coping strategies for students research paper

ORIGINAL RESEARCH article

Coping strategies and self-efficacy in university students: a person-centered approach.

• 1 Department of Psychology, University of A Coruña, A Coruña, Spain
• 2 Department of Pedagogy and Didactics, University of Santiago de Compostela, Santiago de Compostela, Spain
• 3 Faculty of Psychology, University of Oviedo, Oviedo, Spain

In daily academic life, students are exposed to a wide range of potentially stressful situations which could negatively affect their academic achievement and their health. Among the factors that could be weakened by academic stress, attention has been paid to expectations of self-efficacy, which are considered one of the most important determinants for student engagement, persistence, and academic success. From a proactive perspective, research on academic stress has emphasized the importance of coping strategies in preventing harmful consequences. In recent years, there has been a growing interest in discovering the extent to which individuals are able to combine different coping strategies and the adaptive consequences this flexibility entails. However, studies using this person-centered approach are still scarce in the academic context. On that basis, this current study had two objectives: (a) to examine the existence of different profiles of university students based on how they combined different approach coping strategies (positive reappraisal, support seeking, and planning) and (b) to determine the existence of differences in general expectations of self-efficacy between those coping profiles. A total of 1,072 university students participated in the study. The coping profiles were determined by latent profile analysis (LPA). The differences in the self-efficacy variable were determined using ANCOVA, with gender, university year, and degree type as covariates. Four approach coping profiles were identified: (a) low generalized use of approach coping strategies; (b) predominance of social approach coping approaches; (c) predominance of cognitive approach coping approaches; and (d) high generalized use of approach coping strategies. The profile showed that a greater combination of the three strategies was related to higher general self-efficacy expectations and vice versa. These results suggest that encouraging flexibility in coping strategies would help to improve university students’ self-efficacy.

Introduction

The mental health of university students has been a growing concern in recent years ( Milojevich and Lukowski, 2016 ). Various studies have demonstrated the high frequency of psychological symptoms associated with this stage of education ( Blanco et al., 2008 ; Kim et al., 2015 ), with stress being one of the psychosocial problems that have become prevalent ( Deasy et al., 2014 ; American College Health Association, 2018 ; Gustems-Carnicer et al., 2019 ). In their daily lives, university students have to face a wide variety of demands, both academic and non-academic, that could affect their well-being. Academic demands include adaptation to a new context, overwork, insufficient time to do their academic tasks, preparation for and doing of exams, and the pressure to perform ( Beiter et al., 2015 ; Vizoso and Arias, 2016 ; Erschens et al., 2018 ; Webber et al., 2019 ). Non-academic demands include change of where they live; the need to create new social relationships; conflicts with partners, family, or friends; money worries; and concerns about future work ( Howard et al., 2006 ; Galatzer-Levy et al., 2012 ; DeRosier et al., 2013 ; Beiter et al., 2015 ). Stress can bring with it significant harm to the student’s academic performance (e.g., reduced ability to pay attention or to memorize, less dedication to study, and more absences from class) ( Chou et al., 2011 ; Turner et al., 2015 ), as well as to the student’s physical and psychological health (e.g., substance abuse, insomnia, anxiety, and physical and emotional exhaustion) ( Waqas et al., 2015 ; Schönfeld et al., 2016 ). These harmful effects have triggered interest in the identification of individual psychological resources that could be protective factors against the inherent stressors of the university context ( Tavolacci et al., 2013 ). These resources would modulate the relationship between the potential threats and the stress response, encouraging better psychological adjustment ( Leiva-Bianchi et al., 2012 ). Two of the most widely studied resources are coping strategies and self-efficacy.

Coping Strategies

Lazarus and Folkman (1984) thought of stress as an interactive process between the person and their surroundings, in which the influence of stressful events on physical and psychological well-being is determined by coping. From this widely accepted transactional approach, coping would come to be defined by cognitive and behavioral efforts employed in response to external or internal demands that the individual deems to be threats to their well-being.

Despite the documentation of more than 400 coping strategies ( Skinner et al., 2003 ), they are generally categorized into two broad types (for a complete categorization, see Zimmer-Gembeck and Skinner, 2016 ): approach (also called active) strategies and evasive (or disengagement) strategies. Approach strategies involve cognitive and behavioral mechanisms aimed at making an active response to the stressor, directly changing the problem (primary control) or the negative emotions associated with it (secondary control). This category includes strategies such as planning, taking specific action, seeking support (instrumental and emotional), positive reappraisal of the situation, or acceptance. Evasive strategies are those which involve cognitive and behavioral mechanisms used to evade the stressful situation, such as distraction, denial, and wishful thinking. Based on this classification, there is a broad consensus that approach strategies are related to good academic, physical, and psychological adjustment ( Clarke, 2006 ; Syed and Seiffge-Krenke, 2015 ; Gustems-Carnicer et al., 2019 ), whereas evasive strategies usually mean maladaptive consequences for the students ( Tavolacci et al., 2013 ; Deasy et al., 2014 ; Skinner et al., 2016 ; Tran and Lumley, 2019 ).

Self-Efficacy

Expectations of self-efficacy are a central element of the social cognitive theory proposed by Bandura (1997) . This construct is about a person’s beliefs about their ability to mobilize courses of action needed to achieve desired personal goals. It is, therefore, a fundamental psychological resource for exercising control over events in one’s life ( Wood and Bandura, 1989 ). In fact, self-efficacy is considered a powerful motivational, cognitive, and affective determinant of student behavior, with significant influence on their involvement, effort, persistence, self-regulation, and achievement ( Schunk and Pajares, 2010 ; Honicke and Broadbent, 2016 ; Ritchie, 2016 ; Zumbrunn et al., 2019 ). These characteristics make self-efficacy an important variable in controlling stress ( Bandura et al., 2003 ; Sahin and Çetin, 2017 ; Lanin et al., 2019 ), and it is a protection factor against the impact of day-to-day stressors at university ( Freire et al., 2019 ; Schönfeld et al., 2019 ).

Although self-efficacy has commonly been characterized as an expectation that is strongly linked to a specific task or situation, various studies have demonstrated the existence of a more generalized belief—that is, general self-efficacy—around perceived competence in the face of a broad range of demands ( Scholz et al., 2002 ; Feldman et al., 2015 ; Volz et al., 2019 ).

Current Study

The literature reviewed reiterated the importance of considering both coping strategies and expectations of self-efficacy in protection against stress. However, far from being independent resources, some studies have suggested that coping strategies and self-efficacy are related. They postulate that coping behaviors would influence an individual’s expectations of control ( Lazarus and Folkman, 1984 ), such that self-efficacy would be a mediator between coping strategies and the stress response ( Zimmer-Gembeck and Skinner, 2016 ).

Given that, our study aimed to examine the possible influence of coping strategies on the expectations of self-efficacy in a population that is particularly vulnerable to stress, university students. Some studies have shown a positive, significant influence of approach coping strategies on self-efficacy in infant samples ( Sandler et al., 2000 ) and in adults with rheumatoid arthritis ( Keefe et al., 1997 ). However, as far as we are aware, there have been none in the university context.

The main contribution of this study lies in the analysis of student coping strategies using a person-centered focus. Traditionally, research on coping strategies has attempted to determine the suitability of a given strategy, evaluating the benefit or harm that it produces for the individual. This variable-centered approach assumes that certain coping mechanisms are universally adaptive or maladaptive, an argument that has been called the “fallacy of uniform efficacy” ( Bonanno and Burton, 2013 ).

The very characterization of coping strategies as responses to a specific challenge demonstrates their situational specificity. This has led in recent years to the adoption of an approach based on the flexibility of coping, under the supposition that a single individual can combine different strategies, using one or the other depending on the specific situation they are facing ( Eisenbarth, 2012 ; Kobylińska and Kusev, 2019 ). In this vein, the benefits provided by approach coping strategies are maximized if the individual employs problem-focused coping strategies (e.g., planning and seeking instrumental support) or emotion-centered strategies (e.g., positive reappraisal and seeking emotional support) based on the perceived controllability of the stressor facing them ( Cheng, 2001 ; Siltanen et al., 2019 ). In contrast, people who are less flexible in their coping have a smaller repertoire of strategies, which are less effective adjusting to the specific demands of the situation ( Cheng and Cheung, 2005 ).

Studying individuals’ profiles in light of the flexibility of their coping is therefore adopting a person-centered focus ( Laursen and Hoff, 2006 ), making it possible to identify subgroups of students characterized by high internal similarity in their repertoire of coping strategies, who differ from the way that other students combine their strategies. An additional advantage over the traditional, variable-focused approaches is that studying profiles of flexibility of coping makes it possible to identify specific groups of individuals who can be prioritized in the design of interventions ( Kaluza, 2000 ).

Considering a perspective based on coping flexibility, the research question we posed in this study was whether the different student profiles—in the way they combine their coping strategies—would be related to significantly different levels of general self-efficacy. In the university context, various studies have demonstrated that, in comparison to those with less flexible profiles, students who are more flexible in their coping demonstrate lower vulnerability to stress ( Cheng, 2001 ; Kato, 2012 ; Doron et al., 2014 ; González Cabanach et al., 2018 ) and to depressive symptomatology ( Gabrys et al., 2018 ; Hasselle et al., 2019 ), as well as greater psychological well-being ( Freire et al., 2018 ). Based on that research, our hypothesis is that students who exhibit a more flexible profile of strategies will demonstrate significantly higher levels of self-efficacy than less flexible students.

Assuming that in the young population the use of approach coping strategies is more typical ( Cheng et al., 2014 ), in our study, we examined coping profiles based on the combination of three approach strategies that are very common in educational contexts ( Skinner et al., 2016 ): a primary control (planning), a secondary control (positive reappraisal), and a mixed type (seeking instrumental and emotional support). Similarly, given the extensive and varied range of demands faced by students in their daily lives (both academic and non-academic), we examined their level of general self-efficacy. Finally, in this study, we also tried to control for the effects of the variables gender, university year, and degree type. It would seem that men report higher levels of self-efficacy than women, with this difference emerging at the end of adolescence ( Huang, 2013 ). It may also be the case that students in their first year of university, because of their inexperience, may have lower levels of self-efficacy than students with more academic experience ( Honicke and Broadbent, 2016 ). As for the type of course, scientific disciplines have been related to lower levels of self-efficacy ( Findley-Van Nostrand and Pollenz, 2017 ).

Materials and Methods

Participants.

The study used a sample of 1,085 undergraduate students from the University of A Coruña (Spain). The inclusion criteria were for subjects to be undergraduate students at the time of the study. Exclusion criteria included failing to respond to more than 20% of the items. We excluded 13 cases because they failed to respond to enough items. There were a smaller number of missing values in 28 other cases, which were dealt with using full information maximum likelihood (FIML) via Mplus 7.11 ( Muthén and Muthén, 1998–2012 ). This means that the definitive sample was made up of 1,072 students aged between 18 and 48 years ( M = 21.09; SD = 3.16). Just over two thirds ( n = 729; 68%) were women, and 343 (32%) were men. The distribution by degree course was as follows: 383 (37.5%) were studying educational sciences (infant education, primary education, social education, physical education, language and hearing, speech therapy, and educational psychology); 203 (19%) were studying health sciences (physiotherapy, nursing, and sports science); 207 (19.3%) were studying legal and social sciences (law and sociology); and 279 (26%) were studying technical sciences (architecture, technical architecture, and civil engineering). The distribution of students in terms of their university year was 304 (28.4%) in their first year, 307 (28.6%) in their second year, 302 (28.2%) in their third year, 91 (8.5%) in their fourth year, and 68 (6.3%) in their fifth year.

Instruments

We used the coping scale from the Academic Stress Questionnaire to measure coping strategies ( Cabanach et al., 2010 ). This instrument has 23 items evaluating three approach strategies for coping: positive reappraisal, support seeking, and planning. Positive reappraisal is a secondary control strategy in which the student seeks to reassign the stressful event, highlighting the positive (e.g., “When I am faced with a problematic situation, I forget unpleasant aspects and highlight the positive ones”). The psychometric properties were acceptable, in terms of both reliability (α = 0.860; ω = 0.864; construct reliability = 0.857; composite reliability = 0.857) and validity (convergent validity = 0.483; construct validity: χ 2 = 119.87; df = 30; p > 0.05; GFI = 0.98; AGFI = 0.96; TLI = 0.96; CFI = 0.98; RMR = 0.03; RMSEA = 0.05). Support seeking is a mixed coping strategy, as the student can do that with the aim of seeking information and advice from others to resolve the issue at hand (e.g., “When I am faced with a problematic situation, I ask for advice from a family member or a close friend”) or they can seek consolation and emotional relief (e.g., “When I am faced with a problematic situation, I manifest my feelings and opinions to others”). The psychometric properties of this subscale were good, in reliability (α = 0.902; ω = 0.903; construct reliability = 0.900; composite reliability = 0.900) and validity (convergent validity = 0.566; construct validity: χ 2 = 35.43; df = 12; p > 0.05; GFI = 0.99; AGFI = 0.98; TLI = 0.99; CFI = 0.99; RMR = 0.02; RMSEA = 0.04). Planning is a primary control strategy, characterized by analysis and the design of a plan of action aimed at resolving the problematic situation (“When I am faced with a problematic situation, I draw up an action plan and follow it”). The psychometric properties were acceptable, in terms of both reliability (α = 0.81; ω = 0.81; construct reliability = 0.85; composite reliability = 0.82) and validity (convergent validity = 0.504; construct validity: χ 2 = 33.52; df = 8; p > 0.05; GFI = 0.99; AGFI = 0.97; TLI = 0.97; CFI = 0.98; RMR = 0.03; RMSEA = 0.05). The participants’ responses are recorded on a five-point Likert scale (1 = never to 5 = always).

We used the Spanish validation of the General Self-efficacy Scale from Baessler and Schwarzer (1996) . The scale has 10 items (e.g., “I can solve difficult problems if I try hard enough”) that the participants respond to on a Likert scale from 1 (never) to 5 (always). In this study, the psychometric properties were good, in reliability (α = 0.91; ω = 0.91; construct reliability = 0.909; composite reliability = 0.909) and validity (convergent validity = 0.514; construct validity: χ 2 = 121.36; df = 30; p > 0.05; GFI = 0.98; AGFI = 0.96; TLI = 0.98; CFI = 0.98; RMR = 0.02; RMSEA = 0.05).

The study protocol was designed and executed in compliance with the code of ethics set out by the university in which the research was done, with the informed consent of all participants, as required by the Helsinki Declaration. Data collection was carried out at the beginning of the academic year in order to avoid periods of high academic demands (e.g., work overload and preparation for exams) that could favor greater emotional activation in students and, therefore, influence their responses to the questionnaires. Before beginning the study, the participants were informed of the objectives and were asked to participate; they were assured of anonymity and the confidentiality of their responses. Likewise, the instructor explained that students who did not wish to participate in the study could leave the classroom until the end of the tests, without any repercussions or negative consequences. The questionnaires were administered in the classrooms where the students had their usual classes, during normal class hours, and in a single session without a time limit.

Data Analysis

To identify the student profiles according to the flexibility of their coping, we performed a latent profile analysis (LPA) ( Lanza et al., 2003 ) using the statistical program Mplus 7.11 ( Muthén and Muthén, 1998–2012 ). LPA allows the identification of latent categorical variables to group the subjects into classes (profiles), establishing what fits best from a finite set of models. The following were used as reference parameters to determine the optimum model: the Akaike Information Criterion (AIC), the Schwarz Bayesian information criterion (BIC), the BIC adjusted for sample size (SSA-BIC), the formal adjusted maximum likelihood ratio test from Lo et al. (2001) (LMRT), the parametric bootstrap likelihood ratio test (PBLRT), and the sample size for each subgroup. The AIC, BIC, and SSA-BIC indices are descriptive, the lowest values indicating the best fit of the model, whereas LMRT and PBLRT are the indices that allow the final decision to be made. The values of p associated with LMRT and PBLRT indicate whether the solution with more ( p < 0.05) or fewer classes ( p > 0.05) is the one with the best fit to the data. Another of the exclusion criteria was the existence of spurious classes ( n ≤ 5% of the sample), which would indicate excessive extraction of profiles ( Hipp and Bauer, 2006 ).

Once the optimal model was selected based on the above criteria, we moved on to determining its classifying accuracy using the entropy statistic and calculation of a posteriori probabilities as references. Another criterion for evaluating the validity of the model was a MANOVA analyzing the differences between classes in the three criterion variables (positive reappraisal, support seeking, and planning). Statistically significant differences between the three variables would indicate that the latent classes suggested by the model were distinct. Finally, the differences in self-efficacy between the different coping profiles were established using an ANCOVA, with gender, year, and degree type as covariables. The effect size of the differences between the groups was determined using partial eta squared and Cohen’s (1988) d : null, η p 2 < 0.01 ( d < 0.09); small, η p 2 = 0.01 to η p 2 = 0.058 ( d = 0.10 to d = 0.49); medium, η p 2 = 0.059 to η p 2 = 0.137 ( d = 0.50 to d = 0.79); and large, η p 2 ≥ 0.138 ( d ≥ 0.80). These analyses were performed using SPSS 26.0 ( IBM Corp, 2019 ).

Preliminary Analysis

Descriptive statistics and the values of (Pearson) correlations between the variables are given in Table 1 . The asymmetry and kurtosis data indicate that the variables followed a normal distribution (all values between −1 and 1). Similarly, all of the correlations were statistically significant ( p < 0.001). Statistically speaking, the results of the Bartlett sphericity test indicate that the variables were sufficiently intercorrelated [χ 2 (6) = 1,066.75; p < 0.001)], an important requirement for subsequent multivariate analysis.

Table 1. Means, standard deviations, and correlations for the three strategies for coping with stress and general self-efficacy ( N = 1072).

Identification of Coping Profiles

The fit of various latent profile models was examined (models from two to five classes). In the model fit, it was assumed that variances could differ between indicators within each group, with the restriction specifying that they be equal between the groups. Similarly, a restriction was set on the independence between indicators, both within and between groups.

Table 2 gives the results of the model fit. The analysis of fit was stopped at the five-class model for various reasons: (a) the values of BIC and SSA-BIC were higher in the five-class model than in the four-class model, and the AIC was almost the same in the two models; (b) the values of LMRT and PBLRT for the five-class model were not statistically significant ( p > 0.05, in both cases), which indicated that the fit of this model was not better than that of the four-class model; (c) the five-class model included a group made up of fewer than 5% of the total sample, which indicated excessive extraction of profiles. In contrast, in the four-class model, all of the groups made up more than 5% of the total sample. Similarly, all of the data summarized in Table 2 indicated that the four-class model demonstrated better fit than the two- and three-class models, leading to the selection of the four-class model as the optimum.

Table 2. Statistics for the identification of fit of latent class models and classifying accuracy.

Table 3 gives the classifying accuracy of the four-class model, as well as the number of participants (overall sample and by gender) making up each class in that model, both in absolute terms ( n ) and as a percentage (%). The means associated with the groups the participants were assigned to are given in the main diagonal in the table in bold. The first group demonstrated a classification coefficient of 85%, whereas the other three groups had coefficients a little below 80%. Overall, these data indicate that the four-class model demonstrates adequate classification accuracy. Similarly, the value of the entropy statistic of this model (0.639) ( Table 2 ), although modest, is acceptable ( Nylund et al., 2007 ).

Table 3. Characterization of the latent profiles and classifying accuracy of the individuals in each profile.

As an additional criterion for assessing the suitability of the four-class model, the results of the MANOVA showed statistically significant differences between the four classes in the three criterion variables: positive reappraisal [ F (3, 1068) = 391.49; p < 0.001; η p 2 = 0.524], support seeking [ F (3, 1068) = 770.37; p < 0.001; η p 2 = 0.684], and planning [ F (3, 1068) = 463.61; p < 0.001; η p 2 = 0.566]. The effect size was large in all cases.

Description of Coping Profiles

The mean scores (direct and standardized) of the members of each of the latent classes (coping profiles) in the selected model are given in Table 4 . The same profiles are shown graphically in Figure 1 .

Table 4. Description of latent profiles (means, standard errors, and confidence intervals).

Figure 1. Graphical representation of coping profiles (standardized scores). LACS: profile of low approach coping strategies; HACS: profile of high approach coping strategies; SAC: profile with a prevalence of social approach coping strategies; CAC: profile with a prevalence of cognitive approach coping strategies.

The first group ( n = 296; 27.61%) was made up of students with low scores in the three approach coping strategies (profile of low approach coping strategies, LACS), who demonstrated low flexibility in the use of these strategies. The second group ( n = 290; 27.05%) demonstrated the opposite, scoring highly in the three coping strategies (profile of high approach coping strategies, HACS). Compared to the other profiles, these were the students who demonstrated the most flexibility in deploying approach coping strategies. The third group was the largest ( n = 355; 33.12%) and was made up of students with high scores in support seeking and low scores in positive reappraisal and planning. Given the overwhelmingly social nature of support seeking, we called this the social approach coping (SAC) profile. Finally, the smallest group in quantitative terms ( n = 131; 12.22%) was made up of students demonstrating the opposite pattern to SAC, high scores in positive reappraisal and planning and low scores in support seeking. We called this the cognitive approach coping (CAC) profile as these students seemed to prefer more cognitive approach strategies, rather than social strategies.

Relationship Between Coping Profiles and Self-Efficacy

Once the effects of gender, year, and degree course had been controlled for, the results of the ANCOVA demonstrated statistically significant differences between the coping profiles in the variable self-efficacy [ F (3, 1065) = 140.638, p < 0.001, η p 2 = 0.284), with a large effect size. The a posteriori tests (Scheffé) showed that the HACS profile scored highest in self efficacy, with statistically significant differences between it and the SAC and LACS profiles, the effect size being large in both cases ( d = 0.98 and d = 1.55, respectively). The CAC profile also had significantly higher scores in self-efficacy than the SAC and LACS profiles, with large effect sizes ( d = 0.88 and d = 1.46, respectively). The self-efficacy scores from the SAC profile were significantly higher than those from the LACS profile, with a medium effect size ( d = 0.58). These data indicate that the LACS profile scored significantly lower in self-efficacy than the other coping profiles identified in this study. Table 5 gives the descriptive statistics for the four coping profiles with respect to the self-efficacy variable. When we looked at the covariables, there was no statistically significant effect found with the year variable, but there was with the degree type [ F (1065) = 5.163, p < 0.05, η p 2 = 0.005] and gender [ F (1065) = 50.405, p < 0.001, η p 2 = 0.045], although the effect size was null for the degree type and small for gender. Having noted the small effect of gender on self-efficacy, we looked more deeply at this interaction in each of the coping profiles. In the LACS [ t (294) = 6.56, p < 0.001, d = 0.45], HACS [ t (288) = 4.17, p < 0.001, d = 0.27], and SAC profiles [ t (353) = 3.43, p < 0.01, d = 0.26], men scored significantly higher in self-efficacy than women, whereas the effect of gender on self-efficacy was not significant in the CAC profile.

Table 5. Descriptive statistics (means and standard deviations) corresponding to coping profiles in general self-efficacy.

Although previous research has demonstrated the importance of coping strategies and self-efficacy in the prevention of stress, the relationship between these two psychological resources has not been the focus of attention previously in the university context. The main contribution of this study is in the analysis of the relationship between coping strategies and general self-efficacy in university students in light of coping flexibility.

From this person-centered focus, it is assumed that coping strategies are not mutually exclusive categories but instead operate together ( Eisenbarth, 2012 ; Kobylińska and Kusev, 2019 ), such that their functionality depends on the individuals having a repertoire of strategies available that would allow them to respond specifically to the challenge they have to deal with ( Cheng et al., 2014 ; Siltanen et al., 2019 ). The results of our study are consistent with this approach, we have identified four profiles of university students which differ in the extent of their flexibility in approach coping with stress. One of the profiles we identified (HACS) has a coping repertoire which combines high levels of positive reappraisal, support seeking, and planning. This is a group of highly flexible students when it comes to coping with problems, bringing together strategies for primary control of stressors (planning and instrumental support seeking) with others aimed at secondary control (positive reappraisal and emotional support seeking). In general, research suggests that when facing problems, the most effective method is to use primary control strategies when the situation is deemed controllable, whereas relying on secondary control strategies is more beneficial when the challenge is perceived as uncontrollable ( Zimmer-Gembeck and Skinner, 2016 ). From this perspective, the HACS profile would be highly adaptive, as the students in this group would have both types of strategy available. Our findings also demonstrated the existence of two profiles of students who displayed lower levels of coping flexibility than the HACS profiles, as their repertoires included high levels of some but not all of the three approach coping strategies we examined. One group was characterized by the combination of high levels of positive reappraisal and planning, with low levels of support seeking (the CAC profile). The other, in contrast, combined high levels of support seeking with low levels of the other two strategies (the SAC profile).

These two profiles are, to a certain extent, opposites, as students in the SAC group exhibited predominantly social coping, prioritizing their sources of support as the routes to find advice and/or emotional consolation about their problematic situations, whereas students in the CAC group preferred to opt for a more cognitive coping (i.e., focus on the positives of the situation and plan how to deal with it) rather than sharing their problems socially. According to this characterization, the students with a SAC profile would have a much smaller repertoire of approach coping strategies, which could indicate excessive instrumental and emotional dependence on their significant social circle when they have to deal with academic and non-academic stressors. Students with a CAC profile would choose to respond to stressors more autonomously, either because of a lack of interpersonal skills to ask for help or because they feel they do not have this social support or because they feel the advantages of seeking help are outweighed by the disadvantages ( Scharp and Dorrance Hall, 2019 ), such as being considered incompetent or weak. Finally, in this study, we identified the existence of a group of students characterized by a low use of positive reappraisal, support seeking, and planning (the LACS profile). Assuming that these three strategies are highly functional in academic contexts ( Skinner et al., 2016 ), the reduced availability of them in this profile would seem to indicate the students’ lack of flexibility to respond adaptively to the various demands of day-to-day university life.

The identification of these four profiles adds to the growing line of work which supports the benefits of analyzing coping with stress in the university context with a person-centered approach (e.g., Cheng, 2001 ; Kato, 2012 ; Doron et al., 2014 ; Freire et al., 2018 ; Gabrys et al., 2018 ; González Cabanach et al., 2018 ; Hasselle et al., 2019 ). To be specific, the four-profile solution in our study coincides with results from González Cabanach et al. (2018) , in a study which also examined flexibility of coping based on the combination of positive reappraisal, support seeking, and planning strategies. This may point to a potential generalization of the profiles identified when the flexibility of approach coping with stress is examined in a university context.

Beyond affirming the existence of student profiles characterized by differences in the flexibility of coping, the objective of our study was to determine whether these groups diverged in their expectations of self-efficacy. In accordance with our hypothesis, the greater the flexibility in approach coping with stress, the higher the students’ levels of general self-efficacy and vice versa. The student profiles that had most flexibility in their coping (HACS and CAC) exhibited notable differences (i.e., large effect sizes) in self-efficacy compared to less flexible profiles (SAC and LACS). Additionally, the SAC profile exhibited moderately higher self-efficacy (i.e., medium effect size) than the LACS profile.

These results could indicate, in line with other studies from the healthcare context (e.g., Haythornthwaite et al., 1998 ), that flexibility in coping enhances university students’ perception of control over their day-to-day challenges, making them feel better able to handle them. This explanation may be connected with what Hobfoll’s conservation of resources theory ( Hobfoll et al., 2018 ) postulates. According to this theory, individuals who have high levels of personal resources (e.g., a variety of approach coping strategies) participate in an upward spiral of acquisition, development, and preservation of new resources (e.g., self-efficacy). In contrast, scarce resources in the face of a given challenge (e.g., low flexibility in coping) would put the individual into a downward spiral of losing resources (e.g., low self-efficacy) which would make them more vulnerable to stress. In this way, personal resources would act in “convoy” ( Holmgreen et al., 2017 ), one after the other, whether upward or downward. In addition, the fact that we did not find significant differences between the HACS and CAC profiles with regard to general self-efficacy suggests that, in terms of developing generalized self-referential beliefs about personal competency in response to the demands of university life, the combination of cognitive strategies (positive reappraisal and planning) is more important than social strategies (support seeking). This idea is in line with the lower potency that Bandura’s (1997) social cognitive theory ascribes to social sources in making up expectations of self-efficacy. Thus, it is possible that the low availability of cognitive coping resources exhibited by students with the SAC profile would negatively affect their beliefs of competency for dealing with stressors, which would lead them to seek feedback from their sources of support that would give them some degree of self-efficacy, albeit significantly less than students with HACS and CAC profiles, but still somewhat higher than students with the LACS profile.

Implications of the Results of the Study

University stress is a growing psychosocial concern, both because of its prevalence and because of the negative consequences it can have for the student. Although this scenario highlights the need to implement effective coping interventions in the entire university population, this need is even more pronounced in students who are studying healthcare-related degrees ( Saeed et al., 2016 ), in which stress levels are significantly higher ( Heinen et al., 2017 ; Zeng et al., 2019 ). In line with that, the results of our study may represent a significant contribution, in that they help increase our understanding of how two important psychological resources, flexibility of approach coping strategies and general self-efficacy, function in the prevention of stress.

To be more specific, our findings allow the identification of those students who, depending on the level of their flexibility in the use of approach coping strategies, are more (LACS and SAC profiles) or less (HACS and CAC profiles) vulnerable with respect to developing their expectations of generalized self-efficacy.

Not only does self-efficacy play an important role in the prevention of university stress ( Freire et al., 2019 ; Schönfeld et al., 2019 ), it is also one of the most influential factors in the motivational, cognitive, and behavioral responses of the student to the teaching–learning process ( Schunk and Pajares, 2010 ). Consequently, in light of our results, students in the SAC and particularly in the LACS profiles should be the focus of priority intervention in order to enhance flexibility in their repertoire of approach coping strategies as a way of improving their generalized expectations of self-efficacy. In recent years, interventions aimed at improving the coping skills of university students have proliferated. Most of these initiatives have adopted an approach based on cognitive behavioral therapy ( Houston et al., 2017 ), mindfulness ( Kang et al., 2009 ), or a combination of the two ( Recabarren et al., 2019 ). In these programs, students learn to identify the main symptoms associated with stress, as well as the external (environmental demands) and internal (thoughts and emotions) factors that contribute to its appearance. Furthermore, students acquire various primary control (e.g., planning and problem solving) and secondary control (e.g., positive reappraisal and meditation) adaptive coping strategies.

Although these types of interventions have shown their effectiveness both in reducing stress ( Regehr et al., 2013 ; Yusufov et al., 2019 ) and in increasing self-efficacy ( Molla Jafar et al., 2015 ; Phang et al., 2015 ), they have limited influence by themselves on the students’ abilities to be flexible in their coping strategies ( Cheng and Cheung, 2005 ). Prior research offers us evidence of the efficacy of focused training to enhance both individuals’ repertoires of strategies and their metacognitive abilities to evaluate and select the best coping strategies in each situation ( Cheng et al., 2012 ).

From this, it would seem that metacognitive self-regulation and executive functioning skills (e.g., planning, organization, emotional management) constitute an important resource for improving students’ abilities to make their repertoires of strategies more flexible, in addition to specific training aimed at increasing their coping strategies ( Bettis et al., 2017 ; de la Fuente et al., 2018a ). Some online tools in this area, such as e-Coping with Academic Stress TM , have demonstrated good results in the improvement of self-regulating skills (e.g., self-evaluation and decision making) in students when facing potentially stressful situations in the university context ( de la Fuente et al., 2018b ). These results also have important implications at the classroom level, given that if teachers encourage the development of self-regulation skills in university students, they increase the tendency for students to autonomously use approach coping strategies, such as establishing a plan of action, assessing the positive aspects of the situation, or seeking advice and emotional support from other people ( de la Fuente et al., 2020 ). These self-regulatory skills have also been shown to be effective in increasing students’ self-efficacy beliefs ( Cerezo et al., 2019 ).

Limitations of the Study and Lines for Future Research

The contributions of this study should be assessed, taking into account the limitations inherent in its design. First, the transversal nature of the study does not allow causal relationships to be established between the variables studied. Therefore, although our results suggest that flexibility in coping with stress influences the generalized expectations of self-efficacy, the causal order between these variables must be examined in the light of more rigorous study designs (e.g., longitudinal studies). A second limitation lies in the composition of the sample, which was dissimilar in terms of gender representation, university year, and degree type. In this study, those three variables were considered as covariates to statistically control their effect, with degree type and gender exhibiting a null effect and a small effect, respectively. However, new studies are needed that would be able to corroborate the extent to which these variables are important, or not, in the configuration of the profiles of coping flexibility and in the relationship between these profiles and self-efficacy. In fact, based on our findings, the levels of general self-efficacy were significantly higher in men (albeit with a small effect size) in all of the coping profiles except the group which had similar levels of representation of both sexes (the CAC profile), where there were no differences. Therefore, in order to make the results more generalizable to the university student population, future studies should use more thorough recruitment procedures that would give more balanced samples in terms of gender, university year, and degree type. In the same vein, future work should consider the extent to which variables not addressed in this study, such as students’ previous academic performance, their socioeconomic status, or their intellectual abilities (e.g., cognitive and attention level), may be relevant in the relationship between stress coping profiles and general self-efficacy in the university context. The fact that all of the participants were recruited from the same university constitutes a third limitation of our study. In order to facilitate generalization of the results, new studies are needed which involve students from other geographical and cultural contexts.

Fourth, the use of self-reports as a data collection method may limit the veracity of the results, since participants may have response biases, ranging from a misunderstanding of the items to social desirability bias (i.e., the tendency of survey respondents to answer questions in a manner that will be viewed favorably by others, even if the survey is anonymous) ( Rosenman et al., 2011 ). These biases may have been increased by the effect of the data collection method used (collective and pencil-and-paper condition). In fact, this type of method can increase the perception of a lack of privacy and confidentiality when other participants are present ( van de Looij-Jansen and de Wilde, 2008 ), encouraging the social desirability response effect and a higher rate of questions not answered, especially with sensitive questions such as those related to mental health ( Raat et al., 2007 ). These and other limitations—for example, data collection costs and data entry errors ( Colasante et al., 2019 ), physical and emotional fatigue of the participants at the time data collection, and absence of a rigorous control over the time taken to complete the questionnaires ( Díaz de Rada, 2018 )—could be minimized by using computerized administration of questionnaires. Likewise, future studies should corroborate our findings using a combination of methods that include not only questionnaires but also classroom observations and in-depth interviews with the students.

There is another limitation with respect to the questionnaires used, specifically the questionnaire we used to evaluate coping strategies. Although the three strategies evaluated by this instrument (positive reappraisal, support seeking, and planning) are widely used in academic contexts, that does not preclude the possibility of students using other types of strategies. Future research should examine the possible makeup of flexible coping profiles considering other strategies that were not assessed in this study.

Finally, another limitation lies in the operationalization of the concept of coping flexibility. Our results seem to be consistent with the conceptualization of coping flexibility in terms of balanced profiles, according to which the student deploys various strategies at similar levels ( Kaluza, 2000 ). Despite this idea of coping flexibility being widely adopted in the educational field, there are other ways to operationalize this construct (e.g., a broad repertoire or cross-situational variability; for a more precise characterization, see Cheng et al., 2014 ), which might impede comparison between studies and the generalization of the results.

Data Availability Statement

The datasets generated for this study are available on request to the corresponding author.

Ethics Statement

The studies involving human participants were reviewed and approved by the Ethics Committee at the University of A Coruña. The patients/participants provided their written informed consent to participate in this study.

Author Contributions

CF and MF contributed to the conceptualization, investigation, methodology, writing, and supervision of this study. BR and SR contributed to the investigation, writing, and supervision of this study. AV and JN contributed to the methodology, writing, and supervision of this study.

This work was financed by the research projects EDU2013-44062-P (MINECO), EDU2017-82984-P (MEIC), and the Consejería de Empleo, Industria y Turismo del Principado de Asturias (Department of Employment, Industry and Tourism of the Principality of Asturias, Spain) (ref. FC-GRUPIN-IDI/2018/000199).

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Acknowledgments

The authors would like to thank the students who participated in the study.

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Keywords : coping strategies, coping flexibility, stress, self-efficacy, university students

Citation: Freire C, Ferradás MdM, Regueiro B, Rodríguez S, Valle A and Núñez JC (2020) Coping Strategies and Self-Efficacy in University Students: A Person-Centered Approach. Front. Psychol. 11:841. doi: 10.3389/fpsyg.2020.00841

Received: 29 January 2020; Accepted: 06 April 2020; Published: 19 May 2020.

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Copyright © 2020 Freire, Ferradás, Regueiro, Rodríguez, Valle and Núñez. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: María del Mar Ferradás, [email protected]

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• Research Article
• Open access
• Published: 06 April 2021

Health anxiety, perceived stress, and coping styles in the shadow of the COVID-19

• Szabolcs Garbóczy 1 , 2 ,
• Anita Szemán-Nagy 3 ,
• Mohamed S. Ahmad 4 ,
• Szilvia Harsányi 1 ,
• Dorottya Ocsenás 5 , 6 ,
• Viktor Rekenyi 4 ,
• Ala’a B. Al-Tammemi 1 , 7 &
• László Róbert Kolozsvári   ORCID: orcid.org/0000-0001-9426-0898 1 , 7  

BMC Psychology volume  9 , Article number:  53 ( 2021 ) Cite this article

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In the case of people who carry an increased number of anxiety traits and maladaptive coping strategies, psychosocial stressors may further increase the level of perceived stress they experience. In our research study, we aimed to examine the levels of perceived stress and health anxiety as well as coping styles among university students amid the COVID-19 pandemic.

A cross-sectional study was conducted using an online-based survey at the University of Debrecen during the official lockdown in Hungary when dormitories were closed, and teaching was conducted remotely. Our questionnaire solicited data using three assessment tools, namely, the Perceived Stress Scale (PSS), the Ways of Coping Questionnaire (WCQ), and the Short Health Anxiety Inventory (SHAI).

A total of 1320 students have participated in our study and 31 non-eligible responses were excluded. Among the remaining 1289 participants, 948 (73.5%) and 341 (26.5%) were Hungarian and international students, respectively. Female students predominated the overall sample with 920 participants (71.4%). In general, there was a statistically significant positive relationship between perceived stress and health anxiety. Health anxiety and perceived stress levels were significantly higher among international students compared to domestic ones. Regarding coping, wishful thinking was associated with higher levels of stress and anxiety among international students, while being a goal-oriented person acted the opposite way. Among the domestic students, cognitive restructuring as a coping strategy was associated with lower levels of stress and anxiety. Concerning health anxiety, female students (domestic and international) had significantly higher levels of health anxiety compared to males. Moreover, female students had significantly higher levels of perceived stress compared to males in the international group, however, there was no significant difference in perceived stress between males and females in the domestic group.

The elevated perceived stress levels during major life events can be further deepened by disengagement from home (being away/abroad from country or family) and by using inadequate coping strategies. By following and adhering to the international recommendations, adopting proper coping methods, and equipping oneself with the required coping and stress management skills, the associated high levels of perceived stress and anxiety could be mitigated.

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Introduction

On March 4, 2020, the first cases of coronavirus disease were declared in Hungary. One week later, the World Health Organization (WHO) declared COVID-19 as a global pandemic [ 1 ]. The Hungarian government ordered a ban on outdoor public events with more than 500 people and indoor events with more than 100 participants to reduce contact between people [ 2 ]. On March 27, the government imposed a nationwide lockdown for two weeks effective from March 28, to mitigate the spread of the pandemic. Except for food stores, drug stores, pharmacies, and petrol stations, all other shops and educational institutions remained closed. On April 16, a week-long extension was further announced [ 3 ].

The COVID-19 pandemic with its high morbidity and mortality has already afflicted the psychological and physical wellbeing of humans worldwide [ 4 , 5 , 6 , 7 , 8 , 9 ]. During major life events, people may have to deal with more stress. Stress can negatively affect the population’s well-being or function when they construe the situation as stressful and they cannot handle the environmental stimuli [ 10 ]. Various inter-related and inter-linked concepts are present in such situations including stress, anxiety, and coping. According to the literature, perceived stress can lead to higher levels of anxiety and lower levels of health-related quality of life [ 11 ]. Another study found significant and consistent associations between coping strategies and the dimensions of health anxiety [ 12 ].

Health anxiety is one of the most common types of anxiety and it describes how people think and behave toward their health and how they perceive any health-related concerns or threats. Health anxiety is increasingly conceptualized as existing on a spectrum [ 13 , 14 ], and as an adaptive signal that helps to develop survival-oriented behaviors. It also occurs in almost everyone’s life to a certain degree and can be rather deleterious when it is excessive [ 13 , 14 ]. Illness anxiety or hypochondriasis is on the high end of the spectrum and it affects someone’s life when it interferes with daily life by making people misinterpret the somatic sensations, leading them to think that they have an underlying condition [ 14 ].

According to the American Psychiatric Association—Diagnostic and Statistical Manual of Mental Disorders (fifth edition), Illness anxiety disorder is described as a preoccupation with acquiring or having a serious illness, and it reflects the high spectrum of health anxiety [ 15 ]. Somatic symptoms are not present or if they are, then only mild in intensity. The preoccupation is disproportionate or excessive if there is a high risk of developing a medical condition (e.g., family history) or the patient has another medical condition. Excessive health-related behaviors can be observed (e.g., checking body for signs of illness) and individuals can show maladaptive avoidance as well by avoiding hospitals and doctor appointments [ 15 ].

Health anxiety is indeed an important topic as both its increase and decrease can progress to problems [ 14 ]. Looking at health anxiety as a wide spectrum, it can be high or low [ 16 ]. While people with a higher degree of worry and checking behaviors may cause some burden on healthcare facilities by visiting them too many times (e.g., frequent unnecessary visits), other individuals may not seek medical help at healthcare units to avoid catching up infections for instance. A lower degree of health anxiety can lead to low compliance with imposed regulations made to control a pandemic [ 17 ].

The COVID-19 pandemic as a major event in almost everyone’s life has posed a great impact on the population’s perceived stress level. Several studies about the relation between coping and response to epidemics in recent and previous outbreaks found higher perceived stress levels among people [ 18 , 19 , 20 , 21 ]. Being a woman, low income, and living with other people all were associated with higher stress levels [ 18 ]. Protective factors like being emotionally more stable, having self-control, adaptive coping strategies, and internal locus of control were also addressed [ 19 , 20 ]. The findings indicated that the COVID-19 crisis is perceived as a stressful event. The perceived stress was higher amongst people than it was in situations with no emergency. Nervousness, stress, and loss of control of one’s life are the factors that are most connected to perceived stress levels which leads to the suggestion that unpredictability and uncontrollability take an important part in perceived stress during a crisis [ 19 , 20 ].

Moreover, certain coping styles (e.g., having a positive attitude) were associated with less psychological distress experiences but avoidance strategies were more likely to cause higher levels of stress [ 21 ]. According to Lazarus (1999), individuals differ in their perception of stress if the stress response is viewed as the interaction between the environment and humans [ 22 ]. An Individual can experience two kinds of evaluation processes, one to appraise the external stressors and personal stake, and the other one to appraise personal resources that can be used to cope with stressors [ 22 , 23 ]. If there is an imbalance between these two evaluation processes, then stress occurs, because the personal resources are not enough to cope with the stressor’s demands [ 23 ].

During stressful life events, it is important to pay attention to the increasing levels of health anxiety and to the kind of coping mechanisms that are potential factors to mitigate the effects of high anxiety. The transactional model of stress by Lazarus and Folkman (1987) provides an insight into these kinds of factors [ 24 ]. Lazarus and Folkman theorized two types of coping responses: emotion-focused coping, and problem-focused coping. Emotion-focused coping strategies (e.g., distancing, acceptance of responsibility, positive reappraisal) might be used when the source of stress is not embedded in the person’s control and these strategies aim to manage the individual’s emotional response to a threat. Also, emotion-focused coping strategies are directed at managing emotional distress [ 24 ]. On the other hand, problem-focused coping strategies (e.g., confrontive coping, seeking social support, planful problem-solving) help an individual to be able to endure and/or minimize the threat, targeting the causes of stress in practical ways [ 24 ]. It was also addressed that emotion-focused coping mechanisms were used more in situations appraised as requiring acceptance, whereas problem-focused forms of coping were used more in encounters assessed as changeable [ 24 ].

A recent study in Hunan province in China found that the most effective factor in coping with stress among medical staff was the knowledge of their family’s well-being [ 25 ]. Although there have been several studies about the mental health of hospital workers during the COVID-19 pandemic or other epidemics (e.g., SARS, MERS) [ 26 , 27 , 28 , 29 ], only a few studies from recent literature assessed the general population’s coping strategies. According to Gerhold (2020) [ 30 ], older people perceived a lower risk of COVID-19 than younger people. Also, women have expressed more worries about the disease than men did. Coping strategies were highly problem-focused and most of the participants reported that they listen to professionals’ advice and tried to remain calm [ 30 ]. In the same study, most responders perceived the COVID-19 pandemic as a global catastrophe that will severely affect a lot of people. On the other hand, they perceived the pandemic as a controllable risk that can be reduced. Dealing with macrosocial stressors takes faith in politics and in those people, who work with COVID-19 on the frontline.

Mental disorders are found prevalent among college students and their onset occurs mostly before entry to college [ 31 ]. The diagnosis and timely interventions at an early stage of illness are essential to improve psychosocial functioning and treatment outcomes [ 31 ]. According to research that was conducted at the University of Debrecen in Hungary a few years ago, the students were found to have high levels of stress and the rate of the participants with impacted mental health was alarming [ 32 ]. With an unprecedented stressful event like the COVID-19 crisis, changes to the mental health status of people, including students, are expected.

Aims of the study

In our present study, we aimed at assessing the levels of health anxiety, perceived stress, and coping styles among university students amidst the COVID-19 lockdown in Hungary, using three validated assessment tools for each domain.

Methods and materials

Study design and setting.

This study utilized a cross-sectional design, using online self-administered questionnaires that were created and designed in Google Forms® (A web-based survey tool). Data collection was carried out in the period April 30, 2020, and May 15, 2020, which represents one of the most stressful periods during the early stage of the COVID-19 pandemic in Hungary when the official curfew/lockdown was declared along with the closure of dormitories and shifting to online remote teaching. The first cases of COVID-19 were declared in Hungary on March 4, 2020. On April 30, 2020, there were 2775 confirmed cases, 312 deaths, and 581 recoveries. As of May 15, 2020, the number of confirmed cases, deaths, and recovered persons was 3417, 442, and 1287, respectively.

Our study was conducted at the University of Debrecen, which is one of the largest higher education institutions in Hungary. The University is located in the city of Debrecen, the second-largest city in Hungary. Debrecen city is considered the educational and cultural hub of Eastern Hungary. As of October 2019, around 28,593 students were enrolled in various study programs at the University of Debrecen, of whom, 6,297 were international students [ 33 ]. The university offers various degree courses in Hungarian and English languages.

Study participants and sampling

The target population of our study was students at the University of Debrecen. Students were approached through social media platforms (e.g., Facebook®) and the official student administration system at the University of Debrecen (Neptun). The invitation link to our survey was sent to students on the web-based platforms described earlier. By using the Neptun system, we theoretically assumed that our survey questionnaire has reached all students at the University. The students who were interested and willing to participate in the study could fill out our questionnaire anonymously during the determined study period; thus, employing a convenience sampling approach. All students at the University of Debrecen whose age was 18 years or older and who were in Hungary during the outbreak had the eligibility to participate in our study whether undergraduates or postgraduates.

Study instruments

In our present study, the survey has solicited information about the sociodemographic profile of participants including age (in years), gender (female vs male), study program (health-related vs non-health related), and whether the student stayed in Hungary or traveled abroad during the period of conducting our survey in the outbreak. Our survey has also adopted three international scales to collect data about health anxiety, coping styles, and perceived stress during the pandemic crisis. As the language of instruction for international students at the University of Debrecen is English, and English fluency is one of the criteria for international students’ admission at the University of Debrecen, the international students were asked to fill out the English version of the survey and the scales. On the other hand, the Hungarian students were asked to fill out the Hungarian version of the survey and the validated Hungarian scales. Also, we provided contact information for psychological support when needed. Students who felt that they needed some help and psychological counseling could use the contact information of our peer supporters. Four International students have used this opportunity and were referred to a higher level of care. The original scales and their validated Hungarian versions are described in the following sections.

Perceived Stress Scale (PSS)

The Perceived Stress Scale (PSS) measures the level of stress in the general population who have at least completed a junior high school [ 34 ]. In the PSS, the respondents had to report how often certain things occurred like nervousness; loss of control; feeling of upset; piling up difficulties that cannot be handled; or on the contrary how often the students felt they were able to handle situations; and were on top of things. For the International students, we used the 10-item PSS (English version). The statements’ responses were scored on a 5-point Likert scale (from 0 = never to 4 = very often) as per the scale’s guide. Also, in the 10-item PSS, four positive items were reversely scored (e.g. felt confident about someone’s ability to handle personal problems) [ 34 ]. The PSS has satisfactory psychometric properties with a Cronbach’s alpha of 0.78, and this English version was used for international students in our study.

For the Hungarian students, we used the Hungarian version of the PSS, which has 14 statements that cover the same aspects of stress described earlier. In this version of the PSS, the responses were evaluated on a 5-point Likert scale (0–4) to mark how typical a particular behavior was for a respondent in the last month [ 35 ]. The Hungarian version of the PSS was psychometrically validated in 2006. In the validation study, the Hungarian 14-item PSS has shown satisfactory internal consistency with a Cronbach’s alpha of 0.88 [ 35 ].

Ways of Coping Questionnaire (WCQ)

The second scale we used was the 26-Item Ways of Coping Questionnaire (WCQ) which was developed by Sørlie and Sexton [ 36 ]. For the international students, we used the validated English version of the 26-Item WCQ that distinguished five different factors, including Wishful thinking (hoped for a miracle, day-dreamed for a better time), Goal-oriented (tried to analyze the problem, concentrated on what to do), Seeking support (talked to someone, got professional help), Thinking it over (drew on past experiences, realized other solutions), and Avoidance (refused to think about it, minimized seriousness of it). The WCQ examined how often the respondents used certain coping mechanisms, eg: hoped for a miracle, fantasized, prepared for the worst, analyzed the problem, talked to someone, or on the opposite did not talk to anyone, drew conclusions from past things, came up with several solutions for a problem or contained their feelings. As per the 26-item WCQ, responses were scored on a 4-point Likert scale (from 0 = “does not apply and/or not used” to 3 = “used a great deal”). This scale has satisfactory psychometric properties with Cronbach's alpha for the factors ranged from 0.74 to 0.81[ 36 ].

For the Hungarian students, we used the Hungarian 16-Item WCQ, which was validated in 2008 [ 37 ]. In the Hungarian WCQ, four dimensions were identified, which were cognitive restructuring/adaptation (every cloud has a silver lining), Stress reduction (by eating; drinking; smoking), Problem analysis (I tried to analyze the problem), and Helplessness/Passive coping (I prayed; used drugs) [ 37 ]. The Cronbach’s alpha values for the Hungarian WCQ’s dimensions were in the range of 0.30–0.74 [ 37 ].

Short Health Anxiety Inventory (SHAI)

The third scale adopted was the 18-Items Short Health Anxiety Inventory (SHAI). Overall, the SHAI has two subscales. The first subscale comprised of 14 items that examined to what degree the respondents were worried about their health in the past six months; how often they noticed physical pain/ache or sensations; how worried they were about a serious illness; how much they felt at risk for a serious illness; how much attention was drawn to bodily sensations; what their environment said, how much they deal with their health. The second subscale of SHAI comprised of 4 items (negative consequences if the illness occurs) that enquired how the respondents would feel if they were diagnosed with a serious illness, whether they would be able to enjoy things; would they trust modern medicine to heal them; how many aspects of their life it would affect; how much they could preserve their dignity despite the illness [ 38 ]. One of four possible statements (scored from 0 to 3) must be chosen. Alberts et al. (2013) [ 39 ] found the mean SHAI value to be 12.41 (± 6.81) in a non-clinical sample. The original 18-item SHAI has Cronbach’s alpha values in the range of 0.74–0.96 [ 39 ]. For the Hungarian students, the Hungarian version of the SHAI was used. The Hungarian version of SHAI was validated in 2011 [ 40 ]. The scoring differs from the English version in that the four statements were scored from 1 to 4, but the statements themselves were the same. In the Hungarian validation study, it was found that the SHAI mean score in a non-clinical sample (university students) was 33.02 points (± 6.28) and the Cronbach's alpha of the test was 0.83 [ 40 ].

Data analyses

Data were extracted from Google Forms® as an Excel sheet for quality check and coding then we used SPSS® (v.25) and RStudio statistical software packages to analyze the data. Descriptive and summary statistics were presented as appropriate. To assess the difference between groups/categories of anxiety, stress, and coping styles, we used the non-parametric Kruskal–Wallis test, since the variables did not have a normal distribution and for post hoc tests, we used the Mann–Whitney test. Also, we used Spearman’s rank correlation to assess the relationship between health anxiety and perceived stress within the international group and the Hungarian group. Comparison between international and domestic groups and different genders in terms of health anxiety and perceived stress levels were also conducted using the Mann–Whitney test. Binary logistic regression analysis was also employed to examine the associations between different coping styles/ strategies (treated as independent variables) and both, health anxiety level and perceived stress level (treated as outcome variables) using median splits. A p-value less than 5% was implemented for statistical significance.

Ethical considerations

Ethical permission was obtained from the Hungarian Ethical Review Committee for Research in Psychology (Reference number: 2020-45). All methods were carried out following the institutional guidelines and conforming to the ethical standards of the declaration of Helsinki. All participants were informed about the study and written informed consent was obtained before completing the survey. There were no rewards/incentives for completing the survey.

Sociodemographic characteristics of respondents

A total of 1320 students have responded to our survey. Six responses were eliminated due to incompleteness and an additional 25 responses were also excluded as the students filled out the survey from abroad (International students who were outside Hungary during the period of conducting our study). After exclusion of the described non-eligible responses (a total of 31 responses), the remaining 1289 valid responses were included in our analysis. Out of 1289 participants (100%), 73.5% were Hungarian students and around 26.5% were international students. Overall, female students have predominated the sample (n = 920, 71.4%). The median age (Interquartile range) among Hungarian students was 22 years (5) and for the international students was 22 years (4). Out of the total sample, most of the Hungarian students were enrolled in non-health-related programs (n = 690, 53.5%), while most of the international students were enrolled in health-related programs (n = 213, 16.5%). Table 1 demonstrates the sociodemographic profile of participants (Hungarian vs International).

Perceived stress, anxiety, and coping styles

For greater clarity of statistical analysis and interpretation, we created preferences regarding coping mechanisms. That is, we made the categories based on which coping factor (in the international sample) or dimension (in the Hungarian sample) the given person reached the highest scores, so it can be said that it is the person's preferred coping strategy. The four coping strategies among international students were goal-oriented, thinking it over, wishful thinking, and avoidance, while among the Hungarian students were cognitive restructuring, problem analysis, stress reduction, and passive coping.

The 26-item WCQ [ 31 ] contains a seeking support subscale which is missing from the Hungarian 16-item WCQ [ 32 ]; therefore, the seeking support subscale was excluded from our analysis. Moreover, because the PSS contained a different number of items in English and Hungarian versions (10 items vs 14 items), we looked at the average score of the answers so that we could compare international and domestic students.

In the evaluation of SHAI, the scoring of the two questionnaires are different. For the sake of comparability between the two samples, the international points were corrected to the Hungarian, adding plus one to the value of each answer. This may be the reason why we obtained higher results compared to international standards.

Among the international students, the mean score (± standard deviation) of perceived stress among male students was 2.11(± 0.86) compared to female students 2.51 (± 0.78), while the mean score (± standard deviation) of health anxiety was 34.12 (± 7.88) and 36.31 (± 7.75) among males and females, respectively. Table 2 shows more details regarding the perceived stress scores and health anxiety scores stratified by coping strategies among international students.

In the Hungarian sample, the mean score (± standard deviation) of perceived stress among male students was 2.06 (± 0.84) compared to female students 2.18 (± 0.83), while the mean score (± standard deviation) of health anxiety was 33.40 (± 7.63) and 35.05 (± 7.39) among males and females, respectively. Table 3 shows more details regarding the perceived stress scores and health anxiety scores stratified by coping strategies among Hungarian students.

Concerning coping styles among international students, the statements with the highest-ranked responses were “wished the situation would go away or somehow be finished” and “Had fantasies or wishes about how things might turn out” and both fall into the wishful thinking coping. Among the Hungarian students, the statements with the highest-ranked responses were “I tried to analyze the problem to understand better” (falls into problem analysis coping) and “I thought every cloud has a silver lining, I tried to perceive things cheerfully” (falls into cognitive restructuring coping).

On the other hand, the statements with the least-ranked responses among the international students belonged to the Avoidance coping. Among the Hungarians, it was Passive coping “I tried to take sedatives or medications” and Stress reduction “I staked everything upon a single cast, I started to do something risky” to have the lowest-ranked responses. Table 4 shows a comparison of different coping strategies among international and Hungarian students.

To test the difference between coping strategies, we used the non-parametric Kruskal–Wallis test, since the variables did not have a normal distribution. For post hoc tests, we used Mann–Whitney tests with lowered significance levels ( p  = 0.0083). Among Hungarian students, there were significant differences between the groups in stress ( χ 2 (3) = 212.01; p < 0.001) and health anxiety ( χ 2 (3) = 80.32; p  < 0.001). In the post hoc tests, there were significant differences everywhere ( p  < 0.001) except between stress reduction and passive coping ( p  = 0.089) and between problem analysis and passive coping ( p  = 0.034). Considering the health anxiety, the results were very similar. There were significant differences between all groups ( p  < 0.001), except between stress reduction and passive coping ( p  = 0.347) and between problem analysis and passive coping ( p  = 0.205). See Figs.  1 and 2 for the Hungarian students.

Perceived stress differences between coping strategies among the Hungarian students

Health anxiety differences between coping strategies among the Hungarian students

Among the international students, the results were similar. According to the Kruskal–Wallis test, there were significant differences in stress ( χ 2 (3) = 73.26; p  < 0.001) and health anxiety ( χ 2 (3) = 42.60; p  < 0.001) between various coping strategies. The post hoc tests showed that there were differences between the perceived stress level and coping strategies everywhere ( p  < 0.005) except and between avoidance and thinking it over ( p  = 0.640). Concerning health anxiety, there were significant differences between wishful thinking and goal-oriented ( p  < 0.001), between wishful thinking and avoidance ( p  = 0.001), and between goal-oriented and avoidance ( p  = 0.285). There were no significant differences between wishful thinking and thinking it over ( p  = 0.069), between goal-oriented and thinking it over ( p  = 0.069), and between avoidance and thinking it over ( p  = 0.131). See Figs.  3 and 4 .

Perceived stress differences between coping strategies among the international students

Health anxiety differences between coping strategies among the international students

The relationship between coping strategies with health anxiety and perceived stress levels among the international students

We applied logistic regression analyses for the variables to see which of the coping strategies has a significant effect on SHAI and PSS results. In the first model (model a), with the health anxiety as an outcome dummy variable (with median split; median: 35), only two coping strategies had a statistically significant relationship with health anxiety level, including wishful thinking (as a risk factor) and goal-oriented (as a protective factor).

In the second model (model b), with the perceived stress as an outcome dummy variable (with median split; median: 2.40), three coping strategies were found to have a statistically significant association with the level of perceived stress, including wishful thinking (as a risk factor), while goal-oriented and thinking it over as protective factors. See Table 5 .

The relationship between coping strategies with health anxiety and perceived stress levels among domestic students

By employing logistic regression analysis, with the health anxiety as an outcome dummy variable (with median split; median: 33.5) (model a), three coping strategies had a statistically significant relationship with health anxiety level among domestic students, including stress reduction and problem analysis (as risk factors), while cognitive restructuring (as a protective factor).

Similarly, with the perceived stress as an outcome dummy variable (with median split; median: 2.1429) (model b), three coping strategies had a statistically significant relationship with perceived stress level, including stress reduction and problem analysis (as risk factors), while cognitive restructuring (as a protective factor). See Table 6 .

Comparisons between domestic and international students

We compared health anxiety and perceived stress levels of the Hungarian and international students’ groups using the Mann–Whitney test. In the case of health anxiety, the results showed that there were significant differences between the two groups ( W  = 149,431; p  = 0.038) and international students’ levels were higher. Also, there was a significant difference in the perceived stress level between the two groups ( W  = 141,024; p  < 0.001), and the international students have increased stress levels compared to the Hungarian ones.

Comparisons between genders within students’ groups (International vs Hungarian)

Firstly, we compared the international men’s and women’s health anxiety and stress levels using the Mann–Whitney test. The results showed that the international women’s health anxiety ( W  = 11,810; p  = 0.012) and perceived stress ( W  = 10,371; p  < 0.001) levels were both significantly higher than international men’s values. However, in the Hungarian sample, women’s health anxiety was significantly higher than men’s ( W  = 69,643; p  < 0.001), but there was no significant difference in perceived stress levels among between Hungarian women and men ( W  = 75,644.5; p  = 0.064).

Relationship between health anxiety and perceived stress

We correlated the general health anxiety and perceived stress using Spearman’s rank correlation. There was a significant moderate positive relationship between the two variables ( p  < 0.001; ρ  = 0.446). Within the Hungarian students, there was a significant correlation between health anxiety and perceived stress ( p  < 0.001; ρ  = 0.433), similarly among international students as well ( p  < 0.001; ρ  = 0.465).

In our study, we found that individuals who were characterized by a preference for certain coping strategies reported significantly higher perceived stress and/or health anxiety than those who used other coping methods. These correlations can be found in both the Hungarian and international students. In the light of our results, we can say that 48.4% of the international students used wishful thinking as their preferred coping method while around 43% of the Hungarian students used primarily cognitive restructuring to overcome their problems.

Regulation of emotion refers to “the processes whereby individuals monitor, evaluate, and modify their emotions in an effort to control which emotions they have, when they have them, and how they experience and express those emotions” [ 41 ]. There is an overlap between emotion-focused coping and emotion regulation strategies, but there are also differences. The overlap between the two concepts can be noticed in the fact that emotion-focused coping strategies have an emotional regulatory role, and emotion regulation strategies may “tax the individual’s resources” as the emotion-focused coping strategies do [ 23 , 42 ]. However, in emotion-focused coping strategies, non-emotional tools can also be used to achieve non-emotional goals, while emotion regulation strategies may be used for maintaining or reinforcing positive emotions [ 42 ].

Based on the cognitive-behavioral model of health anxiety, emotion-regulating strategies can regulate the physiological, cognitive, and behavioral consequences of a fear response to some degree, even when the person encounters the conditioned stimulus again [ 12 , 43 ]. In the long run, regular use of these dysfunctional emotion control strategies may manifest as functional impairment, which may be associated with anxiety disorders. A detailed study that examined health anxiety in the view of the cognitive-behavioral model found that, regardless of the effect of depression, there are significant and consistent correlations between certain dimensions of health anxiety and dysfunctional coping and emotional regulation strategies [ 12 ].

Similar to our current study, other studies have found that health anxiety was positively correlated with maladaptive emotion regulation and negatively with adaptive emotion regulation [ 44 ], and in the case of state anxiety that emotion-focused coping strategies proved to be less effective in reducing stress, while active coping leads to a sense of subjective well-being [ 17 , 27 , 45 , 46 , 47 ]

SHAI values were found to be high in other studies during the pandemic, and the SHAI results of the international students in our study were found to be even slightly higher compared to those studies [ 44 , 48 ]. Besides, anxiety values for women were found to be higher than for men in several studies [ 44 , 48 , 49 , 50 ]. This was similar to what we found among the international students but not among the Hungarian ones. We can speculate that the ability to contact someone, the closeness of family and beloved ones, familiarity with the living environment, and maybe less online search about the coronavirus news could be factors counting towards that finding among Hungarian students. Also, most international students were enrolled in health-related study programs and his might have affected how they perceived stress/anxiety and their preferred coping strategies as well. Literature found that students of medical disciplines could have obstacles in achieving a healthy coping strategy to deal with stress and anxiety despite their profound medical knowledge compared to non-health-related students [ 51 , 52 ]. Literature also stressed the immense need for training programs to help students of medical disciplines in adopting coping skills and stress-reducing strategies [ 51 ].

The findings of our study may be a starting point for the exploration of the linkage between perceived stress, health anxiety, and coping strategies when people are not in their domestic context. People who are away from their home and friends in a relatively alien environment may tend to use coping mechanisms other than the adequate ones, which in turn can lead to increased levels of perceived stress.

Furthermore, our results seem to support the knowledge that deep-rooted health anxiety is difficult to change because it is closely related to certain coping mechanisms. It was also addressed in the literature that personality traits may have a significant influence on the coping strategy used by a person [ 53 ], revealing sophisticated and challenging links to be considered especially during training programs on effective coping and management skills. On the other hand, perceived stress which has risen significantly above the average level in the current pandemic, can be most effectively targeted by the well-formulated recommendations and advice of major international health organizations if people successfully adhere to them (e.g. physical activity; proper and adequate sleep; healthy eating; avoiding alcohol; meditation; caring for others; relationships maintenance, and using credible information resources about the pandemic, etc.) [ 1 , 54 ]. Furthermore, there may be additional positive effects of these recommendations when published in different languages or languages that are spoken by a wide range of nationalities. Besides, cognitive behavioral therapy techniques, some of which are available online during the current pandemic crisis, can further reduce anxiety. Also, if someone does not feel safe or fear prevails, there are helplines to get in touch with professionals, and this applies to the University of Debrecen in Hungary, and to a certain extent internationally.

Naturally, our study had certain limitations that should be acknowledged and considered. The temporality of events could not be assessed as we employed a cross-sectional study design, that is, we did not have information on the previous conditions of the participants which means that it is possible that some of these conditions existed in the past, while others de facto occurred with COVID-19 crisis. The survey questionnaires were completed by those who felt interested and involved, i.e., a convenience sampling technique was used, this impairs the representativeness of the sample (in terms of sociodemographic variables) and the generalizability of our results. Also, the type of recruitment (including social media) as well as the online nature of the study, probably appealed more to people with an affinity with this kind of instrument. Besides, each questionnaire represented self-reported states; thus, over-reporting or under-reporting could be present. It is also important to note that international students were answering the survey questionnaire in a language that might not have been their mother language. Nevertheless, English fluency is a prerequisite to enroll in a study program at the University of Debrecen for international students. As the options for gender were only male/female in our survey questionnaire, we might have missed the views of students who do not identify themselves according to these gender categories. Also, no data on medical history/current medical status were collected. Lastly, we had to make minor changes to the used scales in the different languages for comparability.

The COVID-19 pandemic crisis has imposed a significant burden on the physical and psychological wellbeing of humans. Crises like the current pandemic can trigger unprecedented emotional and behavioral responses among individuals to adapt or cope with the situation. The elevated perceived stress levels during major life events can be further deepened by disengagement from home and by using inadequate coping strategies. By following and adhering to the international recommendations, adopting proper coping strategies, and equipping oneself with the required coping and stress management skills, the associated high levels of perceived stress and anxiety might be mitigated.

Availability of data and materials

The datasets generated and/or analyzed during the current study are not publicly available due to compliance with institutional guidelines but they are available from the corresponding author (LRK) on a reasonable request.

Abbreviations

Centers for Disease Control and Prevention

Coronavirus Disease 2019

Perceived Stress Scale

Short Health Anxiety Inventory

Middle East Respiratory Syndrome

Severe Acute Respiratory Syndrome

Ways of Coping Questionnaire

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Acknowledgments

We would like to provide our extreme thanks and appreciation to all students who participated in our study. ABA is currently supported by the Tempus Public Foundation’s scholarship at the University of Debrecen.

This research project did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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Szabolcs Garbóczy, Szilvia Harsányi, Ala’a B. Al-Tammemi & László Róbert Kolozsvári

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Anita Szemán-Nagy

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Mohamed S. Ahmad & Viktor Rekenyi

Department of Social and Work Psychology, Institute of Psychology, University of Debrecen, Debrecen, Hungary

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All authors SG, ASN, MSA, SH, DO, VR, ABA, and LRK have worked on the study design, text writing, revising, and editing of the manuscript. DO, SG, and VR have done data management and extraction, data analysis. Drafting and interpretation of the manuscript were made in close collaboration by all authors SG, ASN, MSA, SH, DO, VR, ABA, and LRK. All authors read and approved the final manuscript.

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Garbóczy, S., Szemán-Nagy, A., Ahmad, M.S. et al. Health anxiety, perceived stress, and coping styles in the shadow of the COVID-19. BMC Psychol 9 , 53 (2021). https://doi.org/10.1186/s40359-021-00560-3

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Academic stress is the most common mental state that medical students experience during their training period. To assess academic stress, to find out its determinants, to assess other sources of stress and to explore the various coping styles against academic stress adopted by students. Methods: It was a cross sectional study done among medical students from first to fourth year. Standard self-administered questionnaires were used to assess academic stress and coping behaviour. Mean age of the 400 participants was 20.3 ± 1.5 years. 166(41.5%) of them were males. The academic stress was found to be of mild, moderate and severe level among 68(17%), 309(77.3%) and 23(5.7%) participants respectively. Overall coping with stress was found to be poor, average and good among 15(3.8%), 380(95%) and 5(1.2%) participants respectively. Passive emotional ( p  = 0.054) and passive problem ( p  = 0.001) coping behaviours were significantly better among males. Active problem coping behaviour ( p  = 0.007) was significantly better among females. Active emotional coping behaviour did not vary significantly between genders ( p  = 0.54). Majority of the students preferred sharing their personal problems with parents 211(52.7%) followed by friends 202(50.5%). Binary logistic regression analysis found worrying about future ( p  = 0.023) and poor self-esteem ( p  = 0.026) to be independently associated with academic stress. Academic stress although a common finding among students, the coping style to deal with it, was good only in a few. The coping behaviours were not satisfactory particularly among male participants. This along with other determinants of academic stress identified in this study need to be addressed during counselling sessions.

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Introduction

Academic stress has been reported to be the most common mental state that medical students experience during their training period (Ramli et al. 2018 ). It is on the rise among them probably due to increasing course requirements (Ramli et al. 2018 ; Drolet and Rodgers 2010 ). Kumaraswamy ( 2013 ) observed that the issues known to precipitate academic stress were excessive assignments, peer competition, examinations and problems related to time management. University students, for the life phase they are going through, also have to deal with many other stresses such as detachment from the family, building of self-identity and issues concerning adolescence period and those in relation to student-workers. The stress of the medical student is also connected to the relationship with the patient in the clinical period.

Some amount of academic stress is beneficial as it brings about healthy competition with peer group, promotes learning and helps to excel in academics (Malathi and Damodaran 1999 ; Afolayan et al. 2013 ). Lumley and Provenzano ( 2003 ) however reported that, excess of academic stress adversely affects academic performance, class attendance and psychological well-being of students. If it is not identified early and managed, it can cause depression, anxiety, behavioural problems, irritability, social withdrawal and physical illnesses (Adiele et al. 2018 ; Deb et al. 2015 ; Verma et al. 2002 ; Chen et al. 2013 ).

In addition to assessment of academic stress among under graduate medical students, it is also essential to analyze the various stress coping mechanisms adopted by them. This will help researchers in suggesting appropriate intervention strategies for the benefit of the students. Students in turn can educate their patients in future to identify stress and suggest measures to deal with it.

Previous studies have reported that medical students used active coping mechanisms (Al-Dubai et al. 2011 ; Chawla and Sachdeva 2018 ; Gade et al. 2014 ; Abouammoh et al. 2020 ), positive reframing (Al-Dubai et al. 2011 ; Chawla and Sachdeva 2018 ), planning (Chawla and Sachdeva 2018 ; Wu et al. 2018 ), positive reappraisal (Wu et al. 2018 ), emotional support (Chawla and Sachdeva 2018 ; Gade et al. 2014 ), peer discussions (Oku et al. 2015 ) and acceptance (Al-Dubai et al. 2011 ; Chawla and Sachdeva 2018 ) as means for coping stress. There were minimal reports of usage of avoidance strategies for coping stress among medical students (Al-Dubai et al. 2011 ; Chawla and Sachdeva 2018 ).

Royal College of Psychiatrists ( 2011 ) reported that students with secure attachments to family and those residing in a supportive community are in a better position to handle stress. Therefore assessment of various determinants of academic stress is essential to frame most suitable remedial measures for the benefit of the affected. This study was hence done to assess academic stress, to find out its determinants, to assess other sources of stress and to explore the various coping styles adopted by medical students to deal with academic stress in a coastal city in south India.

Materials and Methods

This cross sectional study was conducted in the month of March 2018 at a private medical college in Mangalore. The institutional ethics committee approval was taken before the commencement of the study. Permission to conduct the study was taken from the Dean. Sample size of 364 participants was calculated at 95% confidence intervals (CI), 90% power and the proportion of medical students with average level of academic stress taken as 51.4% based on the findings of Mostafavian et al. ( 2018 ). A non-response rate of 10% was added to arrive at the final sample size which was calculated as 400 participants. A total of 100 students of Bachelor of Medicine and Bachelor of Surgery course from first year to fourth year were therefore chosen to participate in this study using simple random sampling method.

The students were briefed about academic stress and the objectives of this study, in the classroom setting, and written informed consent was taken for their participation. In order to maintain anonymity, the filled in consent form were first collected back from the participants. Later the questionnaires were distributed by the investigators. It was a semi-structured questionnaire containing both closed and open ended questions. It was pre-tested in a group of ten students before its use in the current study. No changes in the questionnaire resulted following the pre-testing and the data collected in this phase were not included in the final study.

Data Collection Tools

Academic stress was assessed using the academic stress inventory tool for university students prepared by Lin and Chen ( 2009 ). They had reported the alpha value of Cronbach’s reliability test for this questionnaire as 0.90. The questionnaire was slightly modified during the content validation phase in this study to incorporate questions on career related issues along with few other minor changes. This questionnaire contained 35 items which were designed in a five point Likert scale. The responses in the scale were “completely disagree,” “disagree,” “neutral,” “agree,” and “completely agree”, with scores ranging from one to five points respectively. Cumulative scores ranging from 35 to 81, 82 to 128 and 129 to 175 were considered as mild, moderate and severe levels of academic stress respectively.

The coping techniques employed by the respondents was assessed using the academic stress coping style inventory developed by Lin and Chen ( 2010 ). The Cronbach’s alpha value of internal consistency for the stress coping style questionnaires was reported by them to be 0.83. It was shortened during the content validation phase to result in 25 questions designed again in Likert’s five-point scale. Scores were ranging from 5 for “completely agree” to 1 for “completely disagree”. Overall coping with stress was rated as poorly adoptive when cumulative score of the participant ranged from 25 to 58, average when it was 59 to 92 and good when it was 93 to 125.

Coping behaviour were grouped as active emotional coping, active problem coping, passive emotional coping and passive problem coping behaviours. Active emotional coping behaviour involved individuals adopting the attitude of emotional adjustment like positive thinking emotions and self-encouragement, when faced with academic stress. Active problem coping behaviour involved dealing academic stress by focussing at the centre of the problem and finding a solution themselves by being calm and optimistic or by searching assistance from external sources. Passive emotional coping behaviour involved constraining emotions, self-accusation, getting angry, blaming others or God or by giving up. Passive problem coping behaviour involved procrastinations, evasive behaviours or going into alcohol or drug abuse while facing academic stress (Lin and Chen 2010 ).

The overall alpha value of Cronbach’s reliability test for the academic stress and coping style inventory questionnaire used in this study was calculated to be 0.901, indicating excellent reliability.

Statistical Analysis

The data entry and analysis were done using IBM SPSS for Windows version 25.0, Armonk, New York. Statistical tests like Chi square test, Fisher’s exact test, Student’s unpaired t test and Karl Pearson’s coefficient of correlation were used for analysis. All the determinants of academic stress significant at 0.15 level were placed in the multivariable model. Backward stepwise elimination procedure was done to identify the independent determinants of academic stress in the model at the last step. p value 0.05 or less was used as the criterion for significance.

A total of 400 students participated in this study and all of them gave satisfactorily filled forms. Their mean age was 20.3 ± 1.5 years and median age was 20 years with an Inter Quartile Range (19, 22) years. As many as 166(41.5%) of them were males. Out of the total participants, 45(11.2%) were local residents, 51(12.8%) were outsiders but within the same state, 262(65.5%) were from other states within India, 35(8.8%) were non-residential Indians and the rest 7(1.7%) were foreigners. Medium of schooling among 388(97%) students was English.

Among the participants, 67(16.7%) were currently staying at their home or rented apartment while the rest 333(83.3%) were staying in the hostels or were staying as paying guests. Majority of them [228(57%)] were staying with their friends. Among others, 118(29.5%) were staying alone, 46(11.5%) with their parents, 7(1.8%) with their relatives and one with her elder sibling.

With respect to lifestyle habits, majority of the participants [249(62.2%)] went to college by walk, and majority [339(84.7%)] slept for 6 to 8 h on an average per day. (Table 1 ).

Sources of Stress among Participants

Majority of students either agreed or strongly agreed that some teachers provided so much of academic information, making it difficult for students to assimilate knowledge [177(44.2%)]. Fear of failure in the exams was the other major cause of academic stress [206(51.5%)]. (Table 2 ).

Majority of students either agreed or strongly agreed that by missing few lectures, they felt anxious about falling short of attendance towards the end [204(51%)]. They also regretted having wasted time set apart for studies [240(60%)]. (Table 3 ).

Overall the level of academic stress was found to be mild among 68(17%), moderate among 309(77.3%) and severe among 23(5.7%) participants. The mean academic stress score was found to be 100.6 ± 19.7. Gender wise variation in academic stress levels was noticed. It was of mild, moderate and severe level among 29(17.5%), 129(77.7%) and 8(4.8%) males and among 39(16.7%), 180(76.9%) and 15(6.4%) females respectively (X 2  = 0.472, p  = 0.79).

The other non-academic sources of stress reported by participants were lack of sufficient vacations [130(32.5%)], staying away from family [103(25.7%)], worrying about future [70(17.5%)], low self-esteem [52(13%)], having trouble with friends 39(9.7%)], facing financial difficulties [33(8.2%)], interpersonal conflicts [28(16.7%)], conflicts with roommates [26(6.5%)], issues with partners [23(5.8%)], sleeping disorders [21(5.2%)], transportation problems [20(5%)], problems in the family [18(4.5%)], searching a partner [17(4.2%)] and lack of parental support [5(1.2%)].

14(3.5%) participants had underlying chronic morbidities. These morbidities were allergic rhinitis among 3, migraine among 3, polycystic ovarian disease among 3, menorrhagia among 2 and allergy, peptic ulcer, hypothyroidism, and impaired glucose tolerance in one student each.

Coping Strategies Adopted by Participants

Majority of the participants [294(73.5%)] either agreed or strongly agreed that they tried to think or do something, that would make them feel happier and relaxed when they were stressed. (Table 4 ).

Overall coping with stress was found to be poor among 15(3.8%), average among 380(95%) and good among 5(1.2%) participants.

The mean coping with stress score was 75.2 ± 9.2. The mean score of various coping behaviours like active emotional coping (items 1 to 6), active problem coping (items 14 to 18), passive emotional coping (items 7 to 13) and passive problem coping (items 19 to 25) were found to be 21.7 ± 3.4, 13.2 ± 2.7, 18.6 ± 4.6 and 18.3 ± 4.2 respectively. (Table 4 ).

Mean active emotional coping score among males ( n  = 166) was 21.5 ± 3.5 and among females ( n  = 234) was 21.8 ± 3.3 (t = 0.613, p  = 0.54). Mean passive emotional coping score among males (n = 166) was 19.1 ± 5.0 and among females (n = 234) was 18.2 ± 4.1 (t = 1.933, p  = 0.054). Mean active problem coping score among males (n = 166) was 12.8 ± 2.8 and among females (n = 234) was 13.5 ± 2.5 (t = 2.711, p  = 0.007). Mean passive problem coping score among males (n = 166) was 19.1 ± 4.4 and among females (n = 234) was 17.7 ± 3.9 (t = 3.412, p  = 0.001).

The various measures adopted by participants to deal with stress were sharing problems with others [223(56.2%)], meditation [132(56.8%)], performing yoga [50(12.8%)], sleeping [29(7.5%)], practicing Tai Chi [13(3.5%)] and listening to music [11(3%)]. Other methods like watching television and exercising were reported by 8(2.2%) participants each, aromatherapy and sports by 5(1.3%) each, eating favourite food and consuming alcohol by two each and browsing through the internet by one participant.

Majority of the students preferred sharing their personal problems with parents 211(52.7%), followed by friends 202(50.5%), siblings 71(17.7%) and others 26(6.5%).

Eight(2%) participants reported using medications for the management of stress. One of them had taken Lorazepam tablets while another Sertraline tablets. The rest of them did not specify the medications.

Reasons like lack of sufficient vacations and worrying about future were found to have highly significant association with academic stress among participants ( p  ≤ 0.001). (Table 5 ).

Coping with stress was average/good among 328(98.8%) participants with moderate/severe levels of academic stress in comparison to 57(83.8%) with mild level of academic stress ( p  < 0.00001).

Similarly correlation of academic stress scores with stress coping scores was found to be significant (r = 0.467, p  < 0.001). Also correlation between academic stress scores with passive emotional (r = 0.513, p < 0.001) and passive problem (r = 0.401, p < 0.001) coping behaviours were found to be significant. However academic stress was not significantly correlated with active emotional (r = − 0.036, p  = 0.468) and active problem (r = 0.072, p  = 0.149) coping behaviours.

Binary logistic regression analysis found worrying about future ( p  = 0.023) and poor self-esteem ( p  = 0.026) among participants to be significantly associated with academic stress after adjusting the confounding effect of other variables in the model. (Table 6 ).

For calculating unadjusted Odds Ratio and 95% CI, participants staying with friends/alone were compared with those staying with parents/siblings/relatives (reference value), participants reporting speed of internet connection at place of stay as average/poor were compared with those reporting good connectivity (reference value).

An interesting fact about this study was that the response rate was total. This supports the importance of this study which addresses a felt need of every medical student.

Academic stress of moderate to severe level were reported among 83% participants in this study. In other studies done among medical students, academic stress was reported among 50% (Dyrbye et al. 2008 ), 53% (Bamuhair et al. 2015 ), 61% (Zamroni et al. 2018 ) and 74.6% (Mostafavian et al. 2018 ) participants. Academic stress among university students of other courses were reported among 48.8% (Reddy et al. 2018 ), 70.7% (Sharififard et al. 2014 ) and 73% (Adiele et al. 2018 ) participants. From these comparisons, it was obvious that academic stress was high among the participants in this study probably because of cultural factors.

There was no association between academic stress and gender of participants in this study as also reported by Mostafavian et al. ( 2018 ) and Zamroni et al. ( 2018 ). However several other studies done among university students reported females to have significantly greater academic stress than males (Adiele et al. 2018 ; Bamuhair et al. 2015 ; Reddy et al. 2018 ; Al-Sowygh et al. 2013 ).

Academic stress was found to be more among medical students in the first year (Nakalema and Ssenyonga 2014 ; Abdulghani 2008 ) or in the final year (Bamuhair et al. 2015 ). This was in contrast to the findings in this study were no such association was observed.

Place of residence was not associated with academic stress in this study and also in the study done among medical students in Iran by Mostafavian et al. ( 2018 ).

Academic stress in the present study was found to be least among participants who were staying with their parents, siblings or relatives. This may be because, number of students at this setting are outsiders. Studying over here, might also be their first occasion of moving out of their home environment. They therefore may be lacking their previously learnt support system such as banking on their family members and childhood friends during difficult times, as also observed by Kumar and Nancy ( 2011 ). They now have to find solutions to various problems by themselves, or by being dependent looking out for newer social contacts. If they were staying with their family members, perhaps they might have received the necessary emotional support during examinations and other stressful situations. The other benefits like getting hygienic food, good living conditions and people to take care of one’s health would have been best when family members were around. The observations in this study were however contradicting the observation of Mostafavian et al. ( 2018 ) who observed that the academic stress was significantly more among those living at their houses compared to those at dormitories.

As many as 60% participants regretted having wasted time set apart for their studies. Poor time management was found to be associated with academic stress by other researchers too (Misra and McKean 2000 ; Macan et al. 1990 ). Good time management skills involves prioritization of activities and judicious usage of time available for organization of the tasks to be completed. Time management was found to determine academic performance by Misra and McKean ( 2000 ). Moreover those with sound time management behaviour were found to have fewer psychological and physical symptoms related to stress (Misra and McKean 2000 ; Macan et al. 1990 ). Lammers et al. ( 2001 ) reported that close to half of the students had notable weaknesses in their time management skills.

Fear of failure in exams and falling short of attendance towards the end were the reasons for academic stress among more than half the participants in this study. Teachers can play an important role in alleviating examination related fears and anxieties by conducting frequent mock examinations (Sharma et al. 2011 ). Meeting individual students’ needs (Aherne et al. 2016 ), to find out the reason for missing classes, time scheduling of activities and providing constructive feedback to students (Sharma et al. 2016 ) are the other recommended strategies advised by previous researchers. Abouserie ( 1994 ) stated that the amount of guidance and support offered by teachers would be a key factor in determining the stress levels of students in any institution. Students themselves have opined that social support from teachers and peer groups, consulting services, and various extracurricular activities are the most useful strategies to deal with stress (Chang et al. 2012 ). As opined by the student community themselves, every institution need to offer them psychotherapy sessions, trainings for reducing emotional tension and opportunities to improve social intelligence (Ruzhenkov et al. 2016 ).

Issues like worrying about future and poor self-esteem among participants in this study were significantly associated with academic stress in the multivariable analysis model. These problems may be related to issues like concern about clearing the increasingly competitive entrance exams and also about the fear of them not being able to pursue the specialty of their choice in future. To address such sensitive problems, there is a need of the placement of a professional counsellor at various professional colleges. Pressley and McCormick ( 1995 ) also suggested that the learning environment within classrooms should be non-competitive, collaborative and task-oriented and not performance oriented, so as to create a stress free learning environment.

Having said this, the course work at medical schools should not be too light either. Kanter ( 2008 ) suggested that this approach can affect the quality of education. Rather students need to be trained in the right way to directly solve the problems related to academic stress by themselves being a part of a self-help program (Chen et al. 2013 ; Aherne et al. 2016 ).

The various sources of academic stress among medical students listed in other studies were, vastness of curriculum as reported by 61.6% (Anuradha et al. 2017 ), 82.2% (Bamuhair et al. 2015 ), and 82.3% (Oku et al. 2015 ), fear of failure in examination by 61.8% (Anuradha et al. 2017 ), frequency of examination by 52.2% (Anuradha et al. 2017 ), lack of recreation and inadequate holidays by 51.8% (Anuradha et al. 2017 ) and by 76.4% (Oku et al. 2015 ), sleep related problems by 64.3% (Bamuhair et al. 2015 ), worrying about future by 78.2% (Bamuhair et al. 2015 ), family problems by 54% (Bamuhair et al. 2015 ), interpersonal conflicts by 57.1% (Bamuhair et al. 2015 ), low self-esteem by 51.7% (Bamuhair et al. 2015 ) and transportation problems by 56.2% participants (Bamuhair et al. 2015 ).

Coping with stress was found to be average among 95% participants in the present study. Almost three-fourth of the participants in the present study tried to think or do something that would make them feel happier and relaxed when they were stressed. Coping methods commonly used by students in previous studies were effective time management, sharing of problems, planned problem solving, going out with friends, social support, meditation and getting adequate sleep. Even emotion-based strategies to cope stress like self-blaming and taking self-responsibility have been reported (Wolf 1994 ; Supe 1998 ; Stern et al. 1993 ; Redhwan et al. 2009 ).

Coping with stress in this study was better among participants with higher levels of academic stress which was similarly observed among Saudi Arabian medical students by Bamuhair et al. ( 2015 ). This suggests that students who perceived greater academic stress where in a position to apply coping strategies against it in a much better way. However the significant correlation between academic stress scores and passive emotional and passive problem scores indicates that the coping behaviour adopted by participants to deal with stress was not satisfactory. Therefore counselling the participants to adopt active coping behaviours is very essential at this setting. In a study done in Ghana by Atindanbila and Abasimi ( 2011 ), wrong or inadequate coping strategies were practiced by university students resulting in reduction of academic stress by mere 4%. Bamuhair et al. ( 2015 ) observed that 32.1% medical students felt too often that, they could not cope with stress. Therefore coping strategies against academic stress among university students in other parts of the world was not satisfactory either. The coping strategies adopted are generally found to vary depending on socio-cultural factors like region, social group, gender, age, and by individuals’ previous experiences as per the WHO/EHA ( 1998 ).

Passive emotional and problem coping behaviours were significantly more among males. This meant that males adopted a number of unhealthy behaviours to deal with academic stress. Unpleasant social coping behaviour was found to reduce social support and increase loneliness by Kato ( 2002 ). Felsten ( 1998 ) observed that specifically procrastination as a coping behaviour was found to result in depression in both men and women.

Female students on the other hand had significantly better active problem scores under coping behaviour. They were hence more mature and composed than the male participants in analysing the centre of the problem in a calm and optimistic manner, and in finding solutions for the same. Bamuhair et al. ( 2015 ) observed that the mean of coping strategies score was significantly higher among females. Females were also found to be better at time management compared to their male counterparts (Misra and McKean 2000 ; Khatib 2014 ). Males therefore need to be counselled about healthy coping behaviours in dealing with academic stress.

Al-Sowygh et al. ( 2013 ) observed that the denial and behaviour disengagement as stress coping strategies were reported to be significantly more among females while self-blame was reported to be more among males. Bang ( 2009 ) reported that the coping mechanism of choice is related to the differences in the roles expected from gender. Males are expected to deal stressful situations by their outward actions while females are expected to focus on emotions and seek social support. Soffer ( 2010 ) stated that women usually choose health-promoting behaviours while men prefer health-risky behaviours.

There was no association between age of participants with the perceived level of academic stress or with the level of adaptability to cope with it in this study supporting the observations of Bamuhair et al. ( 2015 ).

Limitations

This was a cross-sectional study conducted in a single medical college. Therefore the findings of this study cannot be generalized to all medical students across India.

The results of the study reflect important insights into the nature of stress faced by the medical students and the ways they deal with the same. Academic stress was found to be common and was of moderate level in more than three-fourth of the participants. Level of coping with stress was found to be average among 95% of them. Worrying about future and poor self-esteem were independently associated with academic stress among students. Male participants adopted more of unhealthy means of coping with academic stress. Therefore they need to be educated regarding the healthy coping methods. Counselling sessions and other students’ support systems need to be more organized to cater to the issues like career guidance, healthy coping behaviours, time management and to improve the self-esteem among the affected. Attention should also be paid to make the study environment in the classrooms more stress free without excessive academic load. Educating students about unpleasant consequences of stress is equally important. Teachers can also play a constructive role in mentoring and guiding students regarding choosing the right measures to cope with stress. Interactive academic sessions on stress control can further encourage medical students to single out each and every problematic issue. This would accomplish the aim of reducing the academic stress, adopting healthy academic stress coping behaviours, improving academic performance and minimizing anxiety among those with forethoughts about their future professional careers.

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Acknowledgements

We authors thank all the medical students of who took part in this study.

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This manuscript has been read and approved by all the authors, the requirements for authorship as stated earlier in this document have been met, and each author believes that the manuscript represents honest work.

Nitin Joseph: guarantor of this research work, design, literature search, tool preparation, manuscript preparation, revising the work critically for important intellectual content.

Aneesha Nallapati: data collection, data analysis, statistical analysis, interpretation of data, revising the work critically for important intellectual content.

Mitchelle Xavier Machado: data collection, data entry, literature search, manuscript preparation, manuscript editing, revising the work critically for important intellectual content.

Varsha Nair: concept of this study, data collection, data entry, manuscript editing, revising the work critically for important intellectual content.

Shreya Matele: data collection, literature search, manuscript editing, revising the work critically for important intellectual content.

Navya Muthusamy: data collection, literature search, manuscript editing, revising the work critically for important intellectual content.

Aditi Sinha: data collection, literature search, manuscript editing, revising the work critically for important intellectual content.

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Joseph, N., Nallapati, A., Machado, M.X. et al. Assessment of academic stress and its coping mechanisms among medical undergraduate students in a large Midwestern university. Curr Psychol 40 , 2599–2609 (2021). https://doi.org/10.1007/s12144-020-00963-2

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Research Article

University students’ strategies of coping with stress during the coronavirus pandemic: Data from Poland

Contributed equally to this work with: Anna Babicka-Wirkus, Lukasz Wirkus, Krzysztof Stasiak, Paweł Kozłowski

Roles Conceptualization, Formal analysis, Methodology, Project administration, Supervision, Visualization, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliation Institute of Pedagogy, Pomeranian University in Słupsk, Słupsk, Poland

Roles Conceptualization, Data curation, Investigation, Project administration, Resources, Software, Writing – original draft, Writing – review & editing

Affiliation Institute of Pedagogy, Faculty of Social Science, University of Gdańsk, Gdańsk, Poland

Roles Investigation, Resources, Software, Supervision, Writing – review & editing

Affiliation Department of Material Criminal Law and Criminology, Faculty of Law and Administration, University of Gdańsk, Gdańsk, Poland

Roles Data curation, Software, Validation, Writing – review & editing

• Anna Babicka-Wirkus, 
• Lukasz Wirkus, 
• Krzysztof Stasiak, 
• Paweł Kozłowski

• Published: July 26, 2021
• https://doi.org/10.1371/journal.pone.0255041
• Reader Comments

The COVID-19 pandemic has changed the functioning of universities worldwide. In Poland, the transfer to online teaching was announced without prior warning, which radically changed students’ daily functioning. This situation clearly showed the students’ helplessness and difficulties with coping with this new, stressful situation, highlighted in many previous studies. A sudden and far-reaching change in daily functioning caused anxiety, depression, and stress in this group. Thus, from a pedagogical and psychological point of view, it is pertinent to examine the students’ strategies of coping with stress caused by the COVID-19 pandemic. To this end, in 2020, a sample of Polish students was anonymously measured using the Mini-COPE questionnaire. Data was gathered from 577 students from 17 universities. The statistical analysis showed that during the coronavirus pandemic, Polish students most often used the coping strategies of: acceptance, planning, and seeking emotional support. Such factors as age, gender, and place of residence influenced the choice of specific strategies of coping with stress during the COVID-19 pandemic. The results also showed that the youngest students had the lowest coping skills. The results allow for concluding that the students’ maladaptive strategies of coping with stress, especially during the pandemic, may result in long-term consequences for their psychophysiological health and academic achievements. Thus, based on the current results and on the participatory model of intervention, a support program for students is proposed which would involve psychological, organizational, and instrumental support.

Citation: Babicka-Wirkus A, Wirkus L, Stasiak K, Kozłowski P (2021) University students’ strategies of coping with stress during the coronavirus pandemic: Data from Poland. PLoS ONE 16(7): e0255041. https://doi.org/10.1371/journal.pone.0255041

Editor: Shah Md Atiqul Haq, Shahjalal University of Science and Technology, BANGLADESH

Received: March 24, 2021; Accepted: July 9, 2021; Published: July 26, 2021

Copyright: © 2021 Babicka-Wirkus et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the manuscript and its Supporting Information files.

Funding: The author(s) received no specific funding for this work.

Competing interests: The authors have declared that no competing interests exist.

Introduction

University studies are a stressful period as they mean the transition to independent, adult life. Beginning studies can be stressful to many students, since it means the necessity to establish new relationships, develop new studying habits related to the chosen program, cope with overwork, learn time management, and often also change one’s place of residence [ 1 , 2 ]. In its later stages, university education is related to new, further stressors, such as concern over being able to find employment after graduation. Studies thus far show that many students struggle to cope with these stressors and that the incidence of stress among students is increasing [ 3 , 4 ]. Among other consequences, it has a negative impact on mental health [ 2 , 5 ]. In the US, around 10% of university students reported suffering from depression [ 2 ], and this proportion has increased to 15% since 2000 [ 6 – 9 ]. A significant causal factor behind this increase is the stress related to studying.

Stress is undoubtedly a part of students’ lives and it may impact their ways of coping with the demands of university life. Their daily responsibilities involve numerous challenges which lead to stress [ 10 ]. Results from various studies carried out thus far show a clear increase in mental health problems among students [ 11 ]. As some of them indicate, there is also an urgent need to assess the impact of the current pandemic on students’ mental health and wellbeing [ 12 ], which legitimizes carrying out such studies in various countries, including Poland.

In 2020, a new situation appeared which necessitates a different approach to stress and its causal factors–the SARS-CoV-2 virus. Data published by the Johns Hopkins University indicates that thus far, over 100 million people have become infected with COVID-19, and around 2.5 million have died [ 13 ]. The COVID-19 disease affects everyone, including students [ 14 , 15 ], since even those who have not been infected are subject to various restrictions which many countries have implemented to limit the spread of the disease. The reality of the pandemic has also negatively impacted the students’ quality of social life. Studying at a university is also a period of establishing new relationships and intense social life. This is facilitated by the fact that young people exhibit greater levels of extraversion and openness to experience than do older people [ 16 ]. Studies show that contacts with others positively influence quality of life [ 17 ]. Lack of regular contact with friends throughout all phases of the coronavirus pandemic, results in loneliness, which might not be fully mitigated by regular contacts via telephone or other means [ 18 ]. These conclusions are supported by evidence from studies carried out in Great Britain (with participants aged between 13 and 25 years), in which young people reported having lost support, daily routine, social ties, and experiencing anxiety, loneliness, and loss of motivation and aim. Higher incidence of depression and anxiety, both during as well as after periods of social isolation, was also confirmed [ 19 , 20 ]. This may lead to harmful social and psychological consequences [ 21 – 23 ].

In response to the pandemic, most countries have implemented severe restrictions in societal functioning which comprise many spheres of life: social, economic, cultural, and educational. They led to limited interpersonal contacts, changes in the mode of education (online teaching), and reduced economic activity. As a result, an economic recession has affected nearly all countries (including Poland) [ 24 ], which worsened the material conditions of many people (increased unemployment). This significantly impacts students, as it intensifies their concerns about being able to find or retain a job and thus support themselves during their studies and after graduation. Essen and Owusu showed that work and studies are the most frequent causes of stress for students [ 25 ]. Historical data shows that previous pandemics have negatively impacted young people’s material conditions, which had long-term consequences for their physical and mental health as well as academic achievement [ 26 ]. For many students, COVID-19 has additionally complicated their current plans and changed their mode of functioning.

More recently, Matthew H. E. M. Browning et al. identified a range of psychological consequences of the COVID-19 pandemic on students’ psychosocial functioning. All students in the sample indicated that the pandemic impacted them negatively, with 59% reporting a high level of psychological impact [ 27 ]. Other studies on the effects of the pandemic on student mental health also show greater stress, anxiety, depression symptoms, concerns for own and one’s family’s health, reduced social interactions, and increased concerns over academic achievements. Students try to cope with stress, seek support from others, and prefer either negative or positive coping strategies [ 11 , 28 ].

The COVID-19 situation, its rapid spread, insufficient preparation, and significant changes in everyday functioning, including university culture, may contribute to increased stress among students. When not managed properly, chronic stress leads to emotional and psychosomatic consequences which manifest through physical, cognitive, and emotional exhaustion as well as depersonalization and lowered professional–in case of students, academic–efficiency [ 29 ]. The consequences of stress lower efficiency, productivity, and engagement in life activities as well as the satisfaction with their results [ 30 , 31 ]. As Adler and Park point out, effective coping with stress might buffer the impact of stressful events on the physical and mental health, and individuals differ with regards to the coping strategies they use [ 32 ]. Therefore, the aims of the study were: identifying the students’ dominant strategies of coping with stress in the pandemic situation, assessing the influence of sociodemographic factors on the dominant coping strategies, and diagnosing differences in the students’ coping strategies depending on expected social support and its sources.

The stress and coping concept is the most popular study approach, also explaining the mechanisms mediating between personality and disease. Currently, the transactional model of stress by Lazarus and Folkman [ 33 ] is employed increasingly frequently. It posits mutual interactions between people and their environment. This model served as the theoretical basis of the current study. The perception of stress is a subjective and variable phenomenon. Particular attention is paid to the processes of coping with stress, which decide the positive and negative impact of stress on the individual. Using different strategies of coping with stress involves mobilizing cognitive and behavioral resources to meet the demands which are subjectively perceived as surpassing personal capabilities. The course of the coping process depends on personal resources and social support. It can also lead to various behaviors which have negative health effects (substance use) or are maladaptive [ 34 ]. Also, according to Lazarus and Folkman, coping with stress might be related to negative health behaviors [ 35 ]. Metzger et al. analyzed the frequency of negative health behaviors among students. They found that increased alcohol consumption and risky sexual behaviors are typical for people at risk for significant stress [ 36 ]. Styles of coping with stress are determined by gender, education, age, health, well-being, the nature of the stressful situation, personality factors, and others [ 20 ]. Efficient use of emotions allows for more effective problem solving, while venting anger and frustration and denial of reality are potentially destructive reactions to stress [ 37 ]. Expressing emotions might also lead to lower depression and hostility levels in stressful situations [ 38 ]. Some authors distinguish between emotion-focused and problem-focused coping styles, while others distinguish active and avoidant coping or identify maladaptive coping strategies (denial, substance use, venting of negative emotions) which allow for lowering subjectively experienced stress [ 39 – 41 ].

Research questions

The study concerned students’ strategies of coping with stress during the pandemic. The following research questions were put forward:

• What strategies of coping with stress are most often used by students during the coronavirus pandemic?
• What is the relationship between sociodemographic variables and the dominant coping strategies among students?
• How does anticipated support differentiate the coping strategies used by students?

Study population and procedure

In 2019, 1.230 million students studied at around 400 universities in Poland. Sixty-five percent were full-time students. Seventy-three percent studied at public (national) universities. The number of foreign students is relatively low in Poland, being only 61 thousand in 2019. Moreover, a decisive majority—around 60%—of students in Poland are women [ 42 , 43 ]. This proportion reaches 65% for MA studies. Meanwhile, in the EU in general, women comprise around 54% of students [ 44 ].

In early spring of 2020, soon after online teaching was instituted, the questionnaire was distributed to students of four randomly chosen Polish universities. Those students who filled out the online questionnaire were also asked to share it with their acquaintances from other universities. Using snowball sampling method was determined by difficulties in reaching students directly, as well as by their reluctance, especially in the first phase of the pandemic in Poland, to take part in studies and fill out online questionnaires. Having students to invite their acquaintances to also take part in the study allowed for gathering a relatively large sample in a short time. There were no missing data, since the online platform did not allow for submitting incomplete questionnaires.

Participation in the study was voluntary. Informed written consent was obtained from every participant. Before participants started to fill out the online study questionnaire, they had to read the information about the project and its aims and checked the option ’I agree to take part in the study’. The data were analyzed anonymously. The research project and its procedure were approved by the Commission of Bioethics and Human Rights.

Using the snowball sampling method, data from 17 Polish institutions was obtained: universities, technical universities, medical universities, and higher vocational schools. This allowed for measuring coping strategies during the pandemic among students from various universities in various regions of Poland. However, it has to be noted that snowball sampling does not allow for generalizing the results to the entire student population in Poland. Nevertheless, based on the obtained data, certain trends in coping strategies among social sciences students can be shown.

The study took place in April-May 2020. Five hundred and seventy-seven complete questionnaires were collected. Table 1 shows the demographic characteristics of the sample divided by universities.

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https://doi.org/10.1371/journal.pone.0255041.t001

The data was divided into six groups based on the number of students from each given university who took part in the study. The largest group were the students from the University of Gdańsk (UG). Next, the sample comprised students from: Adam Mickiewicz University in Poznań (UAM) - 22.2%, University of Warsaw (UW) - 17.2%, Jan Kochanowski University of Kielce (UJK- 13.7%, and Pomeranian University in Słupsk (5.9%). Due to a low number of students from other universities, an additional group (different universities—DU) was created, which comprised 6.0% of the total sample.

Polish universities vary with respect to their size and educational profile. There are relatively few large universities with over 20 thousand people (roughly 20 out of 400). Most universities are of medium or small size. The largest university in Poland is the University of Warsaw. It also has one of the broadest selections of programs. A characteristic aspect of Polish universities is that they offer specific educational profiles, for example, universities focusing on medical education. Another example is the Pomeranian University, which specializes in teaching education. Table 2 shows basic characteristics of universities which were widely represented in the research sample [ 45 – 50 ].

https://doi.org/10.1371/journal.pone.0255041.t002

In the current study, women represented 89.6% of the sample. Participants between 21 and 24 years of age and those living in large cities represented the largest group (59.5% and 36.7%, respectively) Over 80% of the participants were full-time students, which reflected the general population distribution of students in Poland [ 51 ]. Undergraduate students also represented a larger group.

The multidimensional COPE inventory by Carver et al [ 52 , 53 ] is one of the most popular measures of strategies of coping with stress. It can be used to measure dispositional (typical) and situational coping. The Mini-COPE inventory in a Polish adaptation by Juczyński and Ogińska-Bulik [ 54 ] was used in the current study. The internal consistency of the Polish version of the Mini-COPE was estimated based on a sample of 200 people aged between 25 and 60. The split-half reliability was 0.86 (Guttman’s coefficient = 0.87). The repeatability was satisfactory for the majority of the scales. The Polish version of the Mini-COPE comprises 28 items, which form 14 coping strategies. It is used to measure typical reactions in situations of intense stress. The main question is: What do you usually do when you are stressed by a problem? The coping strategies are described in statements such as “I work or do other things in order not to think about the problem.” Each statement is graded on a four-point Likert scale: 1 = very seldom, 2 = fairly seldom, 3 = fairly often, 4 = very often. Each of the 14 coping strategies is measured by two items.

The Mini-COPE inventory was supplemented with two other semi-open questions. The first concerned the type of support the students expected during the pandemic. The available answers were: psychological, emotional, financial, organizational support, no support needed, and other (to be filled out by the students if necessary). The second supplemental question concerned the sources from which the students expected support during the pandemic. In this case, the students could select the closest appropriate answer from among: family, friends, the university, the government, and other (to be filled out by the students if necessary). Fig 1 shows the distribution of the students’ answers to the supplementary questions about support.

https://doi.org/10.1371/journal.pone.0255041.g001

Regarding the source of support, 5.0% of the students chose “other.” This category comprised the following answers: significant other (0.9%), nobody (1.2%), psychologist/therapist (0.5%), myself (1.4%), all of the above (0.3%), and other combinations indicating two sources, for example, family and the government (0.7%).

Statistical analyses were carried out using the IBM SPSS Statistics 25.0 software. The program was used to calculate basic descriptive statistics together with the Kolmogorov-Smirnov test of normality. Additionally, the Cronbach’s α coefficient was used to calculate the reliability of the Mini-COPE scales. To compare coping strategies between two groups, Mann-Whitney’s U test was used. To compare a higher number of groups, a one-way analysis of variance (ANOVA) was used, and if variance was not equal between the groups, Welch’s correction was additionally applied. Tukey’s HSD test (if variance was homogenous) or Dunnett’s T3 test (if variance was heterogenous) was used for post hoc analyses. To estimate intergroup differences in coping strategies, Pearson’s r correlation analysis was carried out. The significance level was set at α = 0.05. In order to distinguish the groups of participants in terms of coping strategies, a two-step cluster analysis was carried out.

Students’ dominant strategies of coping with stress during the pandemic

Based on the descriptive statistics and the results of the Kolmogorov-Smirnov test of normality, it was concluded that neither of the analyzed variables assumed a distribution close to the Gaussian curve. Skewness values were within the <-2;2> range, which means that it was not significant [ 55 ]. Additionally, the Cronbach’s α coefficient was used to calculate the reliability of the Mini-COPE scales. The analysis showed satisfactory reliability for most of the scales. Relatively low reliability was obtained for the scales of acceptance, humor, self-distraction, and venting of emotions. Detailed results are shown in Table 3 .

https://doi.org/10.1371/journal.pone.0255041.t003

The dominant coping strategies among Polish students were: acceptance, planning, and seeking emotional support. The least frequent strategies were: substance use, denial, behavioral disengagement, and religious coping.

Pearson’s correlation analysis was used to examine the relationships between individual coping strategies in the current sample ( Table 4 ). Active coping was positively correlated with the following coping strategies: planning (strong correlation), positive reframing, religious coping, emotional support seeking, instrumental support seeking, self-distraction, venting of emotions, and self-blame (weak correlations). The higher the frequency of active coping, the higher the frequencies of the above strategies as well. Active coping was moderately and negatively correlated with behavioral disengagement, which means that the higher the frequency of active coping, the lower the frequency of behavioral disengagement.

https://doi.org/10.1371/journal.pone.0255041.t004

Another coping strategy—planning—was positively and weakly-to-moderately correlated with positive reframing, acceptance, religious coping, emotional support seeking, instrumental support seeking, self-distraction, and self-blame. A weak, negative correlation occurred between planning and denial, and a moderate one between behavioral activation—the higher the frequency of planning, the lower the frequency of denial and behavioral disengagement.

Positive reframing was positively and weakly-to-moderately correlated with acceptance, humor, religious coping, emotional support seeking, instrumental support seeking, and self-distraction. This coping strategy was also weakly and negatively correlated with behavioral disengagement and self-blame.

Acceptance was weakly and positively correlated with humor and negatively with denial, behavioral disengagement, and self-blame. In turn, humor was weakly and positively correlated with emotional support seeking, self-distraction, and substance use. A weak and positive correlation also occurred between religious coping and emotional support seeking, instrumental support seeking, and venting of emotions. Religious coping was also weakly and negatively correlated with substance use.

Another strategy—emotional support seeking—was strongly and positively correlated with instrumental support seeking. A weak and positive correlation occurred between the following coping strategies: self-distraction and venting of emotions. Emotional support seeking was weakly and negatively correlated with behavioral disengagement.

On the other hand, seeking instrumental support was weakly-to-moderately and positively correlated with self-distraction, venting of emotions, and self-blame.

Self-distraction was weakly-to-moderately and positively correlated with denial, venting of emotions, substance use, behavioral disengagement, and self-blame.

Denial, venting of emotions, substance use, behavioral disengagement, and self-blame were positively correlated with each other on a weak-to-moderate level (the relationship between behavioral disengagement and self-blame).

The remaining correlations between the coping strategies were not statistically significant.

Students’ strategies of coping with stress–cluster analysis

To distinguish groups of participants based on their coping strategies, a two-step cluster analysis was carried out. It allowed for distinguishing two clusters ( Fig 2 ) for which the silhouette value was 0.2, indicating a satisfactory quality of clustering. From among the coping strategies included in the model, the most important ones were: seeking instrumental support, seeking emotional support, and planning. These strategies differentiated the two clusters to the highest degree. The least important strategies were substance use, denial, and self-blame.

https://doi.org/10.1371/journal.pone.0255041.g002

Table 5 shows the comparison of the clusters with regard to the analyzed strategies. The analysis showed no statistically significant differences for denial, substance use, and self-blame. Differences for other coping strategies were statistically significant, with Cluster 1 participants scoring higher on active coping, planning, positive reframing, humor, religious coping, seeking emotional and instrumental support, self-distraction, and venting of emotions, and lower on behavioral disengagement compared to Cluster 2 participants.

https://doi.org/10.1371/journal.pone.0255041.t005

Sociodemographic factors and strategies of coping with stress

To estimate the gender differences in coping strategies, Mann-Whitney’s U test was used. The analysis showed statistically significant gender differences for humor, emotional support seeking, instrumental support seeking, self-distraction, denial, and venting of emotions. Men in the current sample reported using humor significantly more often than women, but they reported using religious coping, emotional support seeking, instrumental support seeking, self-distraction, and denial less frequently. The results of the analysis are shown in Table 6 .

https://doi.org/10.1371/journal.pone.0255041.t006

Gender differences could result from differences in gender role socialization [ 56 , 57 ]. Women are socialized to be more emotional and seek support in interpersonal relationships. On the other hand, men are socialized to cope with their problems on their own or use humor.

Using a one-way analysis of variance (ANOVA), coping strategy use was compared between age groups ( Table 7 ). The analysis showed statistically significant differences for six strategies: active coping, planning, positive reframing, venting of emotions, behavioral disengagement, and self-blame. To estimate the character of the intergroup differences, an additional post hoc analysis using Tukey’s HSD test was carried out when the variance was equal between the groups, and Dunnett’s T3 test, when the variance was unequal. This type of post hoc analysis was used due to the disproportions in the size of the compared groups. In the case of unequal variances, the Welch correction was also applied.

https://doi.org/10.1371/journal.pone.0255041.t007

18-20-year-olds reported statistically significantly less frequent active coping than did 25-30-year-olds ( p = 0.032) and those 31 and over ( p = 0.032). The youngest participants also reported less frequent planning than did 25-30-year-olds ( p = 0.039) and those 31 and over ( p = 0.045), while 21-24-year-olds reported significantly less frequent planning than 25-30-year-olds ( p = 0.015) and those 31 and over ( p = 0.030). The coping strategy of positive reframing was more frequent in the oldest group compared to the younger groups (p ≤ 0.013). Those 31 and over also reported significantly less frequent venting of emotions compared to 18-20-year-olds ( p = 0.007) and 21-24-year-olds ( p = 0.002). Behavioral disengagement differed significantly between the youngest and the oldest group ( p = 0.014), with the higher frequency of this strategy being reported in the 18-20-year-olds group. Those 31 and over reported less frequent self-blame than did 18-20-year-olds ( p = 0.036) and 25-30-year-olds ( p = 0.019).

The current data show that the oldest students used active coping strategies more often during the pandemic than did the younger students. The aim of these strategies is to solve the problem causing difficult internal tension rather than to avoid the situation altogether. This effect may be related to the older students having greater life experience, including academic experience, at 31 years of age.

In the next step, differences in coping strategy use depending on the place of residence were examined ( Table 8 ). To this end, a one-factor ANOVA was carried out. It showed significant intergroup differences for the following coping strategies: active coping, planning, humor, religious coping, denial, and substance use. Participants living in cities with over 100 thousand residents reported using planning significantly more often than those living in villages ( p < 0.001) or towns up to 20 thousand residents ( p = 0.006).

https://doi.org/10.1371/journal.pone.0255041.t008

Participants living in towns up to 20 thousand residents reported using humor significantly less frequently than those living in cities with over 100 thousand residents ( p = 0.021). Participants living in villages reported using religious coping significantly more often than those living in cities with over 100 thousand residents ( p = 0.004). This is related to a more traditional upbringing and culture in Polish rural regions, where religious rituals play a significant role. Participants living in cities with over 100 thousand residents reported using denial significantly less frequently than those living in villages ( p = 0.002) and in towns with between 20 and 100 thousand residents ( p = 0.034). Substance use was reported more frequently among participants living in biggest cities compared to participants living in villages ( p = 0.002). This is because various psychoactive substances are more easily available in large cities.

After the correction for multiple comparisons was applied, a post hoc analysis using Tukey’s HSD test did not reveal statistically significant intergroup differences in active coping.

To compare full-time and extramural students’ use of coping strategies, Mann-Whitney’s U test was used. It showed that extramural students reported using active coping and positive reframing more frequently, and humor, instrumental support seeking, self-distraction, venting of emotions, substance use, and self-blame less frequently compared to full-time students. The results of the analysis are presented in Table 9 .

https://doi.org/10.1371/journal.pone.0255041.t009

Using a one-factor ANOVA, coping strategies were compared between students in different program years. The analysis showed significant differences for four strategies: active coping ( Fig 3 ), planning ( Fig 4 ), positive reframing ( Fig 5 ), and behavioral disengagement ( Fig 6 ).

I U–I Undergraduate (n = 142), II U–II Undergraduate (n = 100), III U–III Undergraduate (n = 104), I G–I Graduate (n = 66), II G–II Graduate (n = 70), I-III M–I-III uniform Master’s studies (n = 64), IV-V M–IV-V uniform Master’s studies (n = 31).

https://doi.org/10.1371/journal.pone.0255041.g003

https://doi.org/10.1371/journal.pone.0255041.g004

* Welch’s correction was applied.

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https://doi.org/10.1371/journal.pone.0255041.g006

A detailed post hoc analysis showed that first year undergraduate students reported using active coping less frequently compared to second year graduate students ( p = 0.048), first-third year uniform Master’s students ( p = 0.009), and fourth-fifth year uniform Master’s students ( p < 0.001). Second year undergraduate students also reported using active coping less frequently than did fourth-fifth year uniform Master’s students ( p = 0.001), similar to third year undergraduate students ( p = 0.004). First year undergraduate students reported using planning less frequently compared to second year graduate students ( p = 0.006) and fourth-fifth year uniform Master’s students ( p < 0.001). Fourth-fifth year uniform Master’s students reported using planning more frequently than second year ( p = 0.018) and third year ( p = 0.007) undergraduate students. A significant difference in the frequency of using behavioral disengagement occurred between first year undergraduate students and fourth-fifth year uniform Master’s students ( p = 0.015). First year undergraduate students reported using behavioral disengagement more frequently than did fourth-fifth year uniform Master’s students. For positive reframing, after applying the correction for multiple comparisons, Dunnett’s T3 test did not show statistically significant intergroup differences. A statistical trend ( p = 0.053) was observed between third year undergraduate students and first year graduate students—first year graduate students reported a slightly higher frequency of using positive reframing than did third year undergraduate students.

Students’ strategies of coping with stress and the type and source of needed social support

A one-way ANOVA was used to estimate the differences in coping strategy use depending on the need for a given type of social support ( Table 10 ). The post hoc analysis showed that participants who indicated a need for psychological support reported using the coping strategy of positive reframing less frequently than those who did not indicate any need for support ( p = 0.027). Also, those who indicated a need for financial support reported using positive reframing less frequently than those who did not indicate any need for support ( p = 0.034). Those who did not indicate any need for support used the coping strategy of acceptance more frequently than those who indicated a need for psychological ( p = 0.013) and emotional ( p = 0.002) support. This is due to the fact that these individuals cope with the pandemic-related difficulties on their own. Those who indicated a need for financial support also used religious coping less frequently than those who indicated a need for emotional support ( p = 0.007). Participants who indicated a need for emotional support reported using the coping strategy of emotional support seeking more frequently than those who indicated a need for financial support ( p = 0.004) and those who did not indicate any need for support ( p = 0.034). Analogous differences were observed for instrumental support seeking. Participants who indicated a need for emotional support reported using this coping strategy more often than did those who indicated a need for financial support ( p < 0.001) and those who did not indicate any need for support ( p = 0.001). Those who did not indicate any need for support reported using self-distraction less frequently than those who indicated needing psychological ( p = 0.014) and emotional ( p = 0.003) support. Also, participants who did not indicate any need for support reported using the coping strategy of denial less frequently than did those who indicated a need for psychological ( p = 0.002) or emotional ( p = 0.002) support. Participants who did not indicate any need for support reported using venting of emotions less frequently than did those who indicated a need for psychological ( p < 0.001) and emotional ( p < 0.001) support, whereas participants who indicated a need for financial support reported using venting of emotions less frequently than did those who indicated a need for emotional support ( p = 0.003). Participants who indicated a need for psychological support reported more frequent substance use than did those who did not indicate any need for support ( p = 0.002). Participants also used behavioral disengagement more often than did those who indicated a need for financial ( p = 0.001) and organizational support ( p = 0.001), or did not indicate any need for support ( p < 0.001). In turn, those participants who indicated a need for emotional support reported using behavioral disengagement more frequently than those who did not indicate any need for support at all ( p = 0.006).

https://doi.org/10.1371/journal.pone.0255041.t010

Participants who indicated a need for psychological support and emotional support reported using self-blame more often than did those who indicated a need for financial ( p < 0.001, p = 0.003 respectively). Self-blame is a cognitive judgment related to a belief that not making mistakes is extremely important. However, self-blame causes withdrawal from interpersonal relationships and prevents learning from one’s mistakes. Thus, normal sadness and guilt becomes transformed into depressive disorders [ 58 ]. In this case, seeking psychological support seems warranted. People seek to relieve their suffering and solve their problems through utilizing psychological consultations or therapy. However, in contrast to seeking emotional support from significant others within close relationships, individuals seeking psychological support may discount their own agency, responsibility for their decisions, and independent solution-seeking to a greater extent. Additionally, when describing the pandemic situation, it is worth to consider another context of self-blame, namely, the phenomenon of guiltless guilt, that is, guilt without any specific influence on a given situation which is the source of self-blame. This creates a vicious circle which depends psychological suffering [ 59 ].

A one-factor ANOVA also revealed significant differences between the groups distinguished by the source of expected support. These differences were significant for three coping strategies: religious coping ( Fig 7 ), substance use ( Fig 8 ), and self-blame ( Fig 9 ). A detailed post hoc analysis revealed that those participants who expected support from the government used religious coping less frequently than those who expected support from their families ( p = 0.043) or their universities ( p = 0.026). Participants who expected support from their families reported using the coping strategy of substance abuse significantly less frequently than those who expected support from their friends ( p = 0.013). In turn, participants who expected support from their friends reported using self-blame significantly more often than did those who expected support from the government ( p = 0.027).

https://doi.org/10.1371/journal.pone.0255041.g007

https://doi.org/10.1371/journal.pone.0255041.g008

https://doi.org/10.1371/journal.pone.0255041.g009

The aim of the current study was to examine the strategies of coping with stress among Polish university students during the coronavirus pandemic, as well as to assess the type of support they expected. An analysis of the empirical results allows for drawing conclusions on this topic.

The transactional model of stress [ 33 ] allowed for identifying a specific relation formed between an individual and their surroundings. The participants in the currents study found themselves in a stressful transaction in which they experienced a real risk in the form of the pandemic situation. Coping is a specific adaptative reaction chosen during the secondary appraisal. It emerges when an individual appraises the situation in terms of harm or risk, that is, as a difficulty. Students differed with respect to their tendency to use specific coping strategies, which does not mean that a given individual’s coping strategies are the same in every situation. Emotion-oriented coping strategies seek to reduce tension and unpleasant emotions which arise in reaction to stressful situations. They are unavoidable particularly when the individual has no influence on the external events. Problem-focused coping involves cognitive and behavioral efforts to reduce stress by trying to solve the problem [ 33 ]. Thus, the main condition for appropriate functioning is to develop optimal strategies of coping with stress.

The results of the current study showed that during the stressful situation of the pandemic, which can cause feelings of uncertainty and crisis [ 60 ], Polish students mainly chose such coping strategies as acceptance, planning, and seeking emotional support. The current studies showed that students more often use coping strategies which, according to Lazarus and Folkman’s theory [ 33 ] are emotion-focused (acceptance, seeking emotional support). On the other hand, planning is a problem-focused coping strategy. These three main strategies seem constructive as they direct people towards a future temporal perspective and might facilitate a reorganization of the values–goals–life plans triad driving the dynamic character of the personality [ 61 ], especially in decisive periods of personal crises [ 62 ]. It is also related to reframing one’s own life situation. Substance use, denial, behavioral disengagement, and religious coping were used the least frequently by Polish students to cope with stress during the pandemic.

Among all groups of people in education, students exhibited higher levels of emotional problems and pressure related to the changes in the educational and social situation during the pandemic than did primary and high school students [ 63 , 64 ]. Thus, it was important to assess their need for support and the sources they expect this support from. The results showed that 78% of the students needed support, while 22% did not express such needs. The greatest proportion of students—25%—needed emotional support. This type of support was mainly sought from family (38%) and friends (26%). Participants who expected emotional support simultaneously chose strategies of support seeking and religious coping. Their search for personal resources which would facilitate coping was oriented at close interpersonal relationships. They most likely allowed for conversations which supported another coping strategy preferred by this group, namely, venting and self-blame. Students seeking emotional support–in contrast to those seeking psychological support–likely maintained closer and deeper interpersonal relationships. On the other hand, psychological support was expected by 16% of the participants. They scored the lowest on the strategy of positive reframing. However, they scored higher on substance use, denial, and venting, as well as self-blame. Such a pattern of coping strategies suggests that use of professional psychological help is warranted. These participants showed such difficulties in coping with the pandemic situation that they concluded they should seek professional help from a psychologist.

Those students who expected organizational (18%) and financial (17%) support reported using different coping strategies than did those who expected emotional and psychological support. Such coping strategies as religious coping, support seeking, venting, substance use, behavioral disengagement, and self-blame were lower in this group. Rather, these participants were oriented at gaining concrete material support and support related to organizing their life in the city where they studied, and sometimes also worked to support themselves financially.

Further analyses showed that those students who indicated a need for emotional and social support reported using the coping strategies of positive reframing and acceptance of the pandemic situation less frequently. Need for emotional, organizational, and psychological support was related to typical stressors (studying, pressure to achieve high grades, pass exams, and qualify for scholarships) [ 65 , 66 ], which remained at similar levels during online teaching. However, it was also related to additional limitations stemming from the digitalization of the teaching process [ 67 ]. Moreover, the need for support was also increased by isolation, limitations in social relationships with peers, and limited possibilities for establishing new relationships and realizing affiliative needs [ 68 , 69 ]. Importantly, these needs concern direct relationships rather than telephone or online contact, as these do not fully mitigate loneliness and do not provide the same amount of support [ 18 ]. Seeking real, direct support, the students expressed a perspective of building psychological resilience and improving their emotional state, which corresponds with the results of Bernabé and Botia [ 70 ]. Students mainly expressed a need for emotional, organizational, and psychological support from their families and friends in order to maintain a high level of functioning, which might be explained through the perspective of the resilience theory [ 71 , 72 ]. This is because resilience is strongly related to, among others, perceived emotional support and close, safe relationships with one’s family and friends [ 73 , 74 ], which create networks of emotional and social support [ 75 , 76 ]. The ability to use support serves as a buffer for stress and its negative consequences. It can also prevent the deepening of the problems by providing resources for coping when stress occurs. Studies confirm that people with access to support show less reactivity to stress factors and enjoy higher mental health [ 77 ].

Next, it was showed that the chosen strategies of coping with stress were related to sociodemographic variables such as gender, age, and place of residence, which was confirmed by Cantor [ 61 ]. A detailed analysis revealed gender differences in the use of some specific coping strategies, which is also supported by other studies [ 78 – 80 ]. Women used the strategies of emotional and instrumental support seeking statistically significantly more often than did men. On the other hand, men used humor as a coping strategy more often than did women.

Regarding age, it was shown that younger people who began studying (18-20-year-olds) reported using active coping and planning statistically significantly less frequently than older students (21-24-year-olds, 25-30-year-olds, and those 31 and above). In turn, the higher frequency of using positive reframing and the lowest frequency of using venting of emotions was reported by the oldest students (31 and above). These age-related differences are difficult to relate to previous studies due to methodological differences [ 81 – 83 ]. The strategy of active coping, characteristic for older students, was positively correlated with planning (strong relationship), positive reframing, religious coping, and emotional and instrumental support seeking, which was confirmed by the cluster analysis. Cluster 1 results (statistically significantly higher active coping, planning, positive reframing, humor, religious coping, emotional and instrumental support seeking, self-distraction, and venting, and lower behavioral disengagement) correspond to this profile of active coping.

The youngest students (18–20 years old) did not choose active (adaptive) coping strategies, in contrast to the older students. It is worth noting that, as the youngest persons in the academic community, they have less life and experience and less environmental resources due to the fact that they did not yet develop close and deep social and emotional relationships. This is related to identity development [ 84 , 85 ]. Additionally, the university is a new setting for such students, which makes it more difficult for them to perceive it as a source of instrumental and organizational support. Thus, the youngest students in particular should be the recipients of complex (psychological, instrumental, possibly also spiritual) support from the university intended to shape appropriate adaptive conditions.

Comparing the full-time and extramural students with respect to their coping strategies, it was found that extramural students scored higher on active coping and positive reframing, and lower on humor, instrumental support seeking, self-distraction, venting, substance use, and self-blame compared to full-time students. It is worth noting that extramural students are usually older than full-time students. Thus, they are at a different developmental period in their lives. They often live with their own families, including their children. They attend classes only during the weekends and are most often employed and financially independent Thus, they have different areas of life activities and exhibit different strategies of coping with stress.

Analyzing the variable of place of residence, it was found that students living in cities with over 100 thousand residents used the coping strategies of planning, humor, and substance use more frequently than did students from smaller towns and villages. These results can be interpreter with reference to Bronfebrenner’s [ 86 ] ecological theory. Larger cities have more (both on the mesosystem and the exosystem levels) infrastructural resources, opportunities related to social life, and institutional offers (even during the periods of pandemic-related restrictions). Thus, people living in large cities were subjected to less social isolation during the pandemic than were the people living in rural areas. However, they used religious coping and denial less frequently, which was used more often by students living in villages. Studies on Polish students carried out before the pandemic using the Mini-COPE did not show differences in coping strategies related to place of residence.

The results of the current study allowed for the identification of coping strategies among students. This is important for the process of designing support strategies at universities. Our study also identified the mechanisms of active (adaptive) and passive (maladaptive) coping and directions of support seeking.

Taking into account the current results, future empirical studies can focus on more detailed examinations of the relationships between specific coping strategies used by students. Additional studies on the influence of the later stages of the pandemic on students’ mental health are necessary, as the consequences of this difficult situation may last for a long time, beyond the most intense period of the pandemic.

Strengths and limitations

The strengths of the current study include an examination of students’ strategies of coping with stress during the pandemic as a global situation which, to some extent, warrants the introduction of monitoring and prevention of the “post-COVID syndrome” in the context of students’ coping with stress and rebuilding social and emotional relationships.

The current results might also serve as a point of reference and comparison for further studies on coping strategies among students in other countries. In turn, this could support the development of local strategies of supporting students in organizing their academic careers and personal lives. This is especially important considering the fact that the occurrence of subsequent pandemics is only a matter of time, as was cautioned by the Director General of the World Health Organization, Tedros Adhanom Ghebreyesus. The UN resolution naming December 27 as the International Day of Epidemic Preparedness acknowledges the disproportional harm they cause in people’s lives and highlights the need for increased awareness, exchange of scientific knowledge, and searching for the best solutions on both the local and national levels. This message finds direct expression in the topic of the current study.

A limitation of the current study is the high proportion of female students of social sciences and humanities in the current sample. In Poland, these programs are more often chosen by women (73%) than men (27%) [ 87 ]. This resulted in a high gender imbalance in the current sample.

Recommendations for universities

The results of the current study lead to formulating several recommendations for universities regarding the organization of teaching in ways that consider the students’ psychosocial functioning to a greater extent. These suggestions include: implementing assessments of students’ psychosocial functioning in order to determine the potential need for emotional, social, and psychological support, and establishing psychological consultation points for students requiring such support.

It also seems warranted to introduce interpersonal training and stress coping workshops for individual student groups. Regarding organizational support, the current results are an argument for providing material support and career counseling in part-time employment for students.

The current results serve as a basis for designing a model of support and-self support solutions for students during the pandemic. The participatory model of intervention development [ 88 ] may be particularly useful in this regard. The Participatory Intervention Model (PIM), rooted in participatory action research, provides aa mechanism for integrating theory, research and practice and for promoting involvement of stakeholders in intervention efforts [ 88 ]. Based on this model, it seems pertinent to revise the role of the year mentor ( opiekun roku ; in Polish universities, students at each year of their academic program are assigned an academic teacher who meets with the students, acquaints them with the university’s structure and the program, etc.) by including screening assessments of the students’ expected sources of support. Additionally, the role of the university counselor should be created. It is worth noting that the youngest students in particular should be incorporated in the design process for such solutions. This is because the presented study shows that the youngest full-time students showed passive and maladaptive coping strategies. Support solutions designed through the participatory model of intervention should be useful for students, should address their specific needs, and should consider the students’ cultural, organizational, and social contexts, including the context of the pandemic and its consequences. Efforts towards designing adequate interventions may prove insufficient if no attempts are made to understand the students’ beliefs, motivations, practices, language, and culture. Such practices can help universities offer more comprehensive support to students of specific populations. Thus, the particular attention should be draw to the notion of acceptability within PIM, which reflects the perception of the beneficiaries (mainly the university inn this context) as partners in identifying problems and developing the offer of psychological, organizational, and instrumental support solutions created through the process of researching the specificity of the pandemic situation and post-pandemic adaptation. Identifying problems, as well as the scope and range of partnership between the university and its personal and infrastructural resources in planning psychological, organizational, and infrastructural support for students requires an evidence base.

The necessity of carrying out research that would lead to effective practical solutions through PIM is also underscored by Nastasi (et. al.) [ 89 ]. The study presented in this article fits this proposal. The current study results showed also that 10% of the sample expecting support from the university. This situation indicates that the current support offer could be insufficient in the context of the pandemic. Thus far, support given to students has been limited mainly to material support–financial support and academic scholarships. Verifying its role as a source of support and an important social environment for its students is also a significant new challenge for universities in the pandemic and post-pandemic reality.

Conclusions

Studies in this direction should continue in order to examine how students cope with subsequent stages of studying both during the pandemic as well as after its end.

Despite the limitations indicated above, the current results contribute to understanding the social and emotional changes related to the coronavirus pandemic, especially in the area of higher education. Studies on stress and coping among students carried out thus far have not sufficiently considered a range of factors such as the study system (paid vs. free), sources of institutional support (scholarships, student loans, material support), unemployment, or job prospects after graduation. Additionally, similarities and differences in the experience of stress and coping strategies between students in various countries (ethnic and cultural differences) have not been researched to an appropriate degree.

The current study indicates, among others, that younger students who are in the beginning stages of their academic careers cope with stress less effectively. This is largely a consequence of the fact that they do not yet possess appropriate life experience, and thus do not have sufficient competences in coping with difficult situations. This suggests that university administrations should pay particular attention to this group. An obligatory course on coping skills should be recommended for the first year curriculum. This could improve students’ competences, wellbeing, and resilience.

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• Published: 11 May 2024

Nursing students’ stressors and coping strategies during their first clinical training: a qualitative study in the United Arab Emirates

• Jacqueline Maria Dias 1 ,
• Muhammad Arsyad Subu 1 ,
• Nabeel Al-Yateem 1 ,
• Fatma Refaat Ahmed 1 ,
• Syed Azizur Rahman 1 , 2 ,
• Mini Sara Abraham 1 ,
• Sareh Mirza Forootan 1 ,
• Farzaneh Ahmad Sarkhosh 1 &
• Fatemeh Javanbakh 1  

BMC Nursing volume  23 , Article number:  322 ( 2024 ) Cite this article

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Metrics details

Understanding the stressors and coping strategies of nursing students in their first clinical training is important for improving student performance, helping students develop a professional identity and problem-solving skills, and improving the clinical teaching aspects of the curriculum in nursing programmes. While previous research have examined nurses’ sources of stress and coping styles in the Arab region, there is limited understanding of these stressors and coping strategies of nursing students within the UAE context thereby, highlighting the novelty and significance of the study.

A qualitative study was conducted using semi-structured interviews. Overall 30 students who were undergoing their first clinical placement in Year 2 at the University of Sharjah between May and June 2022 were recruited. All interviews were recorded and transcribed verbatim and analyzed for themes.

During their first clinical training, nursing students are exposed to stress from different sources, including the clinical environment, unfriendly clinical tutors, feelings of disconnection, multiple expectations of clinical staff and patients, and gaps between the curriculum of theory classes and labatories skills and students’ clinical experiences. We extracted three main themes that described students’ stress and use of coping strategies during clinical training: (1) managing expectations; (2) theory-practice gap; and (3) learning to cope. Learning to cope, included two subthemes: positive coping strategies and negative coping strategies.

Conclusions

This qualitative study sheds light from the students viewpoint about the intricate interplay between managing expectations, theory practice gap and learning to cope. Therefore, it is imperative for nursing faculty, clinical agencies and curriculum planners to ensure maximum learning in the clinical by recognizing the significance of the stressors encountered and help students develop positive coping strategies to manage the clinical stressors encountered. Further research is required look at the perspective of clinical stressors from clinical tutors who supervise students during their first clinical practicum.

Peer Review reports

Nursing education programmes aim to provide students with high-quality clinical learning experiences to ensure that nurses can provide safe, direct care to patients [ 1 ]. The nursing baccalaureate programme at the University of Sharjah is a four year program with 137 credits. The programmes has both theoretical and clinical components withs nine clinical courses spread over the four years The first clinical practicum which forms the basis of the study takes place in year 2 semester 2.

Clinical practice experience is an indispensable component of nursing education and links what students learn in the classroom and in skills laboratories to real-life clinical settings [ 2 , 3 , 4 ]. However, a gap exists between theory and practice as the curriculum in the classroom differs from nursing students’ experiences in the clinical nursing practicum [ 5 ]. Clinical nursing training places (or practicums, as they are commonly referred to), provide students with the necessary experiences to ensure that they become proficient in the delivery of patient care [ 6 ]. The clinical practicum takes place in an environment that combines numerous structural, psychological, emotional and organizational elements that influence student learning [ 7 ] and may affect the development of professional nursing competencies, such as compassion, communication and professional identity [ 8 ]. While clinical training is a major component of nursing education curricula, stress related to clinical training is common among students [ 9 ]. Furthermore, the nursing literature indicates that the first exposure to clinical learning is one of the most stressful experiences during undergraduate studies [ 8 , 10 ]. Thus, the clinical component of nursing education is considered more stressful than the theoretical component. Students often view clinical learning, where most learning takes place, as an unsupportive environment [ 11 ]. In addition, they note strained relationships between themselves and clinical preceptors and perceive that the negative attitudes of clinical staff produce stress [ 12 ].

The effects of stress on nursing students often involve a sense of uncertainty, uneasiness, or anxiety. The literature is replete with evidence that nursing students experience a variety of stressors during their clinical practicum, beginning with the first clinical rotation. Nursing is a complex profession that requires continuous interaction with a variety of individuals in a high-stress environment. Stress during clinical learning can have multiple negative consequences, including low academic achievement, elevated levels of burnout, and diminished personal well-being [ 13 , 14 ]. In addition, both theoretical and practical research has demonstrated that increased, continual exposure to stress leads to cognitive deficits, inability to concentrate, lack of memory or recall, misinterpretation of speech, and decreased learning capacity [ 15 ]. Furthermore, stress has been identified as a cause of attrition among nursing students [ 16 ].

Most sources of stress have been categorized as academic, clinical or personal. Each person copes with stress differently [ 17 ], and utilizes deliberate, planned, and psychological efforts to manage stressful demands [ 18 ]. Coping mechanisms are commonly termed adaptation strategies or coping skills. Labrague et al. [ 19 ] noted that students used critical coping strategies to handle stress and suggested that problem solving was the most common coping or adaptation mechanism used by nursing students. Nursing students’ coping strategies affect their physical and psychological well-being and the quality of nursing care they offer. Therefore, identifying the coping strategies that students use to manage stressors is important for early intervention [ 20 ].

Studies on nursing students’ coping strategies have been conducted in various countries. For example, Israeli nursing students were found to adopt a range of coping mechanisms, including talking to friends, engaging in sports, avoiding stress and sadness/misery, and consuming alcohol [ 21 ]. Other studies have examined stress levels among medical students in the Arab region. Chaabane et al. [ 15 ], conducted a systematic review of sudies in Arab countries, including Saudi Arabia, Egypt, Jordan, Iraq, Pakistan, Oman, Palestine and Bahrain, and reported that stress during clinical practicums was prevalent, although it could not be determined whether this was limited to the initial clinical course or occurred throughout clinical training. Stressors highlighted during the clinical period in the systematic review included assignments and workload during clinical practice, a feeling that the requirements of clinical practice exceeded students’ physical and emotional endurance and that their involvement in patient care was limited due to lack of experience. Furthermore, stress can have a direct effect on clinical performance, leading to mental disorders. Tung et al. [ 22 ], reported that the prevalence of depression among nursing students in Arab countries is 28%, which is almost six times greater than the rest of the world [ 22 ]. On the other hand, Saifan et al. [ 5 ], explored the theory-practice gap in the United Arab Emirates and found that clinical stressors could be decreased by preparing students better for clinical education with qualified clinical faculty and supportive preceptors.

The purpose of this study was to identify the stressors experienced by undergraduate nursing students in the United Arab Emirates during their first clinical training and the basic adaptation approaches or coping strategies they used. Recognizing or understanding different coping processes can inform the implementation of corrective measures when students experience clinical stress. The findings of this study may provide valuable information for nursing programmes, nurse educators, and clinical administrators to establish adaptive strategies to reduce stress among students going clinical practicums, particularly stressors from their first clinical training in different healthcare settings.

A qualitative approach was adopted to understand clinical stressors and coping strategies from the perspective of nurses’ lived experience. Qualitative content analysis was employed to obtain rich and detailed information from our qualitative data. Qualitative approaches seek to understand the phenomenon under study from the perspectives of individuals with lived experience [ 23 ]. Qualitative content analysis is an interpretive technique that examines the similarities and differences between and within different areas of text while focusing on the subject [ 24 ]. It is used to examine communication patterns in a repeatable and systematic way [ 25 ] and yields rich and detailed information on the topic under investigation [ 23 ]. It is a method of systematically coding and categorizing information and comprises a process of comprehending, interpreting, and conceptualizing the key meanings from qualitative data [ 26 ].

Setting and participants

This study was conducted after the clinical rotations ended in April 2022, between May and June in the nursing programme at the College of Health Sciences, University of Sharjah, in the United Arab Emirates. The study population comprised undergraduate nursing students who were undergoing their first clinical training and were recruited using purposive sampling. The inclusion criteria for this study were second-year nursing students in the first semester of clinical training who could speak English, were willing to participate in this research, and had no previous clinical work experience. The final sample consisted of 30 students.

Research instrument

The research instrument was a semi structured interview guide. The interview questions were based on an in-depth review of related literature. An intensive search included key words in Google Scholar, PubMed like the terms “nursing clinical stressors”, “nursing students”, and “coping mechanisms”. Once the questions were created, they were validated by two other faculty members who had relevant experience in mental health. A pilot test was conducted with five students and based on their feedback the following research questions, which were addressed in the study.

How would you describe your clinical experiences during your first clinical rotations?

In what ways did you find the first clinical rotation to be stressful?

What factors hindered your clinical training?

How did you cope with the stressors you encountered in clinical training?

Which strategies helped you cope with the clinical stressors you encountered?

Data collection

Semi-structured interviews were chosen as the method for data collection. Semi structured interviews are a well-established approach for gathering data in qualitative research and allow participants to discuss their views, experiences, attitudes, and beliefs in a positive environment [ 27 ]. This approach allows for flexibility in questioning thereby ensuring that key topics related to clinical learning stressors and coping strategies would be explored. Participants were given the opportunity to express their views, experiences, attitudes, and beliefs in a positive environment, encouraging open communication. These semi structured interviews were conducted by one member of the research team (MAS) who had a mental health background, and another member of the research team who attended the interviews as an observer (JMD). Neither of these researchers were involved in teaching the students during their clinical practicum, which helped to minimize bias. The interviews took place at the University of Sharjah, specifically in building M23, providing a familiar and comfortable environment for the participant. Before the interviews were all students who agreed to participate were provided with an explanation of the study’s purpose. The time and location of each interview were arranged. Before the interviews were conducted, all students who provided consent to participate received an explanation of the purpose of the study, and the time and place of each interview were arranged to accommodate the participants’ schedules and preferences. The interviews were conducted after the clinical rotation had ended in April, and after the final grades had been submitted to the coordinator. The timings of the interviews included the month of May and June which ensured that participants have completed their practicum experience and could reflect on the stressors more comprehensively. The interviews were audio-recorded with the participants’ consent, and each interview lasted 25–40 min. The data were collected until saturation was reached for 30 students. Memos and field notes were also recorded as part of the data collection process. These additional data allowed for triangulation to improve the credibility of the interpretations of the data [ 28 ]. Memos included the interviewers’ thoughts and interpretations about the interviews, the research process (including questions and gaps), and the analytic progress used for the research. Field notes were used to record the interviewers’ observations and reflections on the data. These additional data collection methods were important to guide the researchers in the interpretation of the data on the participants’ feelings, perspectives, experiences, attitudes, and beliefs. Finally, member checking was performed to ensure conformability.

Data analysis

The study used the content analysis method proposed by Graneheim and Lundman [ 24 ]. According to Graneheim and Lundman [ 24 ], content analysis is an interpretive technique that examines the similarities and differences between distinct parts of a text. This method allows researchers to determine exact theoretical and operational definitions of words, phrases, and symbols by elucidating their constituent properties [ 29 ]. First, we read the interview transcripts several times to reach an overall understanding of the data. All verbatim transcripts were read several times and discussed among all authors. We merged and used line-by-line coding of words, sentences, and paragraphs relevant to each other in terms of both the content and context of stressors and coping mechanisms. Next, we used data reduction to assess the relationships among themes using tables and diagrams to indicate conceptual patterns. Content related to stress encountered by students was extracted from the transcripts. In a separate document, we integrated and categorized all words and sentences that were related to each other in terms of both content and context. We analyzed all codes and units of meaning and compared them for similarities and differences in the context of this study. Furthermore, the emerging findings were discussed with other members of the researcher team. The final abstractions of meaningful subthemes into themes were discussed and agreed upon by the entire research team. This process resulted in the extraction of three main themes in addition to two subthemes related to stress and coping strategies.

Ethical considerations

The University of Sharjah Research Ethics Committee provided approval to conduct this study (Reference Number: REC 19-12-03-01-S). Before each interview, the goal and study procedures were explained to each participant, and written informed consent was obtained. The participants were informed that participation in the study was voluntary and that they could withdraw from the study at any time. In the event they wanted to withdraw from the study, all information related to the participant would be removed. No participant withdrew from the study. Furthermore, they were informed that their clinical practicum grade would not be affected by their participation in this study. We chose interview locations in Building M23that were private and quiet to ensure that the participants felt at ease and confident in verbalizing their opinions. No participant was paid directly for involvement in this study. In addition, participants were assured that their data would remain anonymous and confidential. Confidentiality means that the information provided by participants was kept private with restrictions on how and when data can be shared with others. The participants were informed that their information would not be duplicated or disseminated without their permission. Anonymity refers to the act of keeping people anonymous with respect to their participation in a research endeavor. No personal identifiers were used in this study, and each participant was assigned a random alpha-numeric code (e.g., P1 for participant 1). All digitally recorded interviews were downloaded to a secure computer protected by the principal investigator with a password. The researchers were the only people with access to the interview material (recordings and transcripts). All sensitive information and materials were kept secure in the principal researcher’s office at the University of Sharjah. The data will be maintained for five years after the study is completed, after which the material will be destroyed (the transcripts will be shredded, and the tapes will be demagnetized).

In total, 30 nursing students who were enrolled in the nursing programme at the Department of Nursing, College of Health Sciences, University of Sharjah, and who were undergoing their first clinical practicum participated in the study. Demographically, 80% ( n  = 24) were females and 20% ( n  = 6) were male participants. The majority (83%) of study participants ranged in age from 18 to 22 years. 20% ( n  = 6) were UAE nationals, 53% ( n  = 16) were from Gulf Cooperation Council countries, while 20% ( n  = 6) hailed from Africa and 7% ( n  = 2) were of South Asian descent. 67% of the respondents lived with their families while 33% lived in the hostel. (Table  1 )

Following the content analysis, we identified three main themes: (1) managing expectations, (2) theory-practice gap and 3)learning to cope. Learning to cope had two subthemes: positive coping strategies and negative coping strategies. An account of each theme is presented along with supporting excerpts for the identified themes. The identified themes provide valuable insight into the stressors encountered by students during their first clinical practicum. These themes will lead to targeted interventions and supportive mechanisms that can be built into the clinical training curriculum to support students during clinical practice.

Theme 1: managing expectations

In our examination of the stressors experienced by nursing students during their first clinical practicum and the coping strategies they employed, we identified the first theme as managing expectations.

The students encountered expectations from various parties, such as clinical staff, patients and patients’ relatives which they had to navigate. They attempted to fulfil their expectations as they progressed through training, which presented a source of stress. The students noted that the hospital staff and patients expected them to know how to perform a variety of tasks upon request, which made the students feel stressed and out of place if they did not know how to perform these tasks. Some participants noted that other nurses in the clinical unit did not allow them to participate in nursing procedures, which was considered an enormous impediment to clinical learning, as noted in the excerpt below:

“…Sometimes the nurses… They will not allow us to do some procedures or things during clinical. And sometimes the patients themselves don’t allow us to do procedures” (P5).

Some of the students noted that they felt they did not belong and felt like foreigners in the clinical unit. Excerpts from the students are presented in the following quotes;

“The clinical environment is so stressful. I don’t feel like I belong. There is too little time to build a rapport with hospital staff or the patient” (P22).

“… you ask the hospital staff for some guidance or the location of equipment, and they tell us to ask our clinical tutor …but she is not around … what should I do? It appears like we do not belong, and the sooner the shift is over, the better” (P18).

“The staff are unfriendly and expect too much from us students… I feel like I don’t belong, or I am wasting their (the hospital staff’s) time. I want to ask questions, but they have loads to do” (P26).

Other students were concerned about potential failure when working with patients during clinical training, which impacted their confidence. They were particularly afraid of failure when performing any clinical procedures.

“At the beginning, I was afraid to do procedures. I thought that maybe the patient would be hurt and that I would not be successful in doing it. I have low self-confidence in doing procedures” (P13).

The call bell rings, and I am told to answer Room No. XXX. The patient wants help to go to the toilet, but she has two IV lines. I don’t know how to transport the patient… should I take her on the wheelchair? My eyes glance around the room for a wheelchair. I am so confused …I tell the patient I will inform the sister at the nursing station. The relative in the room glares at me angrily … “you better hurry up”…Oh, I feel like I don’t belong, as I am not able to help the patient… how will I face the same patient again?” (P12).

Another major stressor mentioned in the narratives was related to communication and interactions with patients who spoke another language, so it was difficult to communicate.

“There was a challenge with my communication with the patients. Sometimes I have communication barriers because they (the patients) are of other nationalities. I had an experience with a patient [who was] Indian, and he couldn’t speak my language. I did not understand his language” (P9).

Thus, a variety of expectations from patients, relatives, hospital staff, and preceptors acted as sources of stress for students during their clinical training.

Theme 2: theory-practice gap

Theory-practice gaps have been identified in previous studies. In our study, there was complete dissonance between theory and actual clinical practice. The clinical procedures or practices nursing students were expected to perform differed from the theory they had covered in their university classes and skills lab. This was described as a theory–practice gap and often resulted in stress and confusion.

“For example …the procedures in the hospital are different. They are different from what we learned or from theory on campus. Or… the preceptors have different techniques than what we learned on campus. So, I was stress[ed] and confused about it” (P11).

Furthermore, some students reported that they did not feel that they received adequate briefing before going to clinical training. A related source of stress was overload because of the volume of clinical coursework and assignments in addition to clinical expectations. Additionally, the students reported that a lack of time and time management were major sources of stress in their first clinical training and impacted their ability to complete the required paperwork and assignments:

“…There is not enough time…also, time management at the hospital…for example, we start at seven a.m., and the handover takes 1 hour to finish. They (the nurses at the hospital) are very slow…They start with bed making and morning care like at 9.45 a.m. Then, we must fill [out] our assessment tool and the NCP (nursing care plan) at 10 a.m. So, 15 only minutes before going to our break. We (the students) cannot manage this time. This condition makes me and my friends very stressed out. -I cannot do my paperwork or assignments; no time, right?” (P10).

“Stressful. There is a lot of work to do in clinical. My experiences are not really good with this course. We have a lot of things to do, so many assignments and clinical procedures to complete” (P16).

The participants noted that the amount of required coursework and number of assignments also presented a challenge during their first clinical training and especially affected their opportunity to learn.

“I need to read the file, know about my patient’s condition and pathophysiology and the rationale for the medications the patient is receiving…These are big stressors for my learning. I think about assignments often. Like, we are just focusing on so many assignments and papers. We need to submit assessments and care plans for clinical cases. We focus our time to complete and finish the papers rather than doing the real clinical procedures, so we lose [the] chance to learn” (P25).

Another participant commented in a similar vein that there was not enough time to perform tasks related to clinical requirements during clinical placement.

“…there is a challenge because we do not have enough time. Always no time for us to submit papers, to complete assessment tools, and some nurses, they don’t help us. I think we need more time to get more experiences and do more procedures, reduce the paperwork that we have to submit. These are challenges …” (P14).

There were expectations that the students should be able to carry out their nursing duties without becoming ill or adversely affected. In addition, many students reported that the clinical environment was completely different from the skills laboratory at the college. Exposure to the clinical setting added to the theory-practice gap, and in some instances, the students fell ill.

One student made the following comment:

“I was assisting a doctor with a dressing, and the sight and smell from the oozing wound was too much for me. I was nauseated. As soon as the dressing was done, I ran to the bathroom and threw up. I asked myself… how will I survive the next 3 years of nursing?” (P14).

Theme 3: learning to cope

The study participants indicated that they used coping mechanisms (both positive and negative) to adapt to and manage the stressors in their first clinical practicum. Important strategies that were reportedly used to cope with stress were time management, good preparation for clinical practice, and positive thinking as well as engaging in physical activity and self-motivation.

“Time management. Yes, it is important. I was encouraging myself. I used time management and prepared myself before going to the clinical site. Also, eating good food like cereal…it helps me very much in the clinic” (P28).

“Oh yeah, for sure positive thinking. In the hospital, I always think positively. Then, after coming home, I get [to] rest and think about positive things that I can do. So, I will think something good [about] these things, and then I will be relieved of stress” (P21).

Other strategies commonly reported by the participants were managing their breathing (e.g., taking deep breaths, breathing slowly), taking breaks to relax, and talking with friends about the problems they encountered.

“I prefer to take deep breaths and breathe slowly and to have a cup of coffee and to talk to my friends about the case or the clinical preceptor and what made me sad so I will feel more relaxed” (P16).

“Maybe I will take my break so I feel relaxed and feel better. After clinical training, I go directly home and take a long shower, going over the day. I will not think about anything bad that happened that day. I just try to think about good things so that I forget the stress” (P27).

“Yes, my first clinical training was not easy. It was difficult and made me stressed out…. I felt that it was a very difficult time for me. I thought about leaving nursing” (P7).

I was not able to offer my prayers. For me, this was distressing because as a Muslim, I pray regularly. Now, my prayer time is pushed to the end of the shift” (P11).

“When I feel stress, I talk to my friends about the case and what made me stressed. Then I will feel more relaxed” (P26).

Self-support or self-motivation through positive self-talk was also used by the students to cope with stress.

“Yes, it is difficult in the first clinical training. When I am stress[ed], I go to the bathroom and stand in the front of the mirror; I talk to myself, and I say, “You can do it,” “you are a great student.” I motivate myself: “You can do it”… Then, I just take breaths slowly several times. This is better than shouting or crying because it makes me tired” (P11).

Other participants used physical activity to manage their stress.

“How do I cope with my stress? Actually, when I get stressed, I will go for a walk on campus” (P4).

“At home, I will go to my room and close the door and start doing my exercises. After that, I feel the negative energy goes out, then I start to calm down… and begin my clinical assignments” (P21).

Both positive and negative coping strategies were utilized by the students. Some participants described using negative coping strategies when they encountered stress during their clinical practice. These negative coping strategies included becoming irritable and angry, eating too much food, drinking too much coffee, and smoking cigarettes.

“…Negative adaptation? Maybe coping. If I am stressed, I get so angry easily. I am irritable all day also…It is negative energy, right? Then, at home, I am also angry. After that, it is good to be alone to think about my problems” (P12).

“Yeah, if I…feel stress or depressed, I will eat a lot of food. Yeah, ineffective, like I will be eating a lot, drinking coffee. Like I said, effective, like I will prepare myself and do breathing, ineffective, I will eat a lot of snacks in between my free time. This is the bad side” (P16).

“…During the first clinical practice? Yes, it was a difficult experience for us…not only me. When stressed, during a break at the hospital, I will drink two or three cups of coffee… Also, I smoke cigarettes… A lot. I can drink six cups [of coffee] a day when I am stressed. After drinking coffee, I feel more relaxed, I finish everything (food) in the refrigerator or whatever I have in the pantry, like chocolates, chips, etc” (P23).

These supporting excerpts for each theme and the analysis offers valuable insights into the specific stressors faced by nursing students during their first clinical practicum. These insights will form the basis for the development of targeted interventions and supportive mechanisms within the clinical training curriculum to better support students’ adjustment and well-being during clinical practice.

Our study identified the stressors students encounter in their first clinical practicum and the coping strategies, both positive and negative, that they employed. Although this study emphasizes the importance of clinical training to prepare nursing students to practice as nurses, it also demonstrates the correlation between stressors and coping strategies.The content analysis of the first theme, managing expectations, paves the way for clinical agencies to realize that the students of today will be the nurses of tomorrow. It is important to provide a welcoming environment where students can develop their identities and learn effectively. Additionally, clinical staff should foster an environment of individualized learning while also assisting students in gaining confidence and competence in their repertoire of nursing skills, including critical thinking, problem solving and communication skills [ 8 , 15 , 19 , 30 ]. Another challenge encountered by the students in our study was that they were prevented from participating in clinical procedures by some nurses or patients. This finding is consistent with previous studies reporting that key challenges for students in clinical learning include a lack of clinical support and poor attitudes among clinical staff and instructors [ 31 ]. Clinical staff with positive attitudes have a positive impact on students’ learning in clinical settings [ 32 ]. The presence, supervision, and guidance of clinical instructors and the assistance of clinical staff are essential motivating components in the clinical learning process and offer positive reinforcement [ 30 , 33 , 34 ]. Conversely, an unsupportive learning environment combined with unwelcoming clinical staff and a lack of sense of belonging negatively impact students’ clinical learning [ 35 ].

The sources of stress identified in this study were consistent with common sources of stress in clinical training reported in previous studies, including the attitudes of some staff, students’ status in their clinical placement and educational factors. Nursing students’ inexperience in the clinical setting and lack of social and emotional experience also resulted in stress and psychological difficulties [ 36 ]. Bhurtun et al. [ 33 ] noted that nursing staff are a major source of stress for students because the students feel like they are constantly being watched and evaluated.

We also found that students were concerned about potential failure when working with patients during their clinical training. Their fear of failure when performing clinical procedures may be attributable to low self-confidence. Previous studies have noted that students were concerned about injuring patients, being blamed or chastised, and failing examinations [ 37 , 38 ]. This was described as feeling “powerless” in a previous study [ 7 , 12 ]. In addition, patients’ attitudes towards “rejecting” nursing students or patients’ refusal of their help were sources of stress among the students in our study and affected their self-confidence. Self-confidence and a sense of belonging are important for nurses’ personal and professional identity, and low self-confidence is a problem for nursing students in clinical learning [ 8 , 39 , 40 ]. Our findings are consistent with a previous study that reported that a lack of self-confidence was a primary source of worry and anxiety for nursing students and affected their communication and intention to leave nursing [ 41 ].

In the second theme, our study suggests that students encounter a theory-practice gap in clinical settings, which creates confusion and presents an additional stressors. Theoretical and clinical training are complementary elements of nursing education [ 40 ], and this combination enables students to gain the knowledge, skills, and attitudes necessary to provide nursing care. This is consistent with the findings of a previous study that reported that inconsistencies between theoretical knowledge and practical experience presented a primary obstacle to the learning process in the clinical context [ 42 ], causing students to lose confidence and become anxious [ 43 ]. Additionally, the second theme, the theory-practice gap, authenticates Safian et al.’s [ 5 ] study of the theory-practice gap that exists United Arab Emirates among nursing students as well as the need for more supportive clinical faculty and the extension of clinical hours. The need for better time availability and time management to complete clinical tasks were also reported by the students in the study. Students indicated that they had insufficient time to complete clinical activities because of the volume of coursework and assignments. Our findings support those of Chaabane et al. [ 15 ]. A study conducted in Saudi Arabia [ 44 ] found that assignments and workload were among the greatest sources of stress for students in clinical settings. Effective time management skills have been linked to academic achievement, stress reduction, increased creativity [ 45 ], and student satisfaction [ 46 ]. Our findings are also consistent with previous studies that reported that a common source of stress among first-year students was the increased classroom workload [ 19 , 47 ]. As clinical assignments and workloads are major stressors for nursing students, it is important to promote activities to help them manage these assignments [ 48 ].

Another major challenge reported by the participants was related to communicating and interacting with other nurses and patients. The UAE nursing workforce and population are largely expatriate and diverse and have different cultural and linguistic backgrounds. Therefore, student nurses encounter difficulty in communication [ 49 ]. This cultural diversity that students encounter in communication with patients during clinical training needs to be addressed by curriculum planners through the offering of language courses and courses on cultural diversity [ 50 ].

Regarding the third and final theme, nursing students in clinical training are unable to avoid stressors and must learn to cope with or adapt to them. Previous research has reported a link between stressors and the coping mechanisms used by nursing students [ 51 , 52 , 53 ]. In particular, the inability to manage stress influences nurses’ performance, physical and mental health, attitude, and role satisfaction [ 54 ]. One such study suggested that nursing students commonly use problem-focused (dealing with the problem), emotion-focused (regulating emotion), and dysfunctional (e.g., venting emotions) stress coping mechanisms to alleviate stress during clinical training [ 15 ]. Labrague et al. [ 51 ] highlighted that nursing students use both active and passive coping techniques to manage stress. The pattern of clinical stress has been observed in several countries worldwide. The current study found that first-year students experienced stress during their first clinical training [ 35 , 41 , 55 ]. The stressors they encountered impacted their overall health and disrupted their clinical learning. Chaabane et al. [ 15 ] reported moderate and high stress levels among nursing students in Bahrain, Egypt, Iraq, Jordan, Oman, Pakistan, Palestine, Saudi Arabia, and Sudan. Another study from Bahrain reported that all nursing students experienced moderate to severe stress in their first clinical placement [ 56 ]. Similarly, nursing students in Spain experienced a moderate level of stress, and this stress was significantly correlated with anxiety [ 30 ]. Therefore, it is imperative that pastoral systems at the university address students’ stress and mental health so that it does not affect their clinical performance. Faculty need to utilize evidence-based interventions to support students so that anxiety-producing situations and attrition are minimized.

In our study, students reported a variety of positive and negative coping mechanisms and strategies they used when they experienced stress during their clinical practice. Positive coping strategies included time management, positive thinking, self-support/motivation, breathing, taking breaks, talking with friends, and physical activity. These findings are consistent with those of a previous study in which healthy coping mechanisms used by students included effective time management, social support, positive reappraisal, and participation in leisure activities [ 57 ]. Our study found that relaxing and talking with friends were stress management strategies commonly used by students. Communication with friends to cope with stress may be considered social support. A previous study also reported that people seek social support to cope with stress [ 58 ]. Some students in our study used physical activity to cope with stress, consistent with the findings of previous research. Stretching exercises can be used to counteract the poor posture and positioning associated with stress and to assist in reducing physical tension. Promoting such exercise among nursing students may assist them in coping with stress in their clinical training [ 59 ].

Our study also showed that when students felt stressed, some adopted negative coping strategies, such as showing anger/irritability, engaging in unhealthy eating habits (e.g., consumption of too much food or coffee), or smoking cigarettes. Previous studies have reported that high levels of perceived stress affect eating habits [ 60 ] and are linked to poor diet quality, increased snacking, and low fruit intake [ 61 ]. Stress in clinical settings has also been linked to sleep problems, substance misuse, and high-risk behaviors’ and plays a major role in student’s decision to continue in their programme.

Implications of the study

The implications of the study results can be grouped at multiple levels including; clinical, educational, and organizational level. A comprehensive approach to addressing the stressors encountered by nursing students during their clinical practicum can be overcome by offering some practical strategies to address the stressors faced by nursing students during their clinical practicum. By integrating study findings into curriculum planning, mentorship programs, and organizational support structures, a supportive and nurturing environment that enhances students’ learning, resilience, and overall success can be envisioned.

Clinical level

Introducing simulation in the skills lab with standardized patients and the use of moulage to demonstrate wounds, ostomies, and purulent dressings enhances students’ practical skills and prepares them for real-world clinical scenarios. Organizing orientation days at clinical facilities helps familiarize students with the clinical environment, identify potential stressors, and introduce interventions to enhance professionalism, social skills, and coping abilities Furthermore, creating a WhatsApp group facilitates communication and collaboration among hospital staff, clinical tutors, nursing faculty, and students, enabling immediate support and problem-solving for clinical situations as they arise, Moreover, involving chief nursing officers of clinical facilities in the Nursing Advisory Group at the Department of Nursing promotes collaboration between academia and clinical practice, ensuring alignment between educational objectives and the needs of the clinical setting [ 62 ].

Educational level

Sharing study findings at conferences (we presented the results of this study at Sigma Theta Tau International in July 2023 in Abu Dhabi, UAE) and journal clubs disseminates knowledge and best practices among educators and clinicians, promoting awareness and implementation of measures to improve students’ learning experiences. Additionally we hold mentorship training sessions annually in January and so we shared with the clinical mentors and preceptors the findings of this study so that they proactively they are equipped with strategies to support students’ coping with stressors during clinical placements.

Organizational level

At the organizational we relooked at the available student support structures, including counseling, faculty advising, and career advice, throughout the nursing program emphasizing the importance of holistic support for students’ well-being and academic success as well as retention in the nursing program. Also, offering language courses as electives recognizes the value of communication skills in nursing practice and provides opportunities for personal and professional development.

For first-year nursing students, clinical stressors are inevitable and must be given proper attention. Recognizing nursing students’ perspectives on the challenges and stressors experienced in clinical training is the first step in overcoming these challenges. In nursing schools, providing an optimal clinical environment as well as increasing supervision and evaluation of students’ practices should be emphasized. Our findings demonstrate that first-year nursing students are exposed to a variety of different stressors. Identifying the stressors, pressures, and obstacles that first-year students encounter in the clinical setting can assist nursing educators in resolving these issues and can contribute to students’ professional development and survival to allow them to remain in the profession. To overcome stressors, students frequently employ problem-solving approaches or coping mechanisms. The majority of nursing students report stress at different levels and use a variety of positive and negative coping techniques to manage stress.

The present results may not be generalizable to other nursing institutions because this study used a purposive sample along with a qualitative approach and was limited to one university in the Middle East. Furthermore, the students self-reported their stress and its causes, which may have introduced reporting bias. The students may also have over or underreported stress or coping mechanisms because of fear of repercussions or personal reasons, even though the confidentiality of their data was ensured. Further studies are needed to evaluate student stressors and coping now that measures have been introduced to support students. Time will tell if these strategies are being used effectively by both students and clinical personnel or if they need to be readdressed. Finally, we need to explore the perceptions of clinical faculty towards supervising students in their first clinical practicum so that clinical stressors can be handled effectively.

Data availability

The data sets are available with the corresponding author upon reasonable request.

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Acknowledgements

The authors are grateful to all second year nursing students who voluntarily participated in the study.

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Jacqueline Maria Dias, Muhammad Arsyad Subu, Nabeel Al-Yateem, Fatma Refaat Ahmed, Syed Azizur Rahman, Mini Sara Abraham, Sareh Mirza Forootan, Farzaneh Ahmad Sarkhosh & Fatemeh Javanbakh

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Contributions

JMD conceptualized the idea and designed the methodology, formal analysis, writing original draft and project supervision and mentoring. MAS prepared the methodology and conducted the qualitative interviews and analyzed the methodology and writing of original draft and project supervision. NY, FRA, SAR, MSA writing review and revising the draft. SMF, FAS, FJ worked with MAS on the formal analysis and prepared the first draft.All authors reviewed the final manuscipt of the article.

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Dr Fatma Refaat Ahmed is an editorial board member in BMC Nursing. Other authors do not have any conflict of interest

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Dias, J.M., Subu, M.A., Al-Yateem, N. et al. Nursing students’ stressors and coping strategies during their first clinical training: a qualitative study in the United Arab Emirates. BMC Nurs 23 , 322 (2024). https://doi.org/10.1186/s12912-024-01962-5

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Received : 06 January 2024

Accepted : 22 April 2024

Published : 11 May 2024

DOI : https://doi.org/10.1186/s12912-024-01962-5

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