after taking permission from the concerned authorities. 6 samples were selected by non-probability purposive sampling technique. The data was collected by administering personal proforma and modified perceived academic stress scale to assess the level of academic stress among the nursing students. The purpose of pilot study was to test the data collection instrument, to find the feasibility of conducting the study and to decide upon the statistical analysis.

DATA COLLECTION PROCEDURE:

Formal administrative permission was obtained from the Principal of JSS College of Nursing, Mysuru prior to the data collection. 60 samples from 1^st year B. Sc Nursing were selected using non-probability purposive sampling technique. Informed consent was obtained from the subjects and were explained about the usefulness of the study. The data was collected by administering personal proforma and modified perceived academic stress scale to assess the level of academic stress among the nursing students. The pre-test was administered on 07/12/22 and video-assisted laughter and demonstration was given to the samples for 30 minutes for 7 consecutive days. On the 8^th day, the same tool was readministered to the same samples and the data was collected. Data collection process was terminated by thanking the respondents for their co-operation.

PLAN FOR DATA ANALYSIS:

Data analysis is a systematic organization and synthesis of research data and testing of research hypotheses using those data. Data analysis consists of examining, categorizing, tabulating or otherwise re-combining the evidence to address initial proposition of the study. Data obtained would be coded and edited into a master sheet. It was planned to use descriptive and inferential statistics for data analysis.

DESCRIPTIVE STATISTICS:

1. Frequency and percentage will be used to analyze the selected demographic variables of nursing students in selected nursing institutions at Mysuru.

2. Mean, Median and Standard deviation will be used to analyze the level of pre-test and post- test academic stress scores among nursing students in selected nursing institutions at Mysuru.

INFERENTIAL STATISTICS:

1. Paired ‘t’ test will be used to determine the effectiveness of video assisted laughter on level of academic stress among nursing students in selected nursing institutions at Mysuru.

2. Chi square test is used to determine the association between the level of pre-test academic stress scores among nursing students with their seected demographic variable.

RESULTS:

ORGANIZATION OF FINDINGS:

The collected data was entered to a master sheet, analyzed using descriptive and inferential statistics and the findings are presented under the following headings.

Section 1: Description of selected demographic variables of the nursing students.

· Frequency and percentage distribution of nursing students according to their selected demographic variables.

Section 2: Effectiveness of laughter on academic stress among nursing students

· Frequency and percentage distribution of level of pre-test and post-test academic stress scores among nursing students.

· Mean, median, range and standard deviation of level of pre-test and post-test academic stress scores.

· Significance of difference between the level of pre-test and post-test academic stress scores among nursing students.

Section 3: Association between the level of pre-test academic stress scores with their selected demographic variables

SECTION – 1

Table – 1 Frequency and percentage distribution of nursing students according to their selected demographic variables n = 60

Sample Characteristics	Frequency (f)	Percentage (%)
_1.Age in years 1.1) 18-20	48	80
1.2) 21-23	12	20
2. Gender 2.1) Male	12	20
2.2) Female	48	80
3. Habits 3.1) Reading	13	21.66
3.2) Yoga and others	47	78.33
_4.Have you attended any Stress reduction programme
4.1) Yes	3	5
4.2) No	57	95

The data in table-1 shows distribution of nursing students according to their Age, Gender, have you attended any Stress Reduction Programme and Habits.

1. AGE:

Data presented in table-1 reveals that 80% (48) of nursing students were in the age group between 18 to 20 years and 20% (12) were 21 to 23 years of age.

Fig-2: Frequency and percentage distribution of nursing students according to their age

Table- 2 shows that in pre-test, majority 50% of them have moderate stress , 33.34% have severe stress and 16.66% of them have mild stress where as in the post-test, 66.68% of them have moderate stress and 16.66% of them have severe stress and 16.66% of them have mild stress.

COMPARISON OF LEVEL OF PRE-TEST AND POST-TEST ACADEMIC STRESS S CORES:

Significance of difference between level of pre-test and post-test academic stress scores among nursing students.

In order to find out the significance of difference between the level of pre-test and post-test academic stress scores , paired ‘t’ test was computed. The data are represented in the table-4. To test the statistical significance following null hypothesis was stated.

^Ho1^:^{There will be no significant difference between the
level of pre-test and post-test}academic stress scores among nursing students who has undergone video- assisted laughter and demonstration.

Table – 3 Mean, median, range, standard deviation of level of pre-test and post-test academic stress scores n = 60

TEST	MEAN	MEDIAN	RANGE	SD
Pre – test	131.8	139	71-168	26.2
Post – test	124.63	126.5	70-168	24.17

Data presented in table-3 shows that the pre-test academic stress scores ranged from 7-168. The mean pre-test academic stress score is 131.8 with a standard deviation of ±26.20. The median score is 139. The post-test academic stress scores ranged from 70-168. The mean post- test academic stress score is 124.63 with a standard deviation of + 24.17 and the median is 126.

Table- 4 Mean, mean difference, paired ‘t’ test of level of pre-test and post- test academic stress scores among nursing students n = 60

Academic score	Stress mean	Mean difference	SD difference	Paired “t” test value
Pre – test	131.8	7.17	2.03	27.57
Post – test	124.63

^t59^{= 1.671; p
<0.05*significant}

The data presented in table- 4 shows that the mean difference between pre-test and post-test academic stress scores is 7.17. This indicates a decrease in academic stress score after undergoing video-assisted laughter and demonstration. To find the significance of decrease in ^{stress, paired ‘t’ test was computed and the obtained value of ‘t’}⁽59^)
=^{27.57 was found to be}significant at 0.05 level of significance. So, the researcher inferred that research hypothesis is accepted and null hypothesis is rejected.

SECTION III ASSOCIATION BETWEEN THE LEVEL OF PRE-TEST ACADEMIC STRESS SCORES WITH THEIR SELECTED DEMOGRAPHIC VARIABLES:

To find the association between level of pre-test academic stress scores with selected demographic variables, chi- square was computed.

To test the statistical significance and following null hypothesis was stated.

^Ho2^:^{There will be no significant association between the level
of pre-test academic stress}scores among nursing students with their selected demographic variable

Table- 5 Chi- square between level of pre-test academic stress scores among nursing students with their selected demographic variables. n=60

Selected demographic Variables	Below average	Above average	Chi square
	(<100)	(>100)	Values
1. Age (in years)
1.1) 18 – 20	5	43	4.4
1.2) 21 – 23	5	7
2. Habits
2.1) Reading	5	8
2.2) Yoga and others	5	42	5.66
3.Gender
3.1) Male	10	2
3.2) Female	38	10	0.04
4. Have you attended any stress reduction programme?
4.1) Yes	1	2
4.2) No	9	48	0.62

The data presented in table-5 shows that the computed chi- square values of pre-test academic stress scores among nursing students were found to be significant at 0.05 level of significance for demographic variables like habits and age and were not significant for gender and stress reduction programme. So, researcher partially accepts the research hypothesis and rejects the null hypothesis.

CONCLUSION:

An pre-experimental study was conducted to assess the effectiveness of laughter on academic stress among nursing students at JSS College of Nursing, Mysuru. The data was collected from 60 nursing students and was analysed by using descriptive and inferential statistics and presented in the form of graphs and tables. We have used selected demographic variables regarding the samples and also 40 items were given in modified perceived academic stress scale in which the interpretation of the stress scores was mild stress (40-100), moderate stress (101-150) and severe stress (151-200).

The research findings were shown that the values of pre-test academic stress scores of nursing students were found to be significant at 0.05 level of significance for demographic variables like habits and age and were not significant for gender and stress reduction programme. So, the researcher partially accepts the research hypothesis and rejects the null hypothesis.

In the present study, in pre-test majority 50% (30) of them have moderate stress, 33.34% (20) have severe stress and 16.66% (10) of them have mild stress. Whereas in the post test, 66.68% (40) of them have moderate stress and 16.66% (10) of them have severe stress and 16.66% (10) have mild stress.

The mean difference between the mean pre-test and mean post-test academic stress ^{scores was 7.17 with the standard
deviation difference of ±2.03. The paired ‘t’}(59) ^{= 27.57 was}found to be significant at 0.05 level of significance.

The findings of present study concluded that the video-assisted laughter and demonstration on academic stress was very effective in reducing academic stress among nursing students at 0.05 level of significance. Hence, the study gave the evidence that laughter can reduce academic stress of nursing students and it will help them to improve their quality of life.

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Received on 13.07.2023 Modified on 27.07.2023

A and V Pub J. of Nursing and Medical Res. 2023; 2(3):77-84.

DOI: 10.52711/jnmr.2023.20

Academic stress	Pre – test		Post - test
Score	Frequency (f)	Percentage (%)	Frequency (f)	Percentage (%)
Mild stress(40 - 100)	10	16.66	10	16.66
Moderate stress(101 – 150)	30	50	40	66.68
Severe stress(151 - 200)	20	33.34	10	16.66