doi 10.1515/ijnes-2012-0032
International Journal of Nursing Education Scholarship 2013; 10(1): 255–266
Wanda M. Chernomas* and Carla Shapiro
Stress, Depression, and Anxiety among Undergraduate Nursing Students Abstract: Admission to a professional program marks the beginning of fulfilling a career goal. However, the rigors of professional education can be demanding. Stress, depression, and anxiety (SDA) can interfere with learning, affect academic performance, and impair clinical practice performance. Studies report a general increase in the severity of and extent of mental health problems among college/university students. The literature regarding nursing students’ mental health distress identifies academic and personal sources of stress and coping efforts, with emphasis on the stress and anxiety associated with clinical practice. This cross-sectional descriptive exploratory study investigated levels of SDA among nursing students in 3 years of a university-based program. The association between quality of life indicators including known stressors, such as financial concerns and balance between school and personal life, and SDA was also investigated. Through an online survey, 437 participants from one mid-western Canadian undergraduate nursing program completed the Depression Anxiety Stress Scales and provided data on quality of life indicators and demographic information. Participants also were invited to provide narrative data about their experiences with SDA. This article will present significant findings including: levels of SDA; comparisons between our sample and a normative sample on the dimensions of SDA; and the results of multiple regression analysis identifying significant predictors of each dimension. Themes from the qualitative comments from 251 of the participants were identified and added depth and clarity to the quantitative findings. The predominant themes represented were: perceptions of clinical practice, coping, personal issues, and balancing school, work, and personal life. Implications and recommendations for curriculum design, ensuring students understand program expectations prior to admission, and enhancing accessibility to mental health/support services need to be considered. Keywords: nursing students, stress, anxiety, mixed methods
*Corresponding author: Wanda M. Chernomas, Faculty of Nursing, University of Manitoba, Winnipeg, MB R3T 2N2, Canada, E-mail: [email protected] Carla Shapiro, Faculty of Nursing, University of Manitoba, Winnipeg, MB R3T 2N2, Canada, E-mail: [email protected]
Nurse educators likely appreciate that their students experience stress as part of their professional education; however, they may not fully be aware of the extent of the distress and the impact it has on students’ lives and learning. Moreover, the actions of faculty can be significant in ameliorating students’ experiences of stress. Although a growing body of literature on stress and nursing students exists, translating this knowledge into practice remains an ongoing issue that warrants further attention. The literature addressing stress in nursing students has increased over the last 15 years. Although studies conducted in Europe dominate (Pulido-Martos, AugustoLanda, & Lopez-Zafra, 2011) with the United States steadily represented (Magnussen & Amundson, 2003; Reeve, Shumaker, Yearwood, Crowell, & Riley, 2013), increasingly researchers from other countries are contributing to this body of work, confirming the international scope and importance of this issue (Chan, So, & Fong, 2009; Lo, 2002; Shaban, Khater, & Akhu-Zaheya, 2012; Shikai, Shono, & Kitamura, 2009). Studies that have examined the extent of psychological distress indicate that the first year of study can be stressful and that some students report high levels of psychological distress throughout their program (Jones & Johnston, 1997; Watson et al., 2008). Within this body of literature, three main sources of stress among nursing students are: clinical practice issues, academic concerns, and personal matters (Jimenez, Navia-Osorio, & Diaz, 2010). For nursing students, the clinical setting in particular is an environment that may cause them to experience stress and anxiety, with initial clinical practice being perhaps the most stressful period in a student’s education (Moscaritolo, 2009; Sheu, Lin, & Hwang, 2002). Reasons cited for the increased stress associated with this aspect of an educational program include: the gap between theory and practice, feeling unprepared for practice, fear of making a mistake, issues related to death and dying, witnessing pain and suffering, problematic interpersonal relationships with clinical teachers and nursing staff, being observed and evaluated, communicating with physicians, and lack of familiarity with the hospital environment (Altiok & Üstün, 2013; Chan et al., 2009; Jimenez et al., 2010; Kim, 2003; Pulido-Martos et al., 2011).
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W. M. Chernomas and C. Shapiro: Stress, Depression, Anxiety, and Nursing Students
Academic concerns outside of clinical learning environments include exams and workload (Altiok & Üstün, 2013; Goff, 2011; Lo, 2002; Magnussen & Amundson, 2003). “Worrying about grades” is cited as a top source of stress for some students (Shaban et al., 2012). Poor grades, not achieving their desired grades or meeting family expectations in this regard, can leave students feeling inadequate and at risk for depression (Dzurec, Allchin, & Engler, 2007). Perceived heavy workloads associated with course requirements combined with personal responsibilities add a further dimension to the stress experienced by some students (Magnussen & Amundson, 2003). Personal sources of stress include finances and limited free time (Jimenez et al., 2010; Lo, 2002; Moscaritolo, 2009; Pryjmachuk & Richards, 2007; Sheu et al., 2002). The demands of juggling studies with employment, family life, and other responsibilities interfere with students’ abilities to receive the needed social support and relaxation that interpersonal connections provide. Studies report that some students have to work to support themselves, thus further reducing their free time (Magnussen & Amundson, 2003). For those students who are also parents concern about access to adequate childcare arrangements can be a source of personal stress (Pryjmachuk & Richards, 2007). Another focus in the literature is an examination of the role of coping and support in students’ lives and a variety of interventions that can be helpful in decreasing students’ distress. Stress and coping frameworks, in particular, Lazarus and Folkman’s framework, are commonly used to understand the process by which students face, cognitively process, and attempt to manage their stress (Gibbons, Dempster, & Moutray, 2010; Jimenez et al., 2010; Sawatzky, 1998). Coping strategies have been examined to indicate, generally, that problem-solving and other direct ways of managing stress are associated with lower stress levels, while avoidance coping and emotion-oriented strategies are associated with emotional exhaustion and anxiety, respectively (Gibbons, 2010; Jones & Johnston, 1997; Shikai et al., 2009). Access to supportive people as a form of coping has also been reported indicating that talking with friends and family members can help decrease stress (Reeve et al., 2013). Interventions designed to assist nursing students with reducing stress are reported in the literature and include stress management courses or workshops (Billingsley, Collins, & Miller, 2007; Capp & Williams, 2012), teaching students mindfulness techniques (Beddoe & Murphy, 2004), promoting students’ use of exercise (Hawker, 2012), and general health promotion strategies such as, relaxation, time management, assertiveness training, and
healthy nutrition (Galbraith & Brown, 2011; Jones & Johnston, 2000). One issue raised in the literature addressing postsecondary students in general is the availability of mental health services and students’ willingness to access them. Cook (2007) commented that most university counseling services are limited in the number of students they can help and do not have adequate supports to meet the needs of students, a finding that accompanies general increases in the severity and number of mental health problems among college/university students. Cook added that students who might benefit from mental health services tend not to seek out these resources. Certain trends in addressing psychological distress in nursing students are evident in the literature. At the same time, the complexity involved in understanding this phenomenon is emerging. For example, clinical practice is frequently cited as a source of stress; however, it can also be viewed as a positive and satisfying learning experience (Warne et al., 2010). While the literature includes studies that tended to examine the concepts of stress, depression, and anxiety (SDA) individually, one of the aims of this study was to gain a broader view of how each of these common manifestations of psychological distress was evident across all years of one program. In addition, we wanted to understand how a number of factors associated with psychological distress, as discussed above, contributed to SDA in order to affect change.
Purpose The aims of this study were to: (i) investigate the prevalence of SDA among undergraduate nursing students; (ii) explore the association between demographic data and quality of life indicators, including known stressors, coping and support, and SDA; (iii) describe students’ quality of life based on select indicators.
Methodology Design overview A cross-sectional descriptive exploratory design was used to measure the extent of SDA (dependent variables). An online survey was used to collect data on the three
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W. M. Chernomas and C. Shapiro: Stress, Depression, Anxiety, and Nursing Students
dependent variables and several independent variables. Independent variables included demographic data (e.g. age, relationship status, and year in program) and quality of life indicators (e.g. satisfaction with sleep and leisure activities). The independent variables considered were factors potentially associated with SDA. In addition, participants were given the opportunity to write about their experiences with SDA through an open-ended question.
Sample and setting All undergraduate students enrolled in a baccalaureate nursing program on the main campus of one mid-western Canadian university (N ¼ 882 potential participants) were invited to participate. Students are admitted to the nursing program after completing one year of university study which includes completion of foundational arts and sciences courses and introductory nursing courses. Students from each of the three years of the nursing program participated (Table 1) with a total sample of 437 useable surveys. The sample included 392 females and 50 males. The predominate age group participating was between 21 and 25 years of age. Other demographic data describing the sample appear in Table 1.
Table 1 Demographic characteristics by frequency (% of total sample) Sex (%) Male 50 (11) Female 392 (89)
Aboriginal (%) Yes 29 (7) No 408 (92)
Year in program (%) Y2 151 (35) Y3 146 (33) Y4 140 (32)
Recent immigrant (%) Yes 27 (6) No 412 (93)
Relationship status (%) Married/partnered Separated/divorced Single/never married Other
130 (29) 12 (3) 278 (63) 20 (5)
Age range in years (%) Under 21 53 (12) 21–25 253 (57) 26–30 55 (12) 31–35 41 (9) >35 39 (9)
257
Depression anxiety stress scales (DASS) The DASS is a 42-item self-report tool designed to measure depression, anxiety, and stress (Lovibond & Lovibond, 1995). These three constructs are conceptualized as related yet separate phenomena. Depression is characterized by a loss of self-esteem, a sad mood, and the altered perception regarding ability to achieve one’s goals. Anxiety is illustrated by an association with feelings of fear and facing situations which challenges one’s perceptions of one’s abilities. Stress is typified by “…a persistent state of overarousal which reflects continuing difficulty in meeting taxing life demands” (Lovibond & Lovibond, 1995, p. 33). The constructs are further conceived as dimensional in nature in that scores can yield mild, moderate, and high levels of each construct. Completion of the scale results in a score for each of the three constructs with higher scores indicative of higher levels of each of the constructs. Reliability and validity of the DASS on nonclinical samples indicates good internal consistency with alphas of 0.91 for depression, 0.84 for anxiety, and 0.90 for stress (Lovibond & Lovibond, 1995, p. 27). The reliability coefficients (Cronbach’s alpha) of the DASS in this study sample were found to be 0.97 for depression, 0.969 for anxiety, and 0.967 for stress. The DASS has been validated against other valid tools purported to measure depression and anxiety, such as the Beck Depression Inventory and the Beck Anxiety Inventory (Lovibond & Lovibond, 1995) and the Personal Disturbance Scale (sAD) (Crawford & Henry, 2003). Completion of the DASS ranges, on average, from 10 to 20 minutes (http://www.2.psy.unsw.edu.au/groups/ dass/DASSFAQ.htm).
Demographic questionnaire The demographic questionnaire was constructed by the researchers and included 19 items. Items addressed: age, sex, relationship status, living arrangements, parenthood and adequacy of child care arrangements, and self-identification as Aboriginal or an immigrant living in Canada five years or less. Participants were also asked questions related to use of professional mental health services, use of prescribed medication for SDA, knowledge of mental health resources and services, and overall adequacy of coping strategies.
Instrumentation Quality of life indicators An online data collection program (Survey Monkey) was used. The online survey included four sections, three structured instruments, and one open-ended question.
Twelve items addressing quality of life were included, using seven items from the World Health Organization
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W. M. Chernomas and C. Shapiro: Stress, Depression, Anxiety, and Nursing Students
Quality of Life Questionnaire (2004), abbreviated version (WHOQOL-BREF),1 and five items developed by the researchers and patterned after the WHOQOL-BREF. The seven items from the WHOQOL-BREF addressed: overall quality of life, satisfaction with health, sleep, money, living arrangements, leisure activities, and support from others. The researcher-developed items addressed: ability to balance school load with personal life, perceived stress before enrolling in nursing (pre-faculty stress) and after enrollment (current faculty stress), extent of anxiety the night before clinical practice, and satisfaction with nutritional intake. One example of a researcher-developed item was: “How anxious do you feel the night before clinical practice?” Options in a Likert-type format were: not anxious, a little anxious, moderately anxious, very anxious, and extremely anxious.
Open-ended question Space at the end of the questionnaire allowed students to write about experiences with SDA. The open-ended statement was: “Please elaborate on your experience of stress, depression and anxiety.”
Procedures A university ethical review board provided ethical approval for the study. Procedures were incorporated to ensure the researchers were not involved in direct recruitment, data collection, and distribution of incentives. Researchers had access only to aggregate, anonymous data. Given the topic of investigation, a number of community-based supportive resources were listed for participants. Several strategies were used to inform students about the study. Recruitment occurred between the late fall of 2009 and early January 2010. Data collection occurred over a three-week period during the winter term of 2010. A university-based research center sent electronic individual invitations through students’ university email accounts. In the invitation, students were directed to the online survey. The research center sent two follow-up reminders based on response to the initial request. To increase the response rate, incentives were offered in the form of six $100 gift 1 We received permission to use selected items from the WHOQOLBREF in this study. It is important to note that these items do not represent the complete WHOQOL-BREF or provide a composite score of the construct quality of life but are borrowed from the instrument.
certificates to the university bookstore. The research center managed the awarding of incentives, so that the researchers were excluded from the process to ensure anonymity of participation.
Data analysis A research assistant as directed by the researchers entered all data into the SPSS version 18 software program. Means and standard deviations on the DASS were calculated to determine the extent and severity of SDA. A two-sample t-test was used to compare means in our sample with means in a normative sample. Correlation coefficients and multiple regression analysis were used to determine the association between demographic variables, quality of life indicators, and the outcome variables of SDA. Frequencies were calculated to describe the sample in relation to each quality of life indicator. Qualitative data were analyzed through the use of content analysis procedures (Hsieh & Shannon, 2005). The investigators, to determine the identification of themes, read data initially independently. The researchers collaborated on the coding of responses. Some participants’ responses were coded to represent more than one theme. The number of times each theme appeared in the data was determined.
Results Results are presented relative to the objectives of the study. The qualitative data provided descriptive accounts of participants’ experiences and added depth and clarity to the quantitative findings. The dominant themes represented were: perceptions of clinical practice, coping, personal issues, and balancing school, work, and personal life.
Prevalence of stress, depression, and anxiety among undergraduate nursing students The mean scores were in the higher end of the “normal” range on each outcome variable (see Table 2). When the high standard deviations are taken into consideration, it is important to note there is a shift toward a significant percentage of scores in the mild to moderate severity ratings. In terms of higher scores, 10% of our sample
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W. M. Chernomas and C. Shapiro: Stress, Depression, Anxiety, and Nursing Students
Table 2 ratings
Depression anxiety stress mean scores and DASS severity
Mean scores (M) and standard deviations (SD)
Percent** of sample scoring in each level of severity (%)
Depression M ¼ 8.10 SD ¼ 8.422
Normal (67) Mild (11) Moderate (11) Severe (5) Extremely severe (5)
Anxiety M ¼ 7.78 SD ¼ 7.412
Normal (61) Mild (8) Moderate (15) Severe (8) Extremely severe (8)
Stress M ¼ 13.27 SD ¼ 8.847
Normal (62) Mild (15) Moderate (13) Severe (8) Extremely severe (3)
Depression
(n ¼ 43) had scores in the severe and extremely severe categories in depression; 16% (n ¼ 70) had scores in the severe and extremely severe categories in anxiety; and 10% (n ¼ 46) had scores in the severe and extremely severe categories in stress. Mean scores by sex are presented in Table 3 and compared with a normative sample. The normative sample included a mix of university students and adults in the work force, ranging in age from 17 to 69 (Lovibond & Lovibond, 1995). In the current sample, mean scores on each dimension were higher than scores in the comparison group, and differences were found to be statistically significant except for males and stress (see Table 3). One limitation of this comparison group is that it does not include university students exclusively, however, the normative data do provide a perspective on the scores in this sample. Comparison of sample with normative sample Males Normative (n ¼ 1,044) Mean (SD)
Nursing (n ¼ 50)
Association between demographic data, quality of life indicators, and stress, depression, and anxiety Multiple regression analysis was used to determine which variables were significant predictors of each of the outcome variables. Semi-partial correlations were used to control for the correlations among the independent variables appearing in the regression model.
Notes: Lovibond and Lovibond (1995), **percent 0.5 are rounded up.
Table 3
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Significant predictors of depression in this sample are presented in Table 4. Higher depression scores were associated with ineffective coping, higher pre-faculty and current faculty stress, poorer quality of life, and limited social support. Students in the final year of the program reported lower depression scores than students in second and third years. Students who were parents tended to have lower depression scores. Students who had higher depression scores were more likely to be taking medication and had sought professional help for depression since enrolling in the faculty.
Anxiety Significant predictors of anxiety are presented in Table 5. Higher anxiety scores were associated with ineffective coping strategies and increased current faculty stress. Students who were better able to balance school load with personal life and were more satisfied with their overall state of health had lower anxiety scores. Demographically, married or partnered students had lower anxiety scores than those who were single, and those who were separated or divorced had lower anxiety scores than single students albeit of borderline significance. In this sample, Aboriginal students experienced lower anxiety scores than non-Aboriginal students.
Females Normative (n ¼ 1,870)
Nursing (n ¼ 387)
Depression 6.55 (7.01) 9.30 (9.18)* 6.14 (6.92) 7.95 (8.32)* Anxiety 4.60 (4.80) 7.34 (6.47)* 4.80 (5.03) 7.83 (7.53)* Stress 9.93 (7.66) 11.81 (7.68) 10.29 (8.16) 13.46 (8.98)* Notes: Between-group comparisons marked with an asterisk (*) are significantly different at the 0.05 level, via two-sample t-test. SD ¼ standard deviation.
Stress Significant predictors of stress are presented in Table 6. Higher stress scores were among those with ineffective coping, more anxiety the night before clinical practice, and presence of higher stress prior to entering the faculty. Participants who sought help for anxiety since enrolling in the faculty tended to have higher stress scores.
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W. M. Chernomas and C. Shapiro: Stress, Depression, Anxiety, and Nursing Students
Table 4 Significant predictors of depression, estimated via multivariable linear regression with the outcome transformed onto the natural log scale Predictor variables Coping Faculty stress Life quality Depression help No vs Yes Support Program year Year 2 vs Year 4 Year 3 vs Year 4 Pre-faculty stress Parent No vs Yes Depression medication No vs Yes
Effect size (%)
95% CI
P-value
Semi-partial correlation
44.1 26.6 26.2
(29.5, 60.2) (15.3, 38.9) (11.6, 42.7)
International Journal of Nursing Education Scholarship 2013; 10(1): 255–266
Wanda M. Chernomas* and Carla Shapiro
Stress, Depression, and Anxiety among Undergraduate Nursing Students Abstract: Admission to a professional program marks the beginning of fulfilling a career goal. However, the rigors of professional education can be demanding. Stress, depression, and anxiety (SDA) can interfere with learning, affect academic performance, and impair clinical practice performance. Studies report a general increase in the severity of and extent of mental health problems among college/university students. The literature regarding nursing students’ mental health distress identifies academic and personal sources of stress and coping efforts, with emphasis on the stress and anxiety associated with clinical practice. This cross-sectional descriptive exploratory study investigated levels of SDA among nursing students in 3 years of a university-based program. The association between quality of life indicators including known stressors, such as financial concerns and balance between school and personal life, and SDA was also investigated. Through an online survey, 437 participants from one mid-western Canadian undergraduate nursing program completed the Depression Anxiety Stress Scales and provided data on quality of life indicators and demographic information. Participants also were invited to provide narrative data about their experiences with SDA. This article will present significant findings including: levels of SDA; comparisons between our sample and a normative sample on the dimensions of SDA; and the results of multiple regression analysis identifying significant predictors of each dimension. Themes from the qualitative comments from 251 of the participants were identified and added depth and clarity to the quantitative findings. The predominant themes represented were: perceptions of clinical practice, coping, personal issues, and balancing school, work, and personal life. Implications and recommendations for curriculum design, ensuring students understand program expectations prior to admission, and enhancing accessibility to mental health/support services need to be considered. Keywords: nursing students, stress, anxiety, mixed methods
*Corresponding author: Wanda M. Chernomas, Faculty of Nursing, University of Manitoba, Winnipeg, MB R3T 2N2, Canada, E-mail: [email protected] Carla Shapiro, Faculty of Nursing, University of Manitoba, Winnipeg, MB R3T 2N2, Canada, E-mail: [email protected]
Nurse educators likely appreciate that their students experience stress as part of their professional education; however, they may not fully be aware of the extent of the distress and the impact it has on students’ lives and learning. Moreover, the actions of faculty can be significant in ameliorating students’ experiences of stress. Although a growing body of literature on stress and nursing students exists, translating this knowledge into practice remains an ongoing issue that warrants further attention. The literature addressing stress in nursing students has increased over the last 15 years. Although studies conducted in Europe dominate (Pulido-Martos, AugustoLanda, & Lopez-Zafra, 2011) with the United States steadily represented (Magnussen & Amundson, 2003; Reeve, Shumaker, Yearwood, Crowell, & Riley, 2013), increasingly researchers from other countries are contributing to this body of work, confirming the international scope and importance of this issue (Chan, So, & Fong, 2009; Lo, 2002; Shaban, Khater, & Akhu-Zaheya, 2012; Shikai, Shono, & Kitamura, 2009). Studies that have examined the extent of psychological distress indicate that the first year of study can be stressful and that some students report high levels of psychological distress throughout their program (Jones & Johnston, 1997; Watson et al., 2008). Within this body of literature, three main sources of stress among nursing students are: clinical practice issues, academic concerns, and personal matters (Jimenez, Navia-Osorio, & Diaz, 2010). For nursing students, the clinical setting in particular is an environment that may cause them to experience stress and anxiety, with initial clinical practice being perhaps the most stressful period in a student’s education (Moscaritolo, 2009; Sheu, Lin, & Hwang, 2002). Reasons cited for the increased stress associated with this aspect of an educational program include: the gap between theory and practice, feeling unprepared for practice, fear of making a mistake, issues related to death and dying, witnessing pain and suffering, problematic interpersonal relationships with clinical teachers and nursing staff, being observed and evaluated, communicating with physicians, and lack of familiarity with the hospital environment (Altiok & Üstün, 2013; Chan et al., 2009; Jimenez et al., 2010; Kim, 2003; Pulido-Martos et al., 2011).
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W. M. Chernomas and C. Shapiro: Stress, Depression, Anxiety, and Nursing Students
Academic concerns outside of clinical learning environments include exams and workload (Altiok & Üstün, 2013; Goff, 2011; Lo, 2002; Magnussen & Amundson, 2003). “Worrying about grades” is cited as a top source of stress for some students (Shaban et al., 2012). Poor grades, not achieving their desired grades or meeting family expectations in this regard, can leave students feeling inadequate and at risk for depression (Dzurec, Allchin, & Engler, 2007). Perceived heavy workloads associated with course requirements combined with personal responsibilities add a further dimension to the stress experienced by some students (Magnussen & Amundson, 2003). Personal sources of stress include finances and limited free time (Jimenez et al., 2010; Lo, 2002; Moscaritolo, 2009; Pryjmachuk & Richards, 2007; Sheu et al., 2002). The demands of juggling studies with employment, family life, and other responsibilities interfere with students’ abilities to receive the needed social support and relaxation that interpersonal connections provide. Studies report that some students have to work to support themselves, thus further reducing their free time (Magnussen & Amundson, 2003). For those students who are also parents concern about access to adequate childcare arrangements can be a source of personal stress (Pryjmachuk & Richards, 2007). Another focus in the literature is an examination of the role of coping and support in students’ lives and a variety of interventions that can be helpful in decreasing students’ distress. Stress and coping frameworks, in particular, Lazarus and Folkman’s framework, are commonly used to understand the process by which students face, cognitively process, and attempt to manage their stress (Gibbons, Dempster, & Moutray, 2010; Jimenez et al., 2010; Sawatzky, 1998). Coping strategies have been examined to indicate, generally, that problem-solving and other direct ways of managing stress are associated with lower stress levels, while avoidance coping and emotion-oriented strategies are associated with emotional exhaustion and anxiety, respectively (Gibbons, 2010; Jones & Johnston, 1997; Shikai et al., 2009). Access to supportive people as a form of coping has also been reported indicating that talking with friends and family members can help decrease stress (Reeve et al., 2013). Interventions designed to assist nursing students with reducing stress are reported in the literature and include stress management courses or workshops (Billingsley, Collins, & Miller, 2007; Capp & Williams, 2012), teaching students mindfulness techniques (Beddoe & Murphy, 2004), promoting students’ use of exercise (Hawker, 2012), and general health promotion strategies such as, relaxation, time management, assertiveness training, and
healthy nutrition (Galbraith & Brown, 2011; Jones & Johnston, 2000). One issue raised in the literature addressing postsecondary students in general is the availability of mental health services and students’ willingness to access them. Cook (2007) commented that most university counseling services are limited in the number of students they can help and do not have adequate supports to meet the needs of students, a finding that accompanies general increases in the severity and number of mental health problems among college/university students. Cook added that students who might benefit from mental health services tend not to seek out these resources. Certain trends in addressing psychological distress in nursing students are evident in the literature. At the same time, the complexity involved in understanding this phenomenon is emerging. For example, clinical practice is frequently cited as a source of stress; however, it can also be viewed as a positive and satisfying learning experience (Warne et al., 2010). While the literature includes studies that tended to examine the concepts of stress, depression, and anxiety (SDA) individually, one of the aims of this study was to gain a broader view of how each of these common manifestations of psychological distress was evident across all years of one program. In addition, we wanted to understand how a number of factors associated with psychological distress, as discussed above, contributed to SDA in order to affect change.
Purpose The aims of this study were to: (i) investigate the prevalence of SDA among undergraduate nursing students; (ii) explore the association between demographic data and quality of life indicators, including known stressors, coping and support, and SDA; (iii) describe students’ quality of life based on select indicators.
Methodology Design overview A cross-sectional descriptive exploratory design was used to measure the extent of SDA (dependent variables). An online survey was used to collect data on the three
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W. M. Chernomas and C. Shapiro: Stress, Depression, Anxiety, and Nursing Students
dependent variables and several independent variables. Independent variables included demographic data (e.g. age, relationship status, and year in program) and quality of life indicators (e.g. satisfaction with sleep and leisure activities). The independent variables considered were factors potentially associated with SDA. In addition, participants were given the opportunity to write about their experiences with SDA through an open-ended question.
Sample and setting All undergraduate students enrolled in a baccalaureate nursing program on the main campus of one mid-western Canadian university (N ¼ 882 potential participants) were invited to participate. Students are admitted to the nursing program after completing one year of university study which includes completion of foundational arts and sciences courses and introductory nursing courses. Students from each of the three years of the nursing program participated (Table 1) with a total sample of 437 useable surveys. The sample included 392 females and 50 males. The predominate age group participating was between 21 and 25 years of age. Other demographic data describing the sample appear in Table 1.
Table 1 Demographic characteristics by frequency (% of total sample) Sex (%) Male 50 (11) Female 392 (89)
Aboriginal (%) Yes 29 (7) No 408 (92)
Year in program (%) Y2 151 (35) Y3 146 (33) Y4 140 (32)
Recent immigrant (%) Yes 27 (6) No 412 (93)
Relationship status (%) Married/partnered Separated/divorced Single/never married Other
130 (29) 12 (3) 278 (63) 20 (5)
Age range in years (%) Under 21 53 (12) 21–25 253 (57) 26–30 55 (12) 31–35 41 (9) >35 39 (9)
257
Depression anxiety stress scales (DASS) The DASS is a 42-item self-report tool designed to measure depression, anxiety, and stress (Lovibond & Lovibond, 1995). These three constructs are conceptualized as related yet separate phenomena. Depression is characterized by a loss of self-esteem, a sad mood, and the altered perception regarding ability to achieve one’s goals. Anxiety is illustrated by an association with feelings of fear and facing situations which challenges one’s perceptions of one’s abilities. Stress is typified by “…a persistent state of overarousal which reflects continuing difficulty in meeting taxing life demands” (Lovibond & Lovibond, 1995, p. 33). The constructs are further conceived as dimensional in nature in that scores can yield mild, moderate, and high levels of each construct. Completion of the scale results in a score for each of the three constructs with higher scores indicative of higher levels of each of the constructs. Reliability and validity of the DASS on nonclinical samples indicates good internal consistency with alphas of 0.91 for depression, 0.84 for anxiety, and 0.90 for stress (Lovibond & Lovibond, 1995, p. 27). The reliability coefficients (Cronbach’s alpha) of the DASS in this study sample were found to be 0.97 for depression, 0.969 for anxiety, and 0.967 for stress. The DASS has been validated against other valid tools purported to measure depression and anxiety, such as the Beck Depression Inventory and the Beck Anxiety Inventory (Lovibond & Lovibond, 1995) and the Personal Disturbance Scale (sAD) (Crawford & Henry, 2003). Completion of the DASS ranges, on average, from 10 to 20 minutes (http://www.2.psy.unsw.edu.au/groups/ dass/DASSFAQ.htm).
Demographic questionnaire The demographic questionnaire was constructed by the researchers and included 19 items. Items addressed: age, sex, relationship status, living arrangements, parenthood and adequacy of child care arrangements, and self-identification as Aboriginal or an immigrant living in Canada five years or less. Participants were also asked questions related to use of professional mental health services, use of prescribed medication for SDA, knowledge of mental health resources and services, and overall adequacy of coping strategies.
Instrumentation Quality of life indicators An online data collection program (Survey Monkey) was used. The online survey included four sections, three structured instruments, and one open-ended question.
Twelve items addressing quality of life were included, using seven items from the World Health Organization
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258
W. M. Chernomas and C. Shapiro: Stress, Depression, Anxiety, and Nursing Students
Quality of Life Questionnaire (2004), abbreviated version (WHOQOL-BREF),1 and five items developed by the researchers and patterned after the WHOQOL-BREF. The seven items from the WHOQOL-BREF addressed: overall quality of life, satisfaction with health, sleep, money, living arrangements, leisure activities, and support from others. The researcher-developed items addressed: ability to balance school load with personal life, perceived stress before enrolling in nursing (pre-faculty stress) and after enrollment (current faculty stress), extent of anxiety the night before clinical practice, and satisfaction with nutritional intake. One example of a researcher-developed item was: “How anxious do you feel the night before clinical practice?” Options in a Likert-type format were: not anxious, a little anxious, moderately anxious, very anxious, and extremely anxious.
Open-ended question Space at the end of the questionnaire allowed students to write about experiences with SDA. The open-ended statement was: “Please elaborate on your experience of stress, depression and anxiety.”
Procedures A university ethical review board provided ethical approval for the study. Procedures were incorporated to ensure the researchers were not involved in direct recruitment, data collection, and distribution of incentives. Researchers had access only to aggregate, anonymous data. Given the topic of investigation, a number of community-based supportive resources were listed for participants. Several strategies were used to inform students about the study. Recruitment occurred between the late fall of 2009 and early January 2010. Data collection occurred over a three-week period during the winter term of 2010. A university-based research center sent electronic individual invitations through students’ university email accounts. In the invitation, students were directed to the online survey. The research center sent two follow-up reminders based on response to the initial request. To increase the response rate, incentives were offered in the form of six $100 gift 1 We received permission to use selected items from the WHOQOLBREF in this study. It is important to note that these items do not represent the complete WHOQOL-BREF or provide a composite score of the construct quality of life but are borrowed from the instrument.
certificates to the university bookstore. The research center managed the awarding of incentives, so that the researchers were excluded from the process to ensure anonymity of participation.
Data analysis A research assistant as directed by the researchers entered all data into the SPSS version 18 software program. Means and standard deviations on the DASS were calculated to determine the extent and severity of SDA. A two-sample t-test was used to compare means in our sample with means in a normative sample. Correlation coefficients and multiple regression analysis were used to determine the association between demographic variables, quality of life indicators, and the outcome variables of SDA. Frequencies were calculated to describe the sample in relation to each quality of life indicator. Qualitative data were analyzed through the use of content analysis procedures (Hsieh & Shannon, 2005). The investigators, to determine the identification of themes, read data initially independently. The researchers collaborated on the coding of responses. Some participants’ responses were coded to represent more than one theme. The number of times each theme appeared in the data was determined.
Results Results are presented relative to the objectives of the study. The qualitative data provided descriptive accounts of participants’ experiences and added depth and clarity to the quantitative findings. The dominant themes represented were: perceptions of clinical practice, coping, personal issues, and balancing school, work, and personal life.
Prevalence of stress, depression, and anxiety among undergraduate nursing students The mean scores were in the higher end of the “normal” range on each outcome variable (see Table 2). When the high standard deviations are taken into consideration, it is important to note there is a shift toward a significant percentage of scores in the mild to moderate severity ratings. In terms of higher scores, 10% of our sample
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W. M. Chernomas and C. Shapiro: Stress, Depression, Anxiety, and Nursing Students
Table 2 ratings
Depression anxiety stress mean scores and DASS severity
Mean scores (M) and standard deviations (SD)
Percent** of sample scoring in each level of severity (%)
Depression M ¼ 8.10 SD ¼ 8.422
Normal (67) Mild (11) Moderate (11) Severe (5) Extremely severe (5)
Anxiety M ¼ 7.78 SD ¼ 7.412
Normal (61) Mild (8) Moderate (15) Severe (8) Extremely severe (8)
Stress M ¼ 13.27 SD ¼ 8.847
Normal (62) Mild (15) Moderate (13) Severe (8) Extremely severe (3)
Depression
(n ¼ 43) had scores in the severe and extremely severe categories in depression; 16% (n ¼ 70) had scores in the severe and extremely severe categories in anxiety; and 10% (n ¼ 46) had scores in the severe and extremely severe categories in stress. Mean scores by sex are presented in Table 3 and compared with a normative sample. The normative sample included a mix of university students and adults in the work force, ranging in age from 17 to 69 (Lovibond & Lovibond, 1995). In the current sample, mean scores on each dimension were higher than scores in the comparison group, and differences were found to be statistically significant except for males and stress (see Table 3). One limitation of this comparison group is that it does not include university students exclusively, however, the normative data do provide a perspective on the scores in this sample. Comparison of sample with normative sample Males Normative (n ¼ 1,044) Mean (SD)
Nursing (n ¼ 50)
Association between demographic data, quality of life indicators, and stress, depression, and anxiety Multiple regression analysis was used to determine which variables were significant predictors of each of the outcome variables. Semi-partial correlations were used to control for the correlations among the independent variables appearing in the regression model.
Notes: Lovibond and Lovibond (1995), **percent 0.5 are rounded up.
Table 3
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Significant predictors of depression in this sample are presented in Table 4. Higher depression scores were associated with ineffective coping, higher pre-faculty and current faculty stress, poorer quality of life, and limited social support. Students in the final year of the program reported lower depression scores than students in second and third years. Students who were parents tended to have lower depression scores. Students who had higher depression scores were more likely to be taking medication and had sought professional help for depression since enrolling in the faculty.
Anxiety Significant predictors of anxiety are presented in Table 5. Higher anxiety scores were associated with ineffective coping strategies and increased current faculty stress. Students who were better able to balance school load with personal life and were more satisfied with their overall state of health had lower anxiety scores. Demographically, married or partnered students had lower anxiety scores than those who were single, and those who were separated or divorced had lower anxiety scores than single students albeit of borderline significance. In this sample, Aboriginal students experienced lower anxiety scores than non-Aboriginal students.
Females Normative (n ¼ 1,870)
Nursing (n ¼ 387)
Depression 6.55 (7.01) 9.30 (9.18)* 6.14 (6.92) 7.95 (8.32)* Anxiety 4.60 (4.80) 7.34 (6.47)* 4.80 (5.03) 7.83 (7.53)* Stress 9.93 (7.66) 11.81 (7.68) 10.29 (8.16) 13.46 (8.98)* Notes: Between-group comparisons marked with an asterisk (*) are significantly different at the 0.05 level, via two-sample t-test. SD ¼ standard deviation.
Stress Significant predictors of stress are presented in Table 6. Higher stress scores were among those with ineffective coping, more anxiety the night before clinical practice, and presence of higher stress prior to entering the faculty. Participants who sought help for anxiety since enrolling in the faculty tended to have higher stress scores.
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W. M. Chernomas and C. Shapiro: Stress, Depression, Anxiety, and Nursing Students
Table 4 Significant predictors of depression, estimated via multivariable linear regression with the outcome transformed onto the natural log scale Predictor variables Coping Faculty stress Life quality Depression help No vs Yes Support Program year Year 2 vs Year 4 Year 3 vs Year 4 Pre-faculty stress Parent No vs Yes Depression medication No vs Yes
Effect size (%)
95% CI
P-value
Semi-partial correlation
44.1 26.6 26.2
(29.5, 60.2) (15.3, 38.9) (11.6, 42.7)
