Stress and Anxiety Level of Nursing Students in Facing Practical Exam During Pandemic 19

Background: Persons enrolled in nursing school are prepared to advance into nursing in the future. Before engaging in nursing clinical practice in hospitals, nursing students are required to be able to advance their competence in the lab. Students studying nursing experience stress and anxiety due to the switch from online to offline lab learning. Objective: To determine and identify nursing students’ stress and anxiety levels in facing practical exams. Method: This study is cross-sectional quantitative descriptive research. A total of 190 nursing students from the second semester at Universitas Muhammadiyah Purwokerto participated in the study as the sample on April 20, 2022. The DASS-21 questionnaire for sub-stress and anxiety was modified for the research instrument. A univariate data analysis with frequency distribution was used as the data analysis. Results: The findings revealed that 115 (60.5%) nursing students reported normal stress, 32 (16.8%) mild stress, 23 (12.1%) moderate stress, 18 (9.5%) severe stress, and 2 (1.1%) very heavy stress. There were 32 (16.8%) students who moderate anxiety, 26 (13.7%) severe anxiety, and 28 (14.7%) very severe anxiety. Conclusion: Most nursing students preparing for practical exams experienced normal stress and moderate anxiety levels. This work is licensed under a Creative Commons Attribution 4.0 International License.


INTRODUCTION
Covid-19 is a disease problem that has not yet been fully resolved. Coronavirus is an infectious disease caused by the SARS-CoV-2 virus [27] . During the covid-19 pandemic mental health problems are increasing every day [16] . Mental health problems that occur are increasing levels of stress and anxiety [27] . The World Health Organization [26] , states that the mental disorders that have the highest prevalence are anxiety and depression. Worldwide there are more than 200 million people who suffer from anxiety (3.6% of the population).
Riskesdas data (2018) states that the prevalence of people with mental emotional disorders aged 15 years and over increased in 2013 from 6% to 9.8% in 2018. Anxiety is an individual's emotional state and subjective feeling of an unclear object. because of the anticipation of danger so as to enable individuals to take action in the face of threats [12] . Stress is an inseparable part of life, which often results in psychological and/or physical changes, which have implications for adult development [20] .
At the beginning of the pandemic, to overcome the Covid-19 problem, the Indonesian government made various policies. One of them is PSBB (Large-Scale Social Restrictions) where schools and other workplaces are closed, religious activities are limited and in public places [10] . During the pandemic, all people The solution made by the government to maintain education during the pandemic is learning activities carried out online, including nursing students who cannot carry out laboratory practices offline. However, entering the 2020/2021 academic year, based on the Circular Letter of the Ministry of Education and Culture No. 6 Th. 2020, lecture activities at universities can be carried out using a combined method of online and offline (hybrid learning) [3] . At the Muhammadiyah University of Purwokerto itself, hybrid learning has been implemented in which nursing students carry out online and offline learning.
In general, everyone can experience stress and anxiety from various professions, as well as students from nursing majors. Nursing students are individuals who are ready to grow into professional nurses in the future [2] . Nursing students are required to be able to improve competence in the laboratory as a provision before carrying out clinical nursing practice in hospitals. Laboratory skills are a form of health training that demands the use of professional nursing knowledge and abilities [24] .
One form of evaluating the skills of nursing students is by conducting practical exams in the laboratory which can be a source of anxiety for students [23] . The emergence of anxiety in students during practical exams can disrupt concentration and reduce competence in thinking and taking action during examS [24] . The change in learning lab skills from online to offline also triggers anxiety in nursing students. Students in Indonesia who experience stress during online learning have an average prevalence of 55.1%, while outside Indonesia it reaches 66.3% [5] .
During the covid pandemic, students carry out lectures online or online at home. Meanwhile, in understanding the learning material, it is not only theory that must be studied by students, but practical knowledge must also be learned. Since the beginning of 2021, after the Covid-19 pandemic conditions began to improve, the Faculty of Health Sciences, University of Muhammadiyah Purwokerto began to apply offline lectures, especially for learning in the laboratory for nursing students, including laboratory practicum exams. Changes that occur from lectures that are conducted online then require students to do practical work offline, causing student concerns. This is what can cause anxiety and stress for nursing students in facing laboratory practicum exams.
Based on research by (D. P. Sari et al., 2021) on 96 medical students of the Faculty of Medicine, Mulawarman University, the results show that the majority of respondents are women aged 20 years. The anxiety level of the respondents showed that most of them experienced anxiety in the category of severe anxiety as many as 40 people (41.67%), 27 people with mild anxiety (28.12%) and 29 people with moderate anxiety (30.21%). Level III (50%) and level II (40.626%) students have a higher level of anxiety when compared to level I (37.5%). So it was concluded from the study that Mulawarman University medical students experienced severe anxiety which was dominated by women aged 20 years.
Research conducted by (Rachmawati & Mustikasari, 2020) on 109 students of the 2015 Faculty of Nursing in the regular undergraduate program. Based on the results, it can be seen that as many as (65.14%) students experienced mild anxiety, moderate anxiety (17.43%), severe anxiety (15.6%), and panic (1.83%). Then the stress level on students showed that as many as (0.9%) experienced mild stress, (71.6%) moderate stress, and (27.5%) severe stress. From the research above, the writer concludes that the highest level of anxiety experienced by students of the Faculty of Nursing UI 2015 Regular Program S1 is mild anxiety and the highest level of stress is moderate stress.Based on this background, researchers are interested in conducting research on "Stress and Anxiety Levels of Nursing Students in Facing Practicum Exams in the 19th Pandemic Period". This study aims to determine and identify the level of stress and anxiety of nursing students in facing practical exams.

RESEARCH METHOD
This type of research is quantitative descriptive using a cross-sectional approach. This research was conducted at the Faculty of Health Sciences, University of Muhammadiyah Purwokerto on April 20, 2022. The population in this study was Nursing Students S1 Semester II with a total of 246 students. The sample in this study were undergraduate nursing students UMP batch 21 who were taken based on the population inclusion criteria who had signed the informed consent. The sampling technique used was total sampling technique. Data were collected using an instrument, namely a questionnaire. The questionnaire used to measure stress and anxiety levels is a modification of the DASS-21 (Depression Anxiety Stress Scale-21) questionnaire.

RESULTS AND DISCUSSIONS
Research on stress and anxiety levels of nursing students in facing practical exams during pandemic 19 in Nursing Students in Semester II UMP involving 190 respondents, the data obtained are as follows. Based on the results from table 1. above, it shows that the distribution of respondents' characteristics by age is mostly 19 years old as much as 85 (44.7%). The sex of the majority of women as much as 140 (73.7%). The origin of the majors taken during SMA/SMK came from SMA IPA as many as 88 (46.3%). The interest in entering nursing majors was mostly due to their own desires as many as 130 (68.4%). Based on table 2. above, the results show that the stress level of nursing students in facing practicum exams during the 19th pandemic was mostly in the normal category as many as 115 respondents (60.5%).

DISCUSSION
The results of research conducted on 190 respondents showed that the age of most of the respondents was 19 years old as many as 85 people (44.7%), while for the age of 17 years as many as 4 people (2.1%), for the age of 18 years as many as 84 people ( 44.2%), for the age of 20 years as many as 16 people (8.4%), and for the age of 22 years as many as 1 person (0.5%).
Respondents in this study were someone in their late teens. Late adolescence is a teenager with an age range of 18 to 22 years [1] . According to Santrock, (2014), adolescence is a transitional development from childhood to adulthood that undergoes changes such as biological, cognitive, and social emotional changes.
Based on the results of the study, it can be seen that the gender of the respondents is mostly female as much as 140 (73.7%). Women are more dominant than men, namely 50 (26.3%). This is in line with research conducted by Rachmawati & Mustikasari, (2020) which showed that the majority of nursing student respondents were women (96.3%) while men (3.7%). This shows that women have a greater interest in nursing than men.
From SMA/SMK majors, most of the respondents came from SMA IPA majors as many as 88 people (46.3%). Other majors such as SMA IPS are 48 (25.3%) and SMK majors are 54 (28.4%). From all majors of origin, students at the time of SMA/SMK did not differ much in the level of stress and anxiety experienced by these students. Most students still experience stress, whether normal, mild, moderate, or severe, this is because it is the first time students are facing a practicum exam.
The majority of respondents 130 people have an interest in nursing because of their own desires, with a percentage that is (68.4%). This result is in line with the research conducted by Tirta et al., (2021) which in each person has different interests and talents from one another, each child has differences in their tendencies and concerns, and each child also has character, values and abilities. his own tendencies.
Based on the results of the study, it can be seen that the stress level of most of the Second Semester Undergraduate Nursing Students in facing the practical exam during the 19th pandemic had a normal stress level of 115 respondents (60.5%), while the category of mild stress was 32 respondents (16, 8%), moderate stress by 23 respondents (12.1%), severe stress by 17 respondents (8.9%), and very heavy stress by 3 respondents (1.6%). The results of this study are in accordance with P. N. Sari & Mirani, (2021) which showed that students experienced normal stress levels (43.8%).
The results of the respondent's data in this study can be seen that it is the first time students take a practicum exam (OSCE) so that the first experience in facing a practicum exam will lead to new situations that can cause stress.
Stress is an unpleasant psychological process that occurs as a reaction to the environment [15] . Stress is a fight to fight syndrome where when individuals experience stress, they respond to stressors by fighting or avoiding them (Aziz & Miftahul, 2014).
Respondents in this study were at normal stress levels, meaning that the body would be able to adjust and not interfere with life. Normal stress is a scientific part of life where almost all humans experience it so that it requires adjustments to deal with stressors (Rahmawati et al., 2019). This is because before the laboratory practicum exams, each individual student performs a simulation of the actions to be tested, so that when students study independently with simulations they can reduce stress which ultimately affects better performance when conducting skills/practical exams (Mills et al., 2016).
Although the results of the analysis found that some respondents experienced normal stress, there were some respondents who experienced moderate stress (23 students), severe stress (17 students) and very heavy stress (3 students). Respondents feel nervous and afraid of their test results that are not in line with expectations. Some respondents said that the action on certain prasat was considered quite difficult. This can be a source of stress and anxiety for students before doing practical exams.
The level of stress experienced by second semester nursing students at the University of Muhammadiyah Purwokerto is different for each individual. This is because students have different coping mechanisms in dealing with stress, this depends on the nature and nature of stress, namely from the intensity, duration, local and general as well as individual characteristics associated with the adaptation process [6] .
Based on the results of the study, it can be seen that the anxiety level of most of the Second Semester Undergraduate Nursing Students in facing the practicum exams during the 19th pandemic was classified as moderate anxiety as many as 77 respondents (40.5%), while those classified as normal were 33 respondents (17.4%), 26 respondents with mild anxiety (13.7%), severe anxiety 26 respondents (13.7%), very severe anxiety 28 respondents (14.7%). The results of this study are in accordance with Hasnah et al., (2021) which shows that most students experience anxiety in the moderate anxiety category (52.4%).
Anxiety is a negative emotional state characterized by premonitions and somatic tension, such as a racing heart, sweating, and difficulty breathing [8] . Students who experience moderate anxiety will show several signs such as increased fatigue, learning is not optimal, decreased concentration, impatient, and easy to forget [22] .
The emergence of anxiety in nursing students can be caused by various factors, one of which is facing practical exams. Practicum is something that is not foreign to nursing students. Laboratory practice is a learning process in the laboratory to strengthen the theory gained through experiential learning, using learning methods that are managed in an integrated manner. Mantika et al., (2019) stated in their research that in a test situation a person can experience anxiety in the form of cognitive, affective and behavioral responses. Anxiety that arises when facing exams, will affect the performance of students themselves, namely when the level of anxiety experienced is lower, students can provide better performance compared to students with moderate to high levels of anxiety [21] . Students before doing the practicum exam make preparations such as studying the material with friends and repeating the actions that will be tested. This is in line with the research of Eyüboğlu et al., (2021) the results showed that students wanted to learn more and practice with their friends immediately before OSCE because they needed a long time to practice. This is a useful form of preparation before the OSCE.

CONCLUSION
The majority of undergraduate nursing students in the second semester of UMP are women, 19 years old, from SMA IPA, and they are interested in entering nursing because of themselves. The stress level of students is in the normal stress category, while the student's anxiety level is in the moderate anxiety category.
It is recommended for educational institutions to improve facilities and infrastructure in the laboratory learning process on campus as an effort to increase student learning motivation in carrying out nursing actions to reduce stress and anxiety so that the results of practicum exams are better.