anxiety nursing research article

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StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

StatPearls [Internet].

Anxiety (nursing).

Suma P. Chand ; Raman Marwaha ; Runez M. Bender .

Affiliations

Last Update: April 24, 2023 .

Learning Outcome
Recall the causes of anxiety
Describe the presentation of anxiety
Summarize the treatment of anxiety
List the nursing management of anxiety
Introduction

Fear is an automatic neurophysiological state of alarm characterized by a fight or flight response to a cognitive appraisal of present or imminent danger (real or perceived). Anxiety is linked to fear and manifests as a future-oriented mood state that consists of a complex cognitive, affective, physiological, and behavioral response system associated with preparation for the anticipated events or circumstances perceived as threatening. Pathological anxiety is triggered when there is an overestimation of perceived threat or an erroneous danger appraisal of a situation which leads to excessive and inappropriate responses. [1] [2] [3]

Nursing Diagnosis
Inadequate management of mood and behavior
Deficient knowledge
Inadequate social skills
Imbalance in social functioning

Anxiety disorders appear to be caused by an interaction of biopsychosocial factors. Genetic vulnerability interacts with situations that are stressful or traumatic to produce clinically significant syndromes.

Risk Factors

Anxiety is one of the most common psychiatric disorders in the general population. Specific phobia is the most common with a 12-month prevalence rate of 12.1%. Social anxiety disorder is the next most common, with a 12-month prevalence rate of 7.4%. The least common anxiety disorder is agoraphobia with a 12-month prevalence rate of 2.5%. Anxiety disorders occur more frequently in females than in males with an approximate 2:1 ratio. [4]

Characteristic Symptoms Pathological Anxiety

Cognitive symptoms: fear of losing control; fear of physical injury or death; fear of "going crazy"; fear of negative evaluation by others; frightening thoughts, mental images, or memories; perception of unreality or detachment; poor concentration, confusion, distractible; narrowing of attention, hypervigilance for threat; poor memory; and difficulty speaking.

Physiological symptoms: increased heart rate, palpitations; shortness of breath, rapid breathing; chest pain or pressure; choking sensation; dizzy, light-headed; sweaty, hot flashes, chills; nausea, upset stomach, diarrhea; trembling, shaking; tingling or numbness in arms and legs; weakness, unsteadiness, faintness; tense muscles, rigidity; and dry mouth.

Behavioral symptoms: avoidance of threat cues or situations; escape, flight; pursuit of safety, reassurance; restlessness, agitation, pacing; hyperventilation; freezing, motionless; and difficulty speaking.

Affective symptoms: nervous, tense, wound up; frightened, fearful, terrified; edgy, jumpy, jittery; and impatient, frustrated.

Anxiety Disorders as defined in the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM–5; American Psychiatric Association, 2013):

Separation Anxiety Disorder : An individual with separation anxiety disorder displays anxiety and fear atypical for his/her age and development level of separation from attachment figures. There is persistent and excessive fear or anxiety about harm to, loss of, or separation from attachment figures. The symptoms include nightmares and physical symptoms. Although the symptoms develop in childhood, they can be expressed throughout adulthood as well.
Selective Mutism: This disorder is characterized by a consistent failure to speak in social situations where there is an expectation to speak even though the individual speaks in other circumstances, can speak, and comprehends the spoken language. The disorder is more likely to be seen in young children than in adolescents and adults.
Specific Phobia: Individuals with a specific phobia are fearful or anxious about specific objects or situations which they avoid or endure with intense fear or anxiety. The fear, anxiety, and avoidance are almost always immediate and tend to be persistently out of proportion to the actual danger posed by the specific object or situation. There are different types of phobias: animal, blood-injection-injury, and situational.
Social Anxiety Disorder: This disorder is characterized by marked or intense fear or anxiety of social situations in which one could be the subject of scrutiny. The individual fears that he/she will be negatively evaluated in such circumstances. He/she also fears being embarrassed, rejected, humiliated, or offending others. These situations always provoke fear or anxiety and are avoided or endured with intense fear and anxiety.
Panic Disorder: Individuals with this disorder experience recurrent, unexpected panic attacks and experience persistent concern and worry about having another panic attack. They also have changes in their behavior linked to panic attacks which are maladaptive, such as avoidance of activities and situations to prevent the occurrence of panic attacks. Panic attacks are abrupt surges of intense fear or extreme discomfort that reach a peak within minutes, accompanied by physical and cognitive symptoms such as palpitations, sweating, shortness of breath, fear of going crazy, or fear of dying. Panic attacks can occur unexpectedly with no obvious trigger, or they may be expected, such as in response to a feared object or situation.
Agoraphobia: Individuals with this disorder are fearful and anxious in two or more of the following circumstances: using public transportation, being in open spaces, being in enclosed spaces like shops and theaters, standing in line or being in a crowd, or being outside of the home alone. The individual fears and avoids these situations because he/she is concerned that escape may be difficult or help may not be available in the event of panic-like symptoms, or other incapacitating or embarrassing symptoms (e.g., falling or incontinence).
Generalized Anxiety Disorder: The key feature of this disorder is persistent and excessive worry about various domains, including work and school performance, that the individual finds hard to control. The person also may experience feeling restless, keyed up, or on edge; being easily fatigued; difficulty concentrating or mind going blank; irritability, muscle tension, and sleep disturbance.
Substance/Medication-Induced Anxiety Disorder : This disorder involves anxiety symptoms due to substance intoxication or withdrawal or to medical treatment.
Anxiety Disorder Due to Other Medical Conditions: Anxiety symptoms are the physiological consequence of another medical condition. Examples include endocrine disease: hypothyroidism, hypoglycemia, and hypercortisolism; cardiovascular disorders: congestive heart failure, arrhythmia, and pulmonary embolism; respiratory illness: asthma and pneumonia; metabolic disturbances: B12 or porphyria; neurological illnesses: neoplasms, encephalitis, and seizure disorder.

When the history and examination do not suggest the symptoms as arising from any other medical disorder, the initial laboratory studies may be limited to the following: complete blood cell count (CBC) chemistry profile, thyroid function tests, urinalysis, and urine drug screen. [5] [6] [7]

If the anxiety symptoms are atypical or there are some abnormalities noted in the physical examination more detailed evaluations may be indicated to identify or exclude underlying medical conditions. This would include the following: electroencephalography, brain computed tomography (CT) scan, electrocardiography, tests for infection, arterial blood gas analysis, chest radiography, and thyroid function tests.

Medical Management

Treatment consists of psychotherapy, pharmacotherapy, or a combination of both.

Pharmacotherapy: selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), benzodiazepines, tricyclic antidepressants, mild tranquilizers, and beta-blockers treat anxiety disorders. [3] [8] [9]

SSRIs (fluoxetine, sertraline, paroxetine, escitalopram, and citalopram) are an effective treatment for all anxiety disorders and considered first-line treatment.
SNRIs (venlafaxine and duloxetine) are considered as effective as SSRIs and also are considered first-line treatment, particularly for generalized anxiety disorder (GAD).
Tricyclic antidepressants (amitriptyline, imipramine, and nortriptyline) are useful in the treatment of anxiety disorders but cause significant adverse effects.
Benzodiazepines (alprazolam, clonazepam, diazepam, and lorazepam) are used for short-term management of anxiety. They are fast-acting and bring relief within 30 minutes to an hour. They are effective in promoting relaxation and reducing muscular tension and other symptoms of anxiety. Because they work quickly, they are effective when taken for panic attacks or overwhelming episodes. Long-term use may require increased doses to achieve the same effect, which may result in problems related to tolerance and dependence.
Buspirone is a mild tranquilizer that is slow acting as compared to benzodiazepines and takes about 2 weeks to start working. It has the advantage of being less sedating and also not being addicting with minimal withdrawal effects. It works for GAD.
Beta-blockers (propranolol and atenolol) control the physical symptoms of anxiety such as rapid heart rate, a trembling voice, sweating, dizziness, and shaky hands. They are most helpful for phobias, particularly social phobia.

Psychotherapy: One of the most effective forms of psychotherapy is cognitive-behavioral therapy. It is a structured, goal-oriented, and didactic form of therapy that focuses on helping individuals identify and modify characteristic maladaptive thinking patterns and beliefs that trigger and maintain symptoms. This form of therapy focuses on building behavioral skills so that patients can behave and react more adaptively to anxiety-producing situations. Exposure therapy is utilized to move individuals towards facing the anxiety-provoking situations and stimuli which they typically avoid. This exposure results in a reduction in anxiety symptoms as they learn that their anxiety is causing them to experience false alarms and they do not need to fear the situation or stimuli and can cope effectively with such a situation.

Nursing Management
Assess the intensity of anxiety
Determine the triggers for anxiety
Assess how the patient responds to anxiety
Administer medications to relieve anxiety
Educate the patient about anxiety
Encourage patient to develop support groups
Encourage patient to seek mental health counseling
Educate patient on self-care
Provide means of support
Interact with the patient in a calm and gentle manner
Converse in simple language
Allow the patient to talk about distressing emotions and feelings
Assess patient for suicidal ideations
Help strengthen patient's problem-solving abilities
Tell the patient to limit alcohol and caffeinated beverages
Encourage patient to participate in social functions
Outcome Identification

Anxiety disorders have very high morbidity including substance abuse, alcoholism, and major depression. In addition, constant anxiety also increases the risk of adverse cardiac events. In others, anxiety impairs the ability to develop social relationships and worsens the quality of life. Severe anxiety has also been linked to high rates of suicide.

Coordination of Care

Anxiety disorders are very common and can present in diverse ways. When a person has chronic anxiety, the condition can be very debilitating, and hence it is best managed by a multidisciplinary team consisting of a mental health nurse, psychiatrist, psychotherapist, social worker, and a primary care provider. The outlook for patients with anxiety is guarded. Data indicate that the high rates of mortality are associated with adverse cardiac events. In those with social phobia, the condition leads to significant functional impairment and a very poor quality of life. The risk of suicides is also high in this population. Patients with anxiety need lifelong follow-up because, despite drug therapy, relapse rates are high. [2] [10] [11] (Level V)

Pearls and Other issues

Characteristic features noted in individuals with clinical anxiety:

False alarms: The presence of intense fear in the absence of threat cues or very minimal threat provocation.
Persistence: There is a future-oriented perspective that involves the anticipation of threat or danger which causes the patient to experience a heightened level of apprehension and thoughts about impending potential threat, regardless of whether it materializes.
Impaired Functioning: Anxiety interferes with effective and adaptive coping in the face of a perceived threat and the person’s daily social or occupational life.
Stimulus hypersensitivity: In clinical states, fear is elicited by a wider range of stimuli or situations of relatively mild intensity that would be innocuous to a person who does not have clinical anxiety.
Dysfunctional cognition and cognitive symptoms: Thinking characterized by overestimation of threat or danger appraisal of a situation that is not confirmed in any way.
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Disclosure: Suma Chand declares no relevant financial relationships with ineligible companies.

Disclosure: Raman Marwaha declares no relevant financial relationships with ineligible companies.

Disclosure: Runez Bender declares no relevant financial relationships with ineligible companies.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

Cite this Page Chand SP, Marwaha R, Bender RM. Anxiety (Nursing) [Updated 2023 Apr 24]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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Research article
Open access
Published: 19 October 2020

Anxiety, perceived stress and coping strategies in nursing students: a cross-sectional, correlational, descriptive study

María Dolores Onieva-Zafra 1 ,
Juan José Fernández-Muñoz 2 ,
Elia Fernández-Martínez ORCID: orcid.org/0000-0002-7700-999X 3 ,
Francisco José García-Sánchez 1 ,
Ana Abreu-Sánchez 3 &
María Laura Parra-Fernández 1

BMC Medical Education volume 20 , Article number: 370 ( 2020 ) Cite this article

53k Accesses

50 Citations

Metrics details

For many nursing students, clinical training represents a stressful experience. The levels of stress and anxiety may vary during students’ educational training, depending on their ability to adopt behavioral strategies for coping with stress, and other factors. This study aimed to investigate the relationship between anxiety, perceived stress, and the coping strategies used by nursing students during their clinical training.

A cross-sectional correlational descriptive study. The sample consisted of 190 nursing students enrolled in the Nursing Faculty of Ciudad Real University in Spain. Participants provided data on background characteristics and completed the following instruments: the Perceived Stress Scale; the State-Trait Anxiety Inventory and the Coping Behavior Inventory. Relationships between scores were examined using Spearman’s rho.

The mean age of participants was 20.71 ± 3.89 years (range 18–46 years). Approximately half of the students (47.92%) indicated a moderate level of stress with a mean Perceived Stress Scale score of 22.78 (±8.54). Senior nursing students perceived higher levels of stress than novice students. The results showed a significant correlation for perceived stress and state anxiety ( r = 0.463, p < .000) and also for trait anxiety ( r = 0.718, p < .000). There was also a significant relationship between the total amount of perceived stress and the following domains of the coping behavior inventory: problem solving ( r = −.452, p < .01), self-criticism ( r = .408 p < .01), wishful thinking ( r = .459, p < .01), social support( r = −.220, p < .01), cognitive restructuring ( r = −.375, p < .01), and social withdrawal ( r = .388, p < .01). In the current study, the coping strategy most frequently used by students was problem-solving, followed by social support and cognitive restructuring.

Conclusions

Nursing students in our study presented a moderate level of stress, in addition there was a significant correlation with anxiety. Nursing teachers and clinical preceptors/mentors should be encouraged to develop programs to help prepare nursing students to cope with the challenges they are about to face during their clinical placements.

Peer Review reports

Research on stress levels among health professionals is an issue of current interest that merits concern [ 1 ]. This is not only due to the many causes of intrinsic stress referred by healthcare professionals, but also because it is worth considering the negative and chronic effects of stress over time [ 2 ].

In nursing, the subject of stress has received much attention in the literature, and continues to be the topic of many studies [ 3 , 4 ]. The practical training of a nurse’s education has been reported to be much more stressful than academic training. Also, the perceived lack of knowledge and skills are considered to be one of the common stressors for many students [ 5 ]. Furthermore, the first experience in clinical practice includes stressors such as fear of making mistakes, having to handle emergency situations, irregularities in clinical practice and visiting specialized units [ 6 ].

Generally, nursing students do not have the same responsibility in the individual care of patients in clinical practice as registered nurses, however they are exposed to some of the same stressors. Examples of the same include the relationships with other professionals, the notorious ranking that exists in hospitals, difficult situations regarding the treatment of patients and dealing with family members and the way they experience the death of the patients they care for [ 7 ]. Furthermore, nursing students coexist with other stressors that are typical considering their role as students, such as those related with their academic program and their role as nursing students [ 8 ]. This is because, as opposed to other degree programs, nursing students are in touch with the job market which requires a certain responsibility in the wellbeing of their patients, distancing them, at times from the student campus life and especially, from normal social activities enjoyed by their peers.

Low or moderate levels of stress may enhance students’ motivation, leading to greater perseverance when studying and achieving future goals [ 9 ]. Conversely, high levels of stress can have a negative influence on students, leading to depression and despair, and therefore affecting students’ health and academic level [ 10 ]. Stress is unavoidable and, in most cases, it is difficult to overcome, however, a good coping strategy may help students to improve their academic results [ 11 ].

Coping mechanisms are essential when trying to deal with the stress and anxiety that nursing students face on a daily basis. Longitudinal studies have shown that stress levels in nursing students may increase or decrease during their educational training depending on coping behavior strategies. However, as noted by Jimenez et al. [ 12 ], these differences regarding stress levels over the course of professional training should be considered with caution, as different programs exist in each country. Whereas some studies identify the first or second year as being the most stressful for students [ 13 ], for others, the third year is the most stressful due to the clinical duties [ 14 , 15 ]. However, other studies show that stress levels increase according to the training or the academic year [ 16 , 17 ] or decrease as the student becomes more trained [ 18 ]. Besides these differences, coping strategies vary according to the characteristics of the individual and the context where the stressors are found. The use of problem solving strategies has been identified as one of the best ways to cope with stress. Conversely, emotional based coping strategies appear to be the least effective strategy [ 19 ]. Therefore, the main aim of this study was to investigate the relationship between anxiety, perceived stress and coping strategies used by nursing students during their clinical training. Moreover, we performed a comparative analysis between perceived stress and coping strategies by gender, course and clinical placement, based on the available literature.

Study design, setting and participants

A cross-sectional, descriptive, correlational design was used. Graduate-level students were recruited from the Ciudad Real Nursing Faculty of Castilla-La Mancha University during the 2017/18 academic year. Currently, in Spain the nursing degree lasts 4 years with a total of 240 credits, under the European Credits Transfer System (ETCS). At the University of Castilla-La-Mancha (UCLM), during the first academic year, nursing students only have academic subjects (theoretical-practical taught in the classroom setting). These classes take place at the Faculty, and, at this point students have no contact with hospital settings. After the first year, once the basic core subjects are taught, the students begin their clinical placements. These begin in the first semester of the second year and are completed in the fourth year, with subjects that are entirely care-based and which take place at the hospital (Table 6 in Appendix ). During these 3 years, students alternate clinical placements with academic subjects.

A prior sample size calculation was not performed for this study, rather the sample size was based on the entire population of students, as described previously. Clinical placements are an essential part of the acquisition of competencies and skills for nursing students, constituting an important element of their education.

The eligibility criteria for this study were as follows: all participants were students enrolled in an academic year of the nursing degree course taught at the university (except first year students). Participants must have been present in the classroom when the researcher visited to collect data. Furthermore, informed consent was required for participation. The population of nursing students studying at the university was 340 students, of these, 115 were excluded because they did not fulfill the inclusion criteria; thirty-three did not participate in the research and, finally, 192 students agreed to participate and complete the self-administered questionnaire. The response rate was 85.33%.

Data collection instruments

Data were collected from the students in the study group using a 20- min online self-report questionnaire comprising the following information:

Demographic characteristics: The demographic questionnaire was constructed by the researchers and was based on the recent literature. This included items such as age, gender, relationship status, academic year of the nursing degree etc.

Perceived stress scale (PSS). The PSS-14 was designed for measuring the degree to which daily life situations are evaluated as stressors. The PSS-14 consists of multiple choice questions measuring stressful experiences and responses to stress over the previous 4 weeks. The European Spanish version PSS (14-item) has demonstrated adequate reliability (internal consistency, alpha = .81) [ 20 ]. Our study demonstrated an alpha =. 87. The range for total scores on the PSS-14 was from 0 to 56. Stress scores below the 25th percentile (0 to 17) were interpreted as low stress, scores between the 25th and 75th percentile (18 to 28.5) were interpreted as moderate stress and scores above the 75th percentile (28.6 to 56) were interpreted as high stress. On the Stress Survey, each item’s mean stress rating was calculated. An item with an average of 5 was interpreted as causing “severe stress”, 4 as causing “a lot of stress”, 3 represented “moderate stress”, 2 was “a little stress”, and 1 equaled “no stress”.

The State-Trait Anxiety Inventory (STAI): Internal consistency coefficients for the Spanish version scale range from .86 to .95 [ 21 ]. In our sample we obtained an alpha of 0.91 for STAI State and an Alpha of 0.86 for STAI trait. The STAI has 40 items with 20 items allocated to each of the subscales, based on a 4-point Likert format (score from 0 to 3). The range of scores for each subscale is 0–60, in which higher scores indicate greater anxiety. The State Anxiety Scale (S-Anxiety) evaluates the current state of anxiety, whereas the Trait Anxiety Scale (T-Anxiety) evaluates relatively stable aspects of “anxiety proneness,” including general states of calmness, confidence, and security [ 21 ].

The Coping Strategy Inventory (CSI) is a self-report questionnaire designed to assess coping thoughts and behaviors in response to a specific stressor [ 22 ]. We used the existing Spanish version [ 22 ]. The internal consistency coefficients were between .63 and .89 [ 23 ] and between .64 and .85 in our sample for each primary subscale. The CSI has 40 items, each item on the CSI may be scored using a 5-point Likert format (scores from 0 to 4), with the total score ranging from 0 to 160. This questionnaire contains eight primary subscales. These are: problem solving, self-criticism, expression of emotions, wishful thinking, social support, cognitive restructuring, problem avoidance, and social withdrawal.

Statistical data analyses

Descriptive analysis and reliability.

Data analyses were carried out using the Statistical Software Package for the Social Sciences (SPSS) version 23.0. Data were examined by calculating the means, standard deviation (±SD), absolute and relative frequencies and percentages, in order to generate a descriptive statistical analysis. In order to measure the internal consistency and homogeneity of the three questionnaires, the Cronbach’s alpha test was performed, accepting a coefficient ≥ 0.70 as an ideal value. The individual analysis of each item was carried out using the homogeneity index which was assessed using the Spearman correlation coefficient. Each item that obtained a coefficient > 0.30 was considered useful for evaluating the attribute. Additionally, no items failed to fulfil this condition.

Correlations and regression analysis

After checking the non-normal distribution of the total scores of the scales in our sample using the Kolmogorv-Smirnof test, the relevant non parametric tests were used for the comparison of means between groups according to gender, course, clinical placement and previous training in health sciences.

Correlations between the scores of the different scales used were assessed using the Spearman’s rho correlation coefficient. The accepted confidence interval was 95% and the significance level for all analyses was set at p < .05; moreover, with the significant correlation between the perceived stress scale and the STAI and CSI a hierarchical regression model was applied to assess the independent variables that contributed significantly to the variance in the score on the PSS. These independent variables were entered into the regression model in five steps. Changes in R 2 were reported after each step of the regression model to further determine the association of the additional variables. The significance criterion of the critical F value for entry into the regression equation was set at p < .05, and was considered significant in all tests.

Descriptive results for the perceived stress scale, and dimensions of the anxiety and coping scale

The mean age of participants was 20.71 ± 3.89 years (range 18–46 years). Most students were female (86.5%) and 17.7% of the students had previous training in health sciences. Up to 52.1% of students were undergoing their first clinical placement in the second year Table 1 .

The mean PSS score was 22.78 (±8.54), indicating a moderate level of stress. Furthermore, the stress scores ranged from 5 to 47 out of a possible 56. In our study, most participants (47.92%) indicated a moderate level of stress. The Anxiety state score was 17.64 (±9.01) classified as ‘no problem’ with a minimum score of 3 and maximum of 54 and Anxiety trait of 20.13 (±8.74) classified as ‘mild anxiety’ with a minimum score of 4 and maximum score of 46.

Comparative analysis between PSS, STAI and clinical placement

Regarding the type of clinical placements, no significant differences were found when comparing the mean perceived stress ( p = .352) using the ANOVA. However, significant differences were identified in relation to anxiety state ( p = .002). When comparing clinical placements two by two, statistically significant differences were identified between Primary Care and Special Services (15.9 ± 8.75 vs 23.77 ± 11.16, p = .006), Geriatrics and Special Services (16.18 ± 7.53 vs 23.77 ± 11.16, p = .004) and Internal Medicine and Special Services (16.14 ± 7.75 vs 23.77 ± 11.16, p = .001). Up to 100% of the students who displayed severe anxiety in the state STAI were in specialized services Table 2 .

Relationships between gender, academic year and dimension of CSI

The CSI displays significant differences between gender for the dimensions Expression of emotion, Social support and Problem avoidance, as, in all cases, the mean of these scores was higher among female students. However, for the total score, despite the fact that the mean score was higher in women (23.22 ± 8.55) than in men (20 ± 8.04), significant differences were not found regarding gender ( p = .069) for the total score. Regarding the students’ academic year, the dimensions that were found to be statistically significant were wishful thinking and social withdrawal. The total mean score of the test for students in their second year was 21.30 ± 8.65 and the total mean score for students in their third year was 24.40 ± 8.16, the statistical analysis was significant ( p = 0.009) (Table 3 ).

Correlation and hierarchical regression analysis

A Spearman’s rho correlation was used to investigate the relationship between total perceived stress and anxiety (state and trait) and the PSS score with the total score on the CSI and all subscales. The results displayed a significant correlation for the total on the PSS and the state STAI ( r = .463, p < .01) and for the total PSS and the trait STAI ( r = .718, p < .01). Regarding the perceived stress and the coping strategies, the results revealed a significant relationship between the total perceived stress and the following domains of the CSI: problem solving ( r = −.452, p < .01), self-criticism( r = .408 p < .01), wishful thinking ( r = .459, p < .01), social support ( r = −.220, p < .01), cognitive restructuring ( r = −.375, p < .01), and social withdrawal ( r = .388, p < .01). (Table 4 ).

Table 5 shows the hierarchical regression analysis developed in this study.

For the first step, the adjustment index of the model was significant F (1, 191) 212.186, p < .01 and the anxiety trait variable was a significant predictor of the perceived stress scale (β = .726, t = 14.56, p < .01).

The significant variables included in the second model were: anxiety trait (β = .624, t = 12.32, p < .01) and wishful thinking (β = .266, t = 5.26, p < .01), the adjustment was F (2, 191) 134.82, p < .01.

For the third model, the significant variables were: anxiety trait (β = .564, t = 11.28, p < .01), wishful thinking (β = .263, t = 5.47, p < .01), cognitive restructuring (β = −.211, t = − 4.53, p < .01) and the adjustment was: F (3, 191), 106.01 p < .01.

For the fourth model anxiety trait (β = .486, t = 8.98, p < .01), wishful thinking (β = .269, t = 5.72, p < .01), cognitive restructuring (β = −.215, t = − 4.75, p < .01), and anxiety state (β = .162, t = 3.30, p < .05) were significant variables, and the adjustment was: F (4, 191) 86.44, p < .01.

For step 5: anxiety trait (β = .450, t = 8.15, p < .01), wishful thinking (β = .268, t = 5.79, p < .01), cognitive restructuring (β = −.133, t = − 2.41, p < .05), anxiety state (β = .170, t = 3.52, p < .01), and problem solving (β = −.147, t = − 2.56, p < .05) were significant variables, furthermore the adjustment was: F (5, 191) 72.53, p < .01. The fifth model explained 66.1% of the variance in perceived stress, representing the model with the best fit.

This study was conducted to assess nursing students’ perceived stress levels and their association with anxiety, as well as the coping behaviors used to reduce the effect of stress during clinical training.

Overall, 47.92% of the students experienced a moderate level of perceived stress and only 25% perceived a high degree of stress. Furthermore, the correlation between perceived stress and anxiety was significant in the present study, i.e. students with high scores of perceived stress had higher anxiety scores.

The prevalence of stress among nursing students found in the literature is variable, which could be due to the different academic programs available worldwide and the use of different scales for measuring the same [ 24 , 25 ]. However, stress levels may also become affected because of different perceptions regarding stress across cultures and among different individuals. Lazarus and Folkman defined stress as “a particular relationship between the person and the environment that is appraised by the person as taxing or exceeding his or her resources and endangering his or her well-being” [ 26 ]. Besides these academic and individual differences, according to this definition of stress, it is important to include the effects of the environment, and more concretely, in our case, the different clinical placements the students visited throughout their training, on the levels of stress or anxiety presented by the student. Regarding other specialized services such as intensive care or emergency care, our study suggested that the students had higher levels of anxiety and stress during these clinical placement units.

Regarding the year of studies, our findings support previous studies where the students with the most experience displayed higher levels of anxiety, whereas the most inexperienced showed lower levels of stress and anxiety [ 16 , 17 ]. This may be because students feel that their teachers and other nurses expect more from them as they are more experienced and therefore more knowledgeable students, thus increasing their stress levels. However, this interpretation should be linked to the previously cited findings, i.e., considering the clinical placements performed by the students. For example, clinical placements in more specialized services are usually completed during the later years, whereas during the first years of study, training takes place in more general services requiring more basic competencies for care and patient responsibility. Therefore, students who have more extensive training, but who are also required to have a greater level of competencies and skills during patient care are those that are exposed to a greater level of anxiety and stress. However, as suggested by Jimenez et al. [ 12 ], it is important to exercise caution in these interpretations as, in this sense, the different training programs, despite being based on the ECTS system, should not be centered only on the number of credits to be completed each year, rather, they should insist on coordinating and developing parallel competencies over time, as differences in training programs exist even within the same country.

In the current study, the coping strategies most frequently used by students were problem-solving, followed by social support and cognitive restructuring. According to Folkman and Lazarus, problem solving is one of the more effective ways to deal with stress as it focuses on behaviors in order to manage or alter the problem [ 26 ]. Problem solving has been found to be the most utilized coping strategy in different studies with nursing students [ 27 , 28 , 29 ], despite the fact that these studies have used a measurement scale for facing stress that is different to the one used in this study. In terms of the relationship between perceived stress and coping strategies, our findings indicate that among these three domains (problem solving, cognitive restructuring and social support) an inverse correlation exists, indicating that people who suffer less stress, will use these strategies more often. Similarly, the positive correlation with the following domains shows how people with greater stress have more anxiety trait and state and use strategies such as wishful thinking, self-criticism, social withdrawal and problem avoidance. The results of this study showed that the greatest predictor of perceived stress was anxiety trait. As for the domains or strategies used to cope with stress, in our study, the use of certain strategies, such as problem solving and cognitive restructuring, were considered to be predictors of less stress, whereas the use of wishful thinking appeared as a predictive factor of greater stress. Former studies using other coping tools found a positive relationship in terms of protection regarding the student’s mental health, in those students who used an optimistic strategy. In this sense, possibly, our study sample did not understand, culturally speaking, what wishful thinking meant or they did not know of any strategies truly framed in this state of optimism or illusion. This could be a protective factor in terms of mental health, however this may hamper optimal results in terms of reducing the stress they suffer [ 30 ].

In a qualitative study by Lopez V et al., nursing students of a University in Singapore reported that talking about their negative emotions with their peers and positive reframing of their negative circumstances were the most used strategies when facing perceived stress (such strategies would be framed within the domains of social support and/or expression of emotion). However, relationships between students and their clinical educators and nurses and medical staff have been widely reported in the literature [ 12 , 27 , 31 , 32 ], as being difficult relationships based on a lack of emotional or social support. Both teachers and mentors should be responsible for the proper implementation of coping strategies as basic tools in the skills to be acquired during their competencies in the clinic. The university faculty should not only be aware of the stress levels of students, but also consider how they manage this stress, i.e. whether they use appropriate and effective tools for coping with the same, as this will be key in their development as a nurse. Getting to know the level of stress and/or anxiety that is experienced by our students is important for determining which negative effects should be changed in their behaviors to improve coping.

Implications for education

Our findings are in line with previous research, highlighting that the study of coping strategies appears instrumental for the prevention of stress. Moreover, it is essential for training in these strategies to begin within the university facilities. These programs could help prepare nursing students to cope with the challenges they are about to face during their clinical rotations. For example, in Spain, none of the universities have a nurse student peer mentoring or support program. This type of peer mentoring program, in which third year students mentor first year students, was implemented in other foreign universities in order to reduce the anxiety experienced by first year nursing students and to facilitate a smooth transition to clinical practice situations [ 33 ]. Other strategies have demonstrated to be effective in the management of stress and anxiety in nursing students, such as the use of biofeedback and mindfulness and meditation interventions [ 34 ], or emotional freedom techniques [ 35 ].

These findings should be considered by nurse educators to create a planning strategy to prevent recurrence of stress based on the use of coping strategies that are more closely correlated with lower levels of perceived stress.

Limitations

This study has limitations that must be considered when interpreting these results. First, these findings cannot be generalized, as the study was conducted in nursing students of only one faculty of nursing and therefore, the socio-demographic structure of the sample was not necessarily the same as other faculties in Spain. The performance of longitudinal studies conducted over several academic years is recommended as these may reveal changes in perceived stress over time. Further studies based on qualitative techniques would provide more detail regarding the stressor factors and their relationship with levels of anxiety and coping strategies. However, despite these limitations, the results of this study appear to concur with previous findings on this topic.

In light of these findings, we recommend that the teaching of positive coping strategies should be implemented in the nursing curriculum prior to clinical placements. Qualitative research focused on the student’s perception on their clinical experience may be helpful for developing an effective clinical teaching strategy in nursing education.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Abbreviations

European Credits Transfer System

Perceived stress scale

The State-Trait Anxiety Inventory

The Coping Strategy Inventory

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Acknowledgements

The authors thank the students who took part in this study and generously granted us their time and provided us details about their experiences in clinical practice.

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

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María Dolores Onieva-Zafra, Francisco José García-Sánchez & María Laura Parra-Fernández

Department of Psychology, Universidad Rey Juan Carlos I, Alcorcón, Madrid, Spain

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Department of Nursing, University of Huelva, Huelva, Spain

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Study conception and design. O-Z MD., F-M E., P-F ML., Data collection, statistical expertise, analysis and interpretation of data. O-Z MD., F-M E., P-F ML.,F-M JJ, G-S FJ., A-S A. Manuscript preparation, supervision, administrative support and critical revision of the paper. O-Z MD., F-M E., P-F ML., G-S FJ., A-S A. All authors read and approved the final manuscript.

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Correspondence to Elia Fernández-Martínez .

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Onieva-Zafra, M.D., Fernández-Muñoz, J.J., Fernández-Martínez, E. et al. Anxiety, perceived stress and coping strategies in nursing students: a cross-sectional, correlational, descriptive study. BMC Med Educ 20 , 370 (2020). https://doi.org/10.1186/s12909-020-02294-z

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Coping behavior
Nursing students
Perceived stress

BMC Medical Education

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Navigating Nursing Student Anxiety: A Conceptual Model

Tanya Heuver MacEwan University
Kylie Morey MacEwan University
Thomas Chase MacEwan University

Nursing students experience high rates of anxiety (Gurková & Zeleníková, 2018; Mills et al., 2020; Wedgeworth, 2016) but little is known about the relationship between anxiety and the learning environment. This study intended to explore and better understand what components of the learning environment are impacted by or impact anxiety. This research utilized a grounded theory approach utilizing constant comparative analysis of findings to develop a theoretical model that identifies and describes the components of the learning environment that impact anxiety. Focus groups revealed that educator practices, participants' sense of self, and social determinants of health impacted student experiences of anxiety. Participants also identified several protective factors including self-management and self-care strategies, professional mental health resources, and relationships. The model provides a conceptual framework that can be used as a resource to guide practices of nurse educators and administrators as they reflect on the relationships between intrinsic and external factors, including the learning environment.

Author Biographies

Christine shumka, macewan university.

Faculty of Nursing, Nurse Educator

Tanya Heuver, MacEwan University

Faculty of Nursing, Department of Nursing Practice, Chair and Assistant Professor

Cheryl Pollard, University of Regina

Faculty of Nursing, Dean

Kylie Morey, MacEwan University

Alumni of BScN, Faculty of Nursing, Registered Nurse

Thomas Chase, MacEwan University

Alumnai, Faculty of Nursing, Registered Nurse

Shivani Solanki, MacEwan University

Alumni, Faculty of Arts

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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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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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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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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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Research Article

Validation of depression, anxiety, and stress scales (DASS-21) among Thai nursing students in an online learning environment during the COVID-19 outbreak: A multi-center study

Roles Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Visualization, Writing – original draft, Writing – review & editing

Affiliations Movement Science and Exercise Research Center-Walailak University (MoveSE-WU), Walailak University, Nakhon Si Thammarat, Thailand, School of Allied Health Sciences, Walailak University, Nakhon Si Thammarat, Thailand

Roles Formal analysis, Investigation, Methodology, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliation Faculty of Nursing, Roi Et Rajabhat University, Roi Et, Thailand

Roles Investigation, Writing – review & editing

Affiliation Faculty of Physical Therapy, Huachiew Chalermprakiet University, Bangkok, Thailand

Roles Writing – review & editing

Affiliation School of Medicine, Walailak University, Nakhon Si Thammarat, Thailand

Roles Investigation, Writing – original draft, Writing – review & editing

Affiliation Faculty of Nursing, Ratchathani University, Udonthani Campus, Udonthani, Thailand

Roles Investigation, Writing – original draft

Affiliation Faculty of Nursing, Chalermkarnchana University, Srisaket Campus, Srisaket, Thailand

Affiliation Faculty of Nursing, University of Jember, Jember, Indonesia

Yuwadee Wittayapun,
Ueamporn Summart,
Panicha Polpanadham,
Thanyaporn Direksunthorn,
Raweewan Paokanha,
Naruk Judabood,
Muhamad Zulfatul A’la

Published: June 30, 2023
https://doi.org/10.1371/journal.pone.0288041
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The Depression, Anxiety and Stress Scale (DASS-21), an introductory scale used to identify common mental disorders (CMDs) among adults, was validated across cultures in Asian populations; nevertheless, its capacity for screening these disorders may be limited for some specified groups, including nursing students. This study attempted to investigate the psychometric scale’s unique features of DASS-21 for Thai nursing students in an online learning environment during the COVID-19 outbreak. A cross-sectional study using the multistage sampling technique recruited 3,705 nursing students from 18 universities located in south and northeast Thailand. The data were gathered using an online web-based survey, and then all respondents were divided into 2 groups (group 1, n = 2,000, group 2, n = 1,705). After using the statistical methods to reduce items, exploratory factor analysis (EFA) using group 1 was performed to investigate the factor structure of the DASS-21. Finally, group 2 used confirmatory factor analysis to verify the modified structure proposed by the EFA and assess the construct validity of the DASS-21. A total of 3,705 Thai nursing students were enrolled. For the factorial construct validity, a three-factor model was initially suggested containing 18 items (DASS-18) spread across 3 components: anxiety (7 items), depression (7 items) and stress (4 items). The internal consistency reliability was acceptable with Cronbach’s alpha in the range of 0.73–0.92for either the total or its subscales. For convergent validity, average variance extracted (AVE) showed that all the DASS-18 subscales achieved convergence effect with AVE in the range of 0.50–0.67. The psychometric features of the DASS-18 will support Thai psychologists and researchers to screen CMDs more easily among undergraduate nursing students in tertiary institutions who enrolled in an online learning environment during the COVID-19 outbreak.

Citation: Wittayapun Y, Summart U, Polpanadham P, Direksunthorn T, Paokanha R, Judabood N, et al. (2023) Validation of depression, anxiety, and stress scales (DASS-21) among Thai nursing students in an online learning environment during the COVID-19 outbreak: A multi-center study. PLoS ONE 18(6): e0288041. https://doi.org/10.1371/journal.pone.0288041

Editor: Omar M. Khraisat, Al-Ahliyya Amman University, JORDAN

Received: November 11, 2022; Accepted: June 18, 2023; Published: June 30, 2023

Copyright: © 2023 Wittayapun 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. We have already generated our minimal data set 2,000 datasets out of the total (3,705) (D1.XLSX).

Funding: This study was supported by The Walailak University's Individual Research Grants provided funding for the study (Grant Number WU-IRG-65-015). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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

Introduction

Depression and anxiety are common mental health disorders (CMDs), leading causes of disability and have gained prominence due to their growing global burden [ 1 ]. Individually, these disorders contribute to poor psychological wellbeing, which interferes with learning and inhibits students’ academic performance [ 2 ]. Early screening for anxiety and depression in primary care and academic settings necessitates an assessment strategy that is rapid and easy to apply and has proven psychometric properties [ 2 ].

During the COVID-19 pandemic, undergraduate students also reported their anxiety or stress [ 3 , 4 ]. According to a network study, 932 nursing students were included. More than one third of these students reported at least moderate symptoms of worry or stress, and almost one half of these students presented at least mild symptoms of depression [ 5 ]. Due to a quick shift from face-to-face to an online learning environment during university lock downs, undergraduate nursing and midwifery curricula had trouble adjusting to "remote learning" that relies on the use of electronic technologies and media sources to conduct learning outside of the traditional classroom [ 6 ]. Thus, being unable to participate in extensive training such as clinical settings make students feel as though they are passing up a good opportunity to learn these abilities that may have decreased students’ mental health [ 5 , 7 ]. In addition, anxiety and depression may occur more commonly among low experienced apprentices including nursing students [ 8 ]. Moreover, this current study also discovered that the levels of anxiety and depression were higher among nursing students than among those students from other disciplines, regarding their probably high risk of infection exposure and fear of communicable diseases [ 8 ]. Currently, rare evidence is available concerning the mental health of Thai nursing students encountering an instant psychological response in relation to COVID-19. To provide psychiatric interventions to people experiencing these negative emotional states, early diagnosis of these diseases is essential [ 2 ]. Early assessment, using an effective screening instrument (such as a rating scale), provides a rapid indicator of the client’s emotional well-being and is helpful for further clinical judgment and early treatment. Likewise, self-reported questionnaires and clinician-rated scales are two commonly used methods to assess CMDs [ 9 ].

The Depression, Anxiety, and Stress Scale (DASS) is a common scale frequently used to detect CMDs [ 10 ]. Both the DASS-42 and its shortened version, the DASS-21, are frequently used to assess depression, anxiety, and stress among adults, and are considered superior to other psychometric tools to identify these CMDs and screen for psychological abnormalities [ 11 ]. Moreover, DASS-21 has several advantages over the original 42-item version (DASS-42), such as fewer items, cleaner factor structure and smaller interfactor correlations [ 12 ]. Data analyses among adults using this measure produced consistent results regarding its psychometric properties [ 2 , 7 , 12 – 14 ]. Findings regarding the DASS-21’s factor structure are contradictory, ranging from one to four factors structures [ 15 – 17 ]. Results from a prior study in Asia, conducted among nursing students in Brunei, have validated the DASS-21 used the final model, including a nine-item scale across three components [ 18 ]. However, this study encountered limitations because this representative sample (n = 126) was the smallest compared with other studies.

In the Thai context, DASS-21 has been validated across cultures among Asian residents from various projects and research objectives such as assessing the work-related stress and coping strategies among employees in the education and health care sectors [ 19 ], so its ability in detecting these mental health problems may be limited for specific groups including undergraduate nursing students. Another study enrolled preclinical medical students to explore psychometric properties of DASS-21, but this study also used this tool as dependent variable and did not report the constructed validity or the Cronbach alpha coefficient [ 20 ]. Insufficient data are available to validate the DASS-21’s psychometric properties in specific Thai populations, which could constitute considerable variation concerning sociocultural backgrounds and political differences among groups.

To date, regarding the context of online learning, no research, concerning factor structures and convergent validity of DASS-21, has been conducted among Thai nursing students. Applying the original subscales scoring for all adulthood categories to only young adult age groups (approximately ages 18 to 26 years) without comprehending the instrument’s psychometric properties could lead to inaccurate conclusions [ 21 ]. This study aimed to examine the psychometric scale‐specific features of DASS-21 for Thai nursing students concerning an online learning situation during the COVID-19 outbreak.

Materials and methods

Study design and population.

This constituted cross-sectional research, obtaining data from one part of the larger multi-center study, aiming to assess the effects of online learning on the prevalence and factors associated with musculoskeletal disorders among Thai, Indonesian, Vietnamese, and Lao faculty members and students during the COVID-19 outbreak. After this study is completed, they recruit some samples and send them the survey of DASS-21. The target population of this study comprised Thai nursing students nationwide undertaken using a multistage sampling technique. Altogether, 96 nursing institutes in Thailand are spread across five regions. Using a simple random sampling technique, two of the five regions, the south and the northeast, were chosen in the first stage. In these areas, 37 nursing institutes are located. Then using a nonproportional stratified sampling technique, 15 nursing institutes were chosen. In addition, three nursing faculties from the Central Region were conveniently sampled, providing a total of 18 institutes. Totally, 5395 students were able to receive participant information sheets online from us. Prior to collecting data, administrators’ approval was obtained after a thorough description of the study’s objective. Before the survey began, a statement of consent was obtained from all participants by permitting only those who pressed "I consent" to go to the questionnaires. A total of 5136 participants indicated their willingness to join the study. Code numbers were created to protect students’ privacy. Finally, nonproportional stratified sampling was used on 4,618 undergraduate students, and 3705 became eligible respondents. Individual student data is only accessible to the authors of this study. These samples were employed to access study participants using an online web-based survey. Recruiting participants and collecting data occurred from April 2022 to June 2022.

Study instruments

The DASS-21 assesses depression, anxiety, and stress symptoms [ 10 ], and is divided into three subscales, each with seven items including depression (DASS 21-D), anxiety (DASS 21-A) and stress (DASS 21-S) (DASS 21S). The translation of this tool from English to Thai was carried out during the cross-culture translation procedure [ 19 ]. Each item is graded on a four-point Likert scale ranging from 0 (“did not apply to me at all”) to 3 (“applied to me a lot”). Because the DASS-21 is a shortened version of the DASS (42 items), the final score of each scale was multiplied by two before being compared with the original DASS scale. Higher scores and response values reflect greater levels of the condition being evaluated. In this study we used the Thai version of the DASS-21 with the original author’s permission [ 19 ]. The Cronbach’s alpha coefficients of depression, anxiety, and stress for The Thai version are 0.82, 0.78, and 0.69, respectively [ 19 ].

The Visual Analog Scale to Evaluate Fatigue Severity (VAS-F) [ 22 ] has 18 components all related to one’s perception of exhaustion. Each question asks respondents to place an “X" along a VAS line that runs between two extremes, such as "not at all fatigued" and "very tired," to identify what they are feeling right now. The score goes from 0 to 100 and is recorded using a vertical line of 10 cm. The line from "No fatigue" to the subject’s stated point indicating their level of fatigue, was measured to obtain the score; the higher the VAFS score, the greater the level of fatigue [ 23 ]. The Cronbach’s alpha for the fatigue subscale was 0.91 and the value of energy subscale was 0.94, respectively [ 22 ]. In addition, questions about general information of the participants, i.e., gender, age, study year, online learning, were included.

Sample size calculation

The sample size was calculated using the formula "sample size = number of items X number of participants," which is an extensively used formula in survey development research. We estimated the minimum sample size based on one item to ten participants [ 24 ]. Therefore, the minimum acceptable sample size, based on 21 items of DASS-21, was 210 respondents. However, our research enrolled 3,705 nursing students from 18 universities mainly located in south and northeast Thailand. Hence, larger sample size could provide more meaningful factor loadings and yield more generalizable results. The inclusion criteria for the participants were age at least 17 years, a nursing student at the institute during the study period more than six months and engaged in the online learning. Individuals who do not fill the administered questionnaire or submit an incompletely filled questionnaire such as responding to only a part of general information in the Thai Version of DASS-21, and nursing students with existing CMDs were excluded from this study. To avoid model overfitting, the exploratory (EFA) and confirmatory factor analyses (CFA) were organized on a random split of the total 3705 subjects in two group samples (group 1, n = 2000, and group 2, n = 1705).

Statistical analysis

All statistical analysis in this study was conducted using IBM SPSS and AMOS version 20. Descriptive statistics with means and standard deviation for continuous variables and counts and percentages for categorical data were used to describe the participant’s demographic characteristics.

To investigate the number of components in the EFA for the DASS-21 measuring model, parallel analysis (based on principle component analysis) was undertaken using sample group 1. Then the structure of factors was investigated using principal axis factoring with varimax rotation. Factor loadings less than 0.5 were suppressed, and item cross loadings more than 0.2 were removed one at a time. Furthermore, factor loadings were used to calculate average variance extracted (AVE) and composite reliability (CR). Regarding the findings of the principal axis factoring, a CFA was applied to the remaining held-out participants. The measurement model was fitted using an unweighted least square estimate CFA, and model fit was evaluated using the cumulative fit index (CFI), adjusted goodness of fit index (AGFI), root-mean-square error of approximation (RMSEA), and Tucker-Lewis’s index (TLI) [ 19 , 25 , 26 ]. Likewise, Root Mean Square Error of Approximation (RMSEA) with a p-value less than 0.08 was considered to indicate a good model fit, so it was reported and used in this investigation for the sake of convention. Along with the CFA, the Kaiser-Meyer-Olkin (KMO) measure of sampling adequacy and the Bartlett’s test of sphericity were developed to provide additional construct validity evidence [ 27 ].

CR and Cronbach’s alpha were used to assess reliability. CR is acceptable when the values for the three subscales are greater than 0.6 [ 28 ]. Cronbach’s alpha was used to assess internal consistency reliability, and Cronbach’s alpha above 0.7 for all the subscales was considered to be an acceptable reliability [ 28 ]. In addition, the relationship between each of the DASS items and its own DASS subscale with that item removed is known as the corrected item-total correlations of the three subscales.

We investigated the convergent validity of DASS-18 using the AVE. To indicate convergent validity, the AVE must be equal to or greater than 0.50, indicating that the construct’s variance accounts for more than 50% of its variation [ 26 ]. Furthermore, the discriminant validity determined whether the three indicators of depression, anxiety and stress domains were distinct factors from one another. Pearson’s correlation (r) lower than 0.85 among variables verified their discriminant validity [ 26 ] Pearson correlations were calculated to investigate the intercorrelations matrix, the temporal stability of DASS-18 subscale scores and the relationship between DASS-18 and VAS-F.

Ethics considerations

This study was examined and authorized by Walailak University’s institutional review board (Ref. No. WUEC-22-007-01) and the Center for Ethics in Human Research, Khon Kaen University (Ref. No. HE652094).

General information of the participants

The details of participant characteristics are described in Table 1 . Most completing the questionnaire were females (94.2%) with a mean age of 20 (SD = 1.26) years. Almost two thirds of these participants (67.2%) were experiencing some semesters of online learning at the time of collecting data.

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(n = 3705).

https://doi.org/10.1371/journal.pone.0288041.t001

Exploratory factor analysis

After randomizing the 2000 participants for EFA, firstly, parallel analysis of the matrix indicated that a three-factor solution could be extracted. Secondly, the rotational factor loading matrix was statistically significant. Three factors having eigenvalues over one were created by the initial analyses of the Group 1 sample. To ascertain the factorial structure of DASS-21 and the underlying dimensions comprising its 21 items. The initial analysis revealed a three-factor structure that explained 69.31% of the original data’s variance. Three items (S8, S11, S12) from the stress scale were found to be loading on multiple factors; therefore, these items were removed from this analysis. The three factors resembled the original structure (9) with a reduced factor in stress component; however, the three-factor component (eigenvalues = 9.82; 1.74; and 1.23) was revealed by the scree plot and the eigenvalues higher than one requirement, and this model accounted for 71.31% of the variance. The result of the KMO test was 0.965 (χ2 = 30932; p<0.001), showing that the model was highly adequate. The factor loadings for each DASS- 18 item are shown in Table 2 , with factor loadings >0.50 indicating acceptable loading ( Table 2 ).

https://doi.org/10.1371/journal.pone.0288041.t002

Confirmatory factor analysis

Three items from the stress scale were eliminated (the remaining 18 items of DASS, thus DASS-18). The DASS-18 measuring model, which included 18 items distributed across three components including DASS-18-A (7 items), DASS-18-D (7 items) and DASS-18-S (4 items) was fitted using an unweighted least square CFA. Based on the five specified fit criteria, the model demonstrated an acceptable fit to the data (CMIN/df = 3.082; p = 0.001; CFI = 0.98; RMSEA = 0.032; GFI = 0.98 and NFI = 0.99. The effect of the large sample size may have prevented the chi-square tests from providing acceptable assessments of model fit, whereas other indices indicated that these models remained well-fitted for the data. In addition, except for each factor-constraint item, so that no significant test could be archived, all model items were significantly loaded a long with their concurrent factors (all p-values <0.05) ( Fig 1 ).

https://doi.org/10.1371/journal.pone.0288041.g001

In all cases, the Pearson’s correlation coefficients between DASS-18-D, DASS-18-A and DASS-18-S presented moderate to remarkably elevated levels (0.52 to 0.92) indicating that these scales were moderately to highly discriminatory.

Convergent validity

AVE calculations showed all the DASS-18 subscales achieved a convergence effect (with the AVE of depression = 0.504; the AVE of anxiety = 0.674 and the AVE of stress = 0.551).

Discriminant validity

The magnitude of the correlations among depression, anxiety and stress domains determined the discriminant validity of the variables ( Fig 1 ). The variables showed correlations (r) lower than 0.85 except the correlation between depression and stress domains (r = 0.91).

Association of the DASS-18 scores among demographic characteristic and VAS-F

The total scale of DASS-18 showed a statistically significant positive and fair to moderate association with the VAS-F total score, sex and online learning. Additionally, the DASS-18 total score showed a moderately positive significance correlated to VAS-F in the anticipated direction, confirming the association between higher levels of fatigue and higher levels of depression, anxiety, and stress ( Table 3 ).

https://doi.org/10.1371/journal.pone.0288041.t003

Reliability analysis

The CR of the three domains of DASS-18 ranging from 0.830 to 0.935 indicated evidence of acceptable reliability. Regarding Cronbach alpha values of 0.92 for the overall scale, 0.87 for depression, 0.79 for anxiety and 0.73 for stress, the DASS-18 exhibited adequate internal consistency reliability. Similarly, the internal consistency of this scale was good, as evidenced by the item-rest correlations for all three subscales being better than 0.3 and the corrected item-rest correlation for the entire scale ranging from 0.53 to 0.91 ( Table 4 ).

https://doi.org/10.1371/journal.pone.0288041.t004

Product moment intercorrelations matrix values were determined between the three domains of DASS-18 and VAS-F. These intercorrelations values were found to be moderately strong the subscales of depression and anxiety showed the strongest intercorrelation among the three (r = 0.735), which was also statistically significant. These results could imply that the stress domain of DASS-18 moderately and positively correlated to VAS-F (r = 0.445) ( Table 5 ).

https://doi.org/10.1371/journal.pone.0288041.t005

The purpose of this study was to evaluate the psychometric properties of DASS-21 among Thai nursing students experiencing online classes during the COVID-19 outbreak. For the results of the factorial construct validity of the DASS-18, a three-factor model showed satisfactory conformity to the psychometric construct of the DASS-21 original version [ 10 ], and these results support the fact that the DASS-18 instrument for this cohort contained 18 items spread across three components as follows: anxiety (seven items), depression (seven items) and stress (four items). The three factors were comparable to the structure found by prior studies exploring the psychometric features and generalization of the DASS-21 for use in Asian nations [ 19 ]. This investigation showed that the DASS-18 is a promising and psychometrically sound tool, ideally suited for determining the frequency and intensity of symptoms associated with negative affective states for these participants. Furthermore, the two-week temporal stability was good for all DASS-18 scale scores; in particular, the DASS-18 stress subscale showed the highest correlation values across time and they had a great internal consistency reliability, agreeing with our hypotheses. The consequences of reducing three items from the stress scale are the reasons for the lower Cronbach’s alpha coefficient of this scale than that of Lovibond and Lovibond’ s original version [ 10 ]. These differences might have resulted from the DASS-18 having fewer items because the quantity of items creates an impact on how Cronbach’s alpha is calculated [ 19 ].

According to our results, only minimal changes were observed between the original DASS-stress (seven items) and our DASS-stress (four items) scales. These disparities might be explained by how diverse culture’s view perception of some items that could be interpreted as besides the stress context cultural factors and the response of the participants may influence how individuals understand item of the DASS-stress scales, but not on the DASS-depression and DASS-anxiety scale as we found no significant cultural problem with these two scales and no concerns were noted regarding the EFA findings as demonstrated by the statistical results of this study. Therefore, the DASS-18 factor structure clearly demonstrated three factors, as in the original DASS-21 scale [ 10 ]. Likewise, one study reported that no invariances were discovered in their multi-group analysis across the six countries [ 19 ]. In addition, findings from this previous study on the correlations of the three subscales with those of other psychiatric instruments measuring similar constructs offered support for the validity of the DASS-18 subscales and were generally favorable [ 19 ]. Moreover, the depression and anxiety subscales of the DASS-18 exhibited specific relationships with the relevant measures of these disorders, indicating that using these constructs was appropriate.

Cronbach’s alpha coefficient from our study revealed that total DASS-18 scores and its subscales exhibited good internal consistency. This coefficient ranged from good to excellent in prior studies comprising both nonclinical and clinical adult samples [ 2 , 9 , 10 , 19 , 21 , 29 – 31 ]. Hence, the data collectively proved that the DASS-18 demonstrated strong internal consistency across a variety of demographics and languages. Moreover, the results of the item analysis indicated that the items in each scale had good discrimination indices (corrected item-total correction). These indices suggested that the DASS-18 Thai version items would be effective at distinguishing between high and low scorers on this scale. Related research has also revealed that this assessment tool provides a good item discrimination index [ 13 , 18 ].

The relationships between demographic characteristics and DASS-18 scale scores were also investigated. This study found a weak positive statistically significant relationship between DASS-18 and sex. Despite the concerns about future endurance and competency aspect, female participants expressed more depression, anxiety, and stress than males. This may be because female nursing students usually have commitments outside of the classroom, such as taking care of their family members and performing chores [ 7 , 32 ]. Our results indicated that online learning moderately, positively correlated to the total DASS-18 score because high standards for performance, learning habits, and training may negative impact students’ mental health [ 7 ]. Similarly, clinical courses in nursing programs call for specialized cognitive, emotional, and psychomotor abilities typically following specialized theoretical courses. Because of being unable to take part in clinical settings, these students felt as though they were missing out on a great opportunity to acquire these abilities [ 6 , 20 ]. Thus, these students may have felt unprepared for learning in a clinical setting due to the extremely brief on campus learning time before lockdown, and the pandemic made it more difficult for nursing students to advance in their practical training [ 6 ]. When lockdowns ended, nursing students had greater opportunity to contract an illness by themselves or face patients with COVID-19 experiencing significant effects [ 5 ].

The internal consistency of the DASS-18 was adequate and consistent with the related Asian research [ 7 , 19 ]. The Thai version’s convergent validity is supported by favorable correlations with the Beck Depression Inventory (BDI), the Beck Anxiety Inventory (BAI); correlations in this direction were anticipated to measure the same construct [ 19 ]. These results demonstrated the validity and reliability of the Thai DASS-18 version as a tool for measuring negative emotional states. This indicated that this scale could prove beneficial for screening CMDs among clinical undergraduate students including nursing students.

The convergent validity of the DASS-18 was examined using the AVE calculation of all three subscales. The results revealed that all sub-scales’ AVE were greater than 0.50, corresponding to the convergent validity acceptance criteria. These findings were also compatible with the findings of a study that aimed to validate the DASS-21 among Vietnam students in an e-learning environment [ 7 ]. Regarding the discriminant validity, factors of this stress subscale also highly correlated to each other, which were higher than the values suggested by Hu and Bentler [ 26 ]. These higher correlations indicated significant overlapping in the content of the DASS-18 scales, indicating a general construct, such as affective distress. One related study also reported a higher correlation among these subscales [ 13 ].

When comparing depression, anxiety and stress scales, anxiety items had higher factor loadings, eigenvalues, and percentage of variation than the other domains. Depression and anxiety continued to have the highest inter-correlations, with a value of 0.708 indicating significant overlap between the two domains. Despite the overlap between domains, they could still be separated. An extraordinarily strong and positive association was noted between these domains. The Thai nursing students’ symptoms of stress, anxiety and depression were all positively connected, according to these positive correlation values. The DASS-18’s correlation coefficients showed beneficial correlations between the two instruments in this regard. Likewise, these coefficients also showed that the subjects’ anxiety and depression were present at the same time. The DASS-18 was thus shown to measure depression and anxiety among the responders in a simultaneous and unique manner. These findings were in line with studies in other countries [ 21 , 29 ].

Strengths and limitations

The strength of this study is the fact that the structure and psychometric features of the DASS-21 were examined for the first time in a large sample of undergraduate nursing students in Thailand. Because the participant-to-questionnaire-item ratio was satisfactory, the prerequisites for component analysis were met, and bias resulting from the number of observations was reduced.

Our study encountered limitations regarding the nursing students comprising our subjects. They could not accurately be generalized to other nonclinical undergraduate students due to their diverse qualities because they may be privileged in terms of socioeconomic status, freedom, and health. The study was cross-sectional; hence, the data were unable to show test-retest reliability over time. The study was limited in terms of criterion validity because we did not test any other parameters besides VAS-F.

The study ‘s main findings demonstrate that the DASS-18 is a valid instrument for detecting CMDs among Thai nursing students enrolled in online courses during the COVID-19 outbreak. The three-factor structure with 18 items proposed in the initial study was supported by the findings. Therefore, the availability of the DASS-18’s psychometric features will enhance performance of Thai psychologists and researchers in effectively screening the population of undergraduate nursing students for CMDs at tertiary institutions.

Supporting information

https://doi.org/10.1371/journal.pone.0288041.s001

Acknowledgments

The authors thank all nursing institutions for supporting students’ data collection. The research collaborators at all involved nursing institutes are thanked by the authors for helping with sample recruitment and data gathering. All nursing students joining this study are gratefully acknowledged.

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28. Kline P. Handbook of psychological testing: Routledge; 2013.

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ICD-10 indicates International Statistical Classification of Diseases and Related Health Problems, 10th Revision .

Since patients who survived more than 1 year after OHCA were targeted, the first year was excluded from this analysis.

eTable 1. Baseline Characteristics of the Study Population With Depression Disorder

eTable 2. Baseline Characteristics of the Study Population With Anxiety Disorder

eFigure. Inverse Kaplan-Meier Curves for Long-term Mortality in OHCA Patients With and Without Depression and Anxiety

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Lee J , Cho Y , Oh J, et al. Analysis of Anxiety or Depression and Long-term Mortality Among Survivors of Out-of-Hospital Cardiac Arrest. JAMA Netw Open. 2023;6(4):e237809. doi:10.1001/jamanetworkopen.2023.7809

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Analysis of Anxiety or Depression and Long-term Mortality Among Survivors of Out-of-Hospital Cardiac Arrest

1 Department of Emergency Medicine, College of Medicine, Hanyang University, Seoul, Republic of Korea

Question Is depression or anxiety associated with increased long-term mortality among patients after out-of-hospital cardiac arrest?

Findings In this cohort study using claims from the Korean National Health Insurance Service database, 2373 patients with out-of-hospital cardiac arrest were followed up for up to 14 years. Patients diagnosed with depression or anxiety had an approximately 40% higher long-term mortality rate than those without such psychiatric disorders.

Meaning The findings of this study suggest that psychological and neurologic rehabilitation intervention for survivors of out-of-hospital cardiac arrest may be needed to improve long-term survival.

Importance The recent American Heart Association guidelines added a sixth link in the chain of survival highlighting recovery and emphasized the importance of psychiatric outcome and recovery for survivors of out-of-hospital cardiac arrest (OHCA). The prevalence of psychiatric disorders among this population was higher than that in the general population.

Objective To examine the prevalence of depression or anxiety and the association of these conditions with long-term mortality among individuals who survive OHCA.

Design, Setting, and Participants A longitudinal population-based cohort study was conducted to analyze long-term prognosis in patients hospitalized for OHCA between January 1, 2005, and December 31, 2015, who survived for 1 year or longer. Patients with cardiac arrest due to traumatic or nonmedical causes, such as injuries, poisoning, asphyxiation, burns, or anaphylaxis, were excluded. Data were extracted on depression or anxiety diagnoses in this population within 1 year from the database of the Korean National Health Insurance Service and analyzed April 7, 2022, and reanalyzed January 19 to 20, 2023.

Main Outcomes and Measures Follow-up data were obtained for up to 14 years, and the primary outcome was long-term cumulative mortality. Long-term mortality among patients with and without a diagnosis of depression or anxiety were evaluated.

Results The analysis included 2373 patients; 1860 (78.4%) were male, and the median age was 53.0 (IQR, 44.0-62.0) years . A total of 397 (16.7%) patients were diagnosed with depression or anxiety, 251 (10.6%) were diagnosed with depression, and 227 (9.6%) were diagnosed with anxiety. The incidence of long-term mortality was significantly higher in the group diagnosed with depression or anxiety than in the group without depression or anxiety (141 of 397 [35.5%] vs 534 of 1976 [27.0%]; P = .001). With multivariate Cox proportional hazards regression analysis, the adjusted hazard ratio of long-term mortality for total patients with depression or anxiety was 1.41 (95% CI, 1.17-1.70); depression, 1.44 (95% CI, 1.16-1.79); and anxiety, 1.20 (95% CI, 0.94-1.53).

Conclusions and Relevance In this study, among the patients who experienced OHCA, those diagnosed with depression or anxiety had higher long-term mortality rates than those without depression or anxiety. These findings suggest that psychological and neurologic rehabilitation intervention for survivors of OHCA may be needed to improve long-term survival.

The incidence rate of out-of-hospital cardiac arrest (OHCA) is 84.0 per 100 000 population; OHCA is a major public health problem and a leading cause of mortality and morbidity. 1 , 2 The rate of survival with good neurologic outcomes after OHCA has increased in recent decades. 2 , 3 As a result of the increase in the rate of good prognosis of patients with OHCA, the long-term outcomes would also be increased. Surviving patients could develop neurologic sequelae caused by both initial anoxia and subsequent ischemia-reperfusion injury, and such sequelae could affect their physical, cognitive, and psychosocial characteristics. 4 - 6

Many previous studies assessed survival rates or neurologic prognoses of patients with OHCA using tools such as the Cerebral Performance Category scale. 7 - 9 However, according to the European Resuscitation Council and European Society of Intensive Care Medicine guidelines, it is also important to perform functional assessments of nonphysical impairments and screen for cognitive and emotional problems in the long term in patients with OHCA. 10 In 2020, a sixth link in the chain of survival highlighting recovery was added to the American Heart Association guideline to emphasize the importance of recovery and survivorship in resuscitation outcomes. 5 Consequently, studies have reported the prevalence of depression and anxiety among patients after OHCA and changes in health-related quality of life due to psychiatric disorders. 11 - 15 A systematic review and meta-analysis recently reported that the prevalence of psychiatric disorders in survivors of OHCA was higher than that in the general population, stressing the importance of improving physical and mental outcomes in individuals who experience OHCA. 16

However, to our knowledge, long-term mortality among surviving individuals with psychiatric disorders after OHCA has not yet been reported. In the present study, we aimed to investigate the association between long-term mortality and psychiatric disorders, such as depression and anxiety, among patients after OHCA.

We conducted a population-based cohort study and extracted data from the database of the Korean National Health Insurance Service (NHIS), which is a nationwide single-payer health program in South Korea. South Korea provides medical insurance coverage to almost all citizens, covering approximately 50 million people according to the NHIS. 17 Each hospital visit is reported to the claims database, which includes diagnostic codes based on the World Health Organization’s International Statistical Classification of Diseases and Related Health Problems, 10th Revision ( ICD-10 ). The NHIS database contains diagnosis codes for clinic outpatients as well as patients admitted to hospitals. The NHIS database also includes inpatient and outpatient medical histories, patient demographic characteristic data, diagnoses, procedures, drug prescriptions, and dates of death. 18 Cause of death data were obtained from Statistics Korea, which is merged with the NHIS database. All the data were analyzed after deidentification, and cause of death was classified based on ICD-10 codes. In South Korea, fees for treatment at an emergency department (ED) are charged to all patients who visit the ED for emergency situations, such as cardiac arrest. The NHIS covers the ED management fee in part for patients with medical insurance and in full for those with medical aid. This study was approved by the institutional review board of Hanyang University Hospital, and a waiver for informed consent was granted because data were deidentified. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology ( STROBE ) reporting guideline.

We conducted a longitudinal cohort study to analyze long-term prognosis. We extracted the data of patients with a primary diagnosis of cardiac arrest ( ICD-10 code I46.x) for the first time from January 1, 2005, to December 31, 2015. We excluded patients with in-hospital cardiac arrest without a code for ED management fees for cardiac arrest or a primary diagnosis code for cardiac arrest. To confirm the definition of OHCA, we reviewed the medical records of 252 patients who visited a tertiary hospital and had a code for ED management fees and a primary diagnosis code for cardiac arrest ( ICD-10 code I46.x). The positive predictive value of this definition was 92.1%. 19 The exclusion criteria were as follows: (1) age younger than 18 years, (2) survival for less than 1 year, or (3) cardiac arrest due to traumatic or nonmedical causes ( ICD-10 S, T codes), such as injuries, poisoning, asphyxiation, burns, or anaphylaxis. In addition, we excluded patients who had a code for depression or anxiety within 3 years of cardiac arrest as a washout period to target newly diagnosed patients after OHCA.

Follow-up data were obtained for up to 14 years (until December 31, 2018) and were analyzed, and the primary outcome was long-term cumulative mortality. In addition, the data of patients diagnosed with depressive or anxiety disorder within 1 year were extracted, and the diagnoses of depression and anxiety were confirmed in patients who visited an outpatient clinic or hospital on at least 1 occasion by the presence of ICD-10 diagnostic codes F32.x (depression) and/or F41.x (anxiety). The date on which the diagnostic code was first entered was regarded as the time of diagnosis. Then, we compared the long-term survival rates among the total group diagnosed with depression or anxiety, group diagnosed with depression, group diagnosed with anxiety, and the undiagnosed group.

The independent variables included age category, sex, and the Charlson Comorbidity Index (CCI) score. The CCI score was calculated at the time of diagnosis within 1 year before the index date using the Quan algorithm. 20 , 21

Several variables were included in the analysis. First, in this study, we examined long-term mortality in patients with newly diagnosed depression or anxiety among those who survived after OHCA. However, additional analysis was conducted on whether a diagnosis of depression or anxiety before OHCA was associated with long-term mortality. Second, there may be many factors associated with long-term mortality in patients who survived after OHCA. Among them, we additionally classified the diagnosis codes of myocardial infarction, and the prescription codes of antipsychotics, antidepressants, and sedatives and analyzed the long-term mortality of patients including these variables. Third, we analyzed the causes of mortality of patients who survived after OHCA. Accordingly, we further classified them into cardiovascular mortality, noncardiovascular mortality, and injury.

The data were analyzed using R, version 4.0.4 (R Foundation for Statistical Computing) and SAS, version 9.4 (SAS Institute Inc). Analysis was conducted on April 7, 2022, and again January 19-20, 2023. Anderson-Darling tests were performed for variables with normal distributions in all data sets. Descriptive statistics were used to describe the baseline characteristics of the patients. Categorical variables are presented as frequencies and percentages and continuous variables as medians (IQRs) or means (SDs) . Independent t tests or Mann-Whitney tests were used for comparisons of continuous variables; the Fisher exact test was used for categorical variables. The cumulative mortality was estimated by the Kaplan-Meier method.

Multivariable Cox proportional hazards regression analyses were used to identify predictors of long-term mortality. Multivariable regression analysis was performed separately for each group, and the results are presented as adjusted hazard ratios (aHRs) and 95% CIs. With 2-sided, unpaired testing, differences were considered statistically significant at P < .05.

We enrolled 2373 patients after OHCA who had survived for 1 year or longer ( Figure 1 ); median age was 53.0 (IQR, 44.0-62.0) years, 513 (21.6%) were women, and 1860 (78.4%) were men. The median follow-up was 5.1 years (IQR, 3.6-7.2 years). The baseline characteristics of the groups diagnosed and not diagnosed with depressive or anxiety disorder are summarized in Table 1 . A total of 1976 patients did not receive a diagnosis of depression or anxiety, 397 (16.7%) patients were diagnosed with depression or anxiety, 251 (10.6%) were diagnosed with depression, and 227 (9.6%) were diagnosed with anxiety. The baseline characteristics of the groups diagnosed and not diagnosed with depressive disorder and diagnosed and not diagnosed with anxiety disorder are summarized in eTable 1 and eTable 2 in Supplement 1 . There were no significant differences in age category, sex, or CCI score between the groups. The incidence of long-term mortality was higher in the group diagnosed with depression or anxiety than in the group not diagnosed with depression or anxiety (141 of 397 [35.5%] vs 534 of 1976 [27.0%]; P = .001).

The cumulative mortality rate of patients diagnosed and not diagnosed with depressive or anxiety disorder is presented in Figure 2 ; the cumulative mortality was significantly higher in the individuals diagnosed with depressive or anxiety disorder (long term death, 141 of 397 [35.5%] vs. 534 of 1976 [27.0%]; P = .002). The cumulative mortality rates among patients diagnosed and not diagnosed with depression and among patients diagnosed and not diagnosed with anxiety are presented in the eFigure in Supplement 1 . The cumulative mortality rate was significantly higher in the group diagnosed with depression (long term death, 94 of 251 [37.5%] vs. 581 of 2122 [27.4%]; P = .008) than in the group without a diagnosis of depression, but there was no significant difference between the group diagnosed with anxiety and the group without a diagnosis of anxiety (long term death, 72 of 227 [31.7%] vs. 603 of 2146 [28.1%]; P = .18).

We constructed a multivariate Cox proportional hazards regression model to assess the long-term mortality among patients with OHCA ( Table 2 ). When other known associations were adjusted for age, sex, and CCI score, the aHR of long-term mortality among the total number of patients with depression or anxiety was 1.41 (95% CI, 1.17-1.70); patients with depression, 1.44 (95% CI, 1.16-1.79); and patients with anxiety, 1.20 (95% CI, 0.94-1.53).

In addition, we analyzed the outcomes of the excluded patients who had an ICD-10 code for depression or anxiety within 3 years before OHCA. We performed a multivariable analysis that included this group. As a result, there was no significant difference in the long-term mortality rate of patients who had already been diagnosed with depression or anxiety within 3 years before OHCA compared with those without depression or anxiety (aHR, 1.06; 95% CI, 0.91-1.23). However, the long-term mortality rate among patients diagnosed with depression or anxiety after OHCA was significantly higher (aHR 1.41; 95% CI, 1.17-1.70). Patients with only depression and those with only anxiety disorder within 3 years before OHCA were analyzed separately. The results also showed no significant difference in long-term mortality compared with patients without psychiatric disorders (depression: aHR, 1.09; 95% CI, 0.92-1.29 vs anxiety: aHR, 0.97; 95% CI, 0.83-1.13).

We also classified the causes of death for individuals who survived OHCA as cardiovascular mortality, noncardiovascular mortality, and injury. A total of 272 patients (14.4%) died of cardiovascular-associated causes after OHCA. Fifty-seven of 397 patients (14.2%) with depression or anxiety and 215 of 1976 individuals (10.9%) without depression or anxiety died. In a multivariable analysis including the group of patients with cardiovascular mortality, the aHR of patients with depression or anxiety was 1.41 (95% CI, 1.05-1.89). Noncardiovascular mortality accounted for the deaths of 84 of 397 (21.2%) patients with and 319 of 1976 (16.1%) patients without depression or anxiety. In multivariable analysis, the aHR of patients with depression or anxiety was 1.41 (95% CI, 1.11-1.80). A total of 24 patients died due to injury, 7 of 397 (1.8%) with and 17 of 1976 (0.9%) without depression or anxiety. In multivariable analysis, the aHR of patients with depression or anxiety was 2.34 (95% CI, 0.97-5.68).

Because new problems, such as myocardial infarction, or new medications, such as antidepressants, may have contributed to a late onset of mortality, we additionally classified the diagnosis codes of myocardial infarction and the prescription codes of antipsychotics, antidepressants, and sedatives. We performed a multivariable analysis including the groups of patients with those diagnosis codes or prescription codes. The aHR of patients with depression or anxiety was 1.63 (95% CI, 1.35-1.97), the aHR of patients with depression was 1.57 (95% CI, 1.26-1.95), and the aHR of those with anxiety disorder was 1.47 (95% CI, 1.14-1.88).

To our knowledge, this was the first population-based study to investigate the association between long-term mortality and psychiatric disorders among patients after OHCA. The patients diagnosed with depression or anxiety had a 1.41 times higher long-term mortality rate than those without such psychiatric disorders. The patients diagnosed with depression had a significantly higher long-term mortality rate than those without the diagnosis (aHR, 1.44), whereas there was no significant difference in the long-term mortality rate between patients diagnosed with anxiety and those without this diagnosis.

Of the 2373 patients enrolled in this study, 397 (16.7%) were diagnosed with anxiety or depressive disorder within 1 year after OHCA. Previous studies have reported that the prevalence of psychiatric disorders, such as depression and anxiety, is high among patients surviving cardiac arrest, and Yaow et al 16 performed a systematic review and meta-analysis of such studies. In the general population, the prevalence rates were 12.9% for depressive disorder, 7.3% for anxiety disorder, and 3.9% for posttraumatic stress disorder; among patients who survived cardiac arrest, the prevalence rates were 19.0% for depressive disorder, 26.0% for anxiety disorder, and 20% for posttraumatic stress disorder. In addition, they found that the prevalence of depression and anxiety in patients who survived OHCA increased over time. Specifically, the prevalence of depression increased from 17.0% at 6 months to 30.0% at 12 months and the prevalence of anxiety increased from 34.0% at 6 months to 38.0% at 12 months. The difference in prevalence between this study and previous studies might be explained by the fact that the present study included only patients diagnosed in hospitals. Postcardiac arrest syndrome is estimated to affect both the physiologic and psychological aspects of long-term prognosis in survivors. The unpredictability and severity of OHCA can cause severe life disruptions for patients. 22 , 23 The neurologic deficit caused by ischemia-reperfusion injury following OHCA can create challenges in accomplishing previously simple daily tasks without assistance. 23 , 24 These realities and arduous transformations can cause extreme limitations and despondency. Such life changes can result in a decrease in health-related quality of life, which affects psychological distress. 11 Most patients with OHCA receive immediate therapy in the intensive care unit after the return of spontaneous circulation. After receiving intensive care unit treatment, new or worsening physical and cognitive or mental disorders are referred to as postintensive care syndrome, which is estimated to affect up to one-third of survivors after intensive care unit stays. 25 Hatch et al 26 reported that, among patients who received intensive care unit treatment following critical illness, those with depression had an approximately 50% higher 2-year mortality rate than those without depression.

The increase in the prevalence of depression and anxiety in patients surviving OHCA is important because the increase may be a factor in a higher prevalence of psychiatric disorders and is associated with outcomes such as mortality. Cuijpers and Smit 27 reported that the overall relative risk of mortality in patients with depression was 1.81 (95% CI, 1.58-2.07) compared with those without depression, and depression should be considered a life-threatening disorder. In addition, Zivin et al 28 reported that the HR of patients with depression for 3-year mortality was 1.17 (95% CI, 1.15-1.18), and depression was associated with an increased risk of death due to nearly all major medical causes, regardless of the presence or absence of multiple primary risk factors. Cardiac disease is one of the factors contributing to the high mortality rate among patients with depression. It was reported that patients experiencing psychological distress had a higher incidence of myocardial infarction and worse survival and prognosis outcomes following myocardial infarction than their counterparts. 29 , 30

Previous studies have reported an increase in the incidence of psychological disorders in individuals following OHCA 11 , 15 , 31 but have not noted an association between psychological disorders and mortality in this population. To analyze this association, we obtained long-term follow-up data from a large sample of patients with OHCA; these data were of great value in evaluating the association between psychiatric disorders and long-term mortality.

In the past, there were no specific guidelines for the prevention and treatment of psychological disorders in patients with critical illness or following OHCA. However, the Society of Critical Care Medicine’s International Consensus Conference recently recommended that serial assessments for postintensive care syndrome–related problems continue for 2 to 4 weeks after hospital discharge and should be prioritized among high-risk patients using identified screening tools to prompt referrals for services or more detailed assessments. 32 Recent studies on the rehabilitation requirement for patients who survive cardiac arrest have been performed, and guidelines for the rehabilitation of patients with critical illness have been published. 14 , 16 , 31 Peskine et al 31 advised that a specific rehabilitation program for patients following OHCA or patients at risk of impaired functioning is warranted. Based on data from these studies, the recent International Liaison Committee on Resuscitation guidelines emphasize the importance of psychological as well as physical rehabilitation in individuals who survive cardiac arrest. 10 The ERC and European Society of Intensive Care Medicine guidelines recommends examinations to detect physical and nonphysical impairment in patients after cardiac arrest and, if necessary, prompt rehabilitation. 10 In addition, a recent American Heart Association guideline introduced a new link in the chain of survival: recovery from cardiac arrhythmias, highlighting for the first time the importance of rehabilitation. 5 Because the present study identified an association between psychological dysfunction and an increase in long-term mortality, we believe it provides evidence that psychological rehabilitation of patients with OHCA is crucial. In addition, we noted that providing adequate rehabilitation benefited not only the patient's health-related quality of life but also long-term survival.

This study has several limitations. First, the clinical information on patients with OHCA could not be evaluated because this study used claims data from the NHIS. Variables that could affect the outcomes in patients with OHCA, such as shockable rhythm, bystander cardiopulmonary resuscitation, and the duration of cardiac arrest, could not be identified in our study. Second, the results of this study might be biased by potential confounders, such as treatment initiation after depression or anxiety and a lifestyle pattern with low levels of physical activity and appetite and the presence of sleep disturbances. Third, new medical problems and new medications may contribute to the causes of long-term mortality, but we were unable to adjust for all variables. Fourth, because this study was performed using diagnostic codes, it was impossible to include those who did not receive a diagnosis of depression and anxiety disorders because they did not visit the hospital. Fifth, the diagnosis of OHCA and cause of death were defined using ICD-10 codes, and we cannot rule out diagnostic inaccuracies. In particular, the identification of patients with OHCA and in-hospital cardiac arrest can be inaccurate. We confirmed the definition of OHCA, but the small sample size is a limitation.

Among patients who survived OHCA, those diagnosed with a psychiatric disorder had a higher long-term mortality rate. The findings of this study suggest that it may be important to provide psychological as well as neurologic rehabilitation to individuals after OHCA to help improve long-term survival.

Accepted for Publication: February 22, 2023.

Published: April 12, 2023. doi:10.1001/jamanetworkopen.2023.7809

Corresponding Author: Jaehoon Oh, MD, PhD, Department of Emergency Medicine, College of Medicine, Hanyang University, 222 Wangsimni-ro, Seongdong-gu, Seoul 04763, Republic of Korea ( [email protected] ).

Author Contributions: Dr Oh had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Drs J. Lee and Cho contributed to this study equally as first authors.

Concept and design: J. Lee, Cho, Oh, Kang, Lim, S.H. Lee.

Acquisition, analysis, or interpretation of data: Cho, Ko, Yoo, S.H. Lee.

Drafting of the manuscript: J. Lee, Kang, S.H. Lee.

Critical revision of the manuscript for important intellectual content: Cho, Oh, Lim, Ko, Yoo, S.H. Lee.

Statistical analysis: J. Lee, S.H. Lee.

Administrative, technical, or material support: Kang.

Supervision: Cho, Oh, Kang, Lim, Ko, Yoo.

Conflict of Interest Disclosures: None reported.

Funding/Support: This study was supported by National Research Foundation of Korea grant NRF-2022R1A2C1012627.

Role of the Funder/Sponsor: The National Research Foundation of Korea had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: This study used the National Health Insurance Service database (NHIS-2022-1-580). The interpretations and conclusions reported herein do not represent those of the National Health Insurance Service.

Data Sharing Statement: See Supplement 2 .

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Published: 08 May 2024

The relationship between childhood adversity and sleep quality among rural older adults in China: the mediating role of anxiety and negative coping

Yuqin Zhang 1 ,
Chengwei Lin 2 ,
Hongwei Li 1 ,
Xueyan Zhou 4 ,
Ying Xiong 5 ,
Jin Yan 1 ,
Mengxue Xie 1 ,
Xueli Zhang 6 ,
Chengchao Zhou 7 &
Lian Yang 1

BMC Psychiatry volume 24 , Article number: 346 ( 2024 ) Cite this article

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Metrics details

Studies have revealed the effects of childhood adversity, anxiety, and negative coping on sleep quality in older adults, but few studies have focused on the association between childhood adversity and sleep quality in rural older adults and the potential mechanisms of this influence. In this study, we aim to evaluate sleep quality in rural older adults, analyze the impact of adverse early experiences on their sleep quality, and explore whether anxiety and negative coping mediate this relationship.

Data were derived from a large cross-sectional study conducted in Deyang City, China, which recruited 6,318 people aged 65 years and older. After excluding non-agricultural household registration and lack of key information, a total of 3,873 rural older adults were included in the analysis. Structural equation modelling (SEM) was used to analyze the relationship between childhood adversity and sleep quality, and the mediating role of anxiety and negative coping.

Approximately 48.15% of rural older adults had poor sleep quality, and older adults who were women, less educated, widowed, or living alone or had chronic illnesses had poorer sleep quality. Through structural equation model fitting, the total effect value of childhood adversity on sleep quality was 0.208 (95% CI: 0.146, 0.270), with a direct effect value of 0.066 (95% CI: 0.006, 0.130), accounting for 31.73% of the total effect; the total indirect effect value was 0.142 (95% CI: 0.119, 0.170), accounting for 68.27% of the total effect. The mediating effects of childhood adversity on sleep quality through anxiety and negative coping were significant, with effect values of 0.096 (95% CI: 0.078, 0.119) and 0.024 (95% CI: 0.014, 0.037), respectively. The chain mediating effect of anxiety and negative coping between childhood adversity and sleep quality was also significant, with an effect value of 0.022 (95% CI: 0.017, 0.028).

Conclusions

Anxiety and negative coping were important mediating factors for rural older adult’s childhood adversity and sleep quality. This suggests that managing anxiety and negative coping in older adults may mitigate the negative effects of childhood adversity on sleep quality.

Peer Review reports

The global population is entering an aging stage, and China has the fastest rate of population aging in the world. According to China’s seventh national census, in 2020, 191 million individuals were aged 65 years and older, accounting for 13.50% of the total population [ 1 ], and the proportion of people aged 65 and above in rural is 6.6% higher than in urban [ 2 ]. In addition, China’s long-standing urban-rural dual structure has resulted in inequality in economic, medical, and educational development, leading to significant differences in the health status of China’s urban and rural older populations [ 3 , 4 ]. Relevant studies have found that, urban residents have a higher survival rate [ 5 ], better self-assessed health status and better self-assessed self-care ability than rural dwellers [ 6 ]. Therefore, to reduce health inequalities among older adults, the health status of rural older adults is an important focus.

Good quality sleep has been found to be essential for health [ 7 , 8 , 9 ]. However, sleep problems are prevalent among the older population [ 10 , 11 ]. Gulia and Tatineny have reported that the current prevalence of sleep disorders in the global older population is 30–40% [ 12 , 13 ]. In a systematic review, Lu reported that the overall prevalence of poor sleep among the older population in China had reached 35.9% [ 14 ]. In the rural older adults, the prevalence of sleep disorders is more than 40% [ 15 ], even as high as 58.40% [ 16 ].There are various factors that affect sleep quality [ 17 , 18 ]. Adverse childhood experiences (ACEs) are stressful and/or traumatic experiences that occur during childhood [ 19 ]. There is growing evidence that ACEs may lead to sleep problems in adulthood [ 20 , 21 ] and that the influence can last up to 50 years [ 22 ]. For example, emotional abuse and neglect experienced early in life impede the development of individuals’ social relationships later in life and negatively affect the subjective sleep quality of older adults [ 23 ]. A study by Dorji. found that older adults with multiple (≥ 7) ACEs had a higher incidence of insomnia [ 24 ]. Although previous investigations have indicated the relationship between childhood adversity and sleep quality in older adults, they have ignored possible potential mechanisms for this relationship.

Previous studies have found that anxiety negatively affects sleep quality in older adults [ 25 ], whereas a good mental state can improve their sleep quality. Notably, childhood adversity may be associated with increased anxiety symptoms in late adulthood [ 26 ]. Raposo have reported that older adults who experienced childhood adversity were more likely to suffer from anxiety (OR = 1.48; 95%CI = 1.20–1.83) [ 27 ]. Considering the relationships among anxiety, childhood adversity, and sleep quality, one aim of this study was to verify whether anxiety mediates the relationship between childhood adversity and sleep quality.

A coping style refers to a psychological and behavioral strategy adopted by an individual in response to changes in the internal and external environment [ 28 ]. Negative coping is usually positively associated with sleep disorders [ 29 , 30 ]. Coping style usually evolves over time and may be influenced by exposure to childhood adversity; for instance, people exposed to early adverse experiences show predominantly emotion-focused and avoidance coping styles, such as denial and disengagement [ 31 , 32 ]. In addition to childhood adversity, negative emotions or psychological states also can influence individuals’ coping strategies [ 33 ]. For example, Orgeta reported that older adults with high levels of anxiety were more likely to adopt dysfunctional coping [ 34 ]. Therefore, we hypothesized that anxiety affects coping styles in older adults and that negative coping may be a potential mediator between childhood adversity and sleep quality.

Stress is defined as the process of adaptive and coping responses when an individual faces or perceives threatening or challenging environmental changes [ 35 ]. People respond to stress with either problem-focused coping or emotion-focused coping [ 36 ]. Stress can be caused by many factors, such as early adversities, and the result of stress is adaptive or maladaptive psychosomatic responses. Based on the above, we constructed a structural equation model of a large cross-sectional dataset to explore the effects of childhood adversity on sleep quality, with childhood adversity as the stressor and anxiety and negative coping as mediators.

Research methods

Research population.

The data were sourced from a large-scale cross-sectional study conducted in 2022 that recruited older adults aged 65 years and older living in 6 districts and counties in Deyang City, Sichuan Province. Using a multistage stratified random cluster sampling method, townships (streets) were randomly selected from six county (districts), administrative villages (communities) were randomly selected from each sample township (streets), finally, people over 65 years old were selected randomly in each chosen village or community. The inclusion criteria were as follows: (1) individuals aged ≥ 65 years; (2) permanent residents in the survey area (those who have lived in the area for 6 months or more); (3) those who signed an informed consent form and agreed to take the questionnaire survey. The exclusion criteria were as follows: (1) unwilling to participate in research; (2) individuals identified by local village doctors who are unable to answer questions independently and have a history of dementia;3) other reasons for not participating in the study. The household registration system is a very important factor affecting the unequal social welfare rights and privileges of urban and rural residents in China [ 37 ], which is associated with poor health [ 38 ]. In this study, rural means that residents with agricultural household registration. A total of 6318 respondents were recruited, excluding non-agricultural household registration (2345) and missing main information (100), and finally included 3873 for analysis. The study was approved by the Medical Ethics Committee of the Affiliated Hospital of Chengdu University of Chinese Medicine, and all participants signed an informed consent form before taking the survey.

Measurement tools

General information.

This includes the age, gender, education level, marital status, chronic disease status, and exercise status of the participating older adults.

Childhood adversity

Childhood adversity was measured using the Adverse Childhood Experiences Scale developed by the Centers for Disease Control and Prevention (USA). The scale contains three major dimensions (abuse, neglect, and household dysfunction) and ten subdimensions including emotional abuse, physical abuse, sexual abuse, and emotional neglect. Higher ACE scores indicate more severe ACE exposure [ 19 , 39 ]. The internal consistency coefficients of the abuse, neglect, and household dysfunction subscales in this study were 0.790, 0.732, and 0.778, respectively.

Sleep quality

Sleep quality was evaluated using the revised Chinese-version Pittsburgh Sleep Quality Index (PSQI). The scale consists of seven dimensions including subjective sleep quality, sleep latency, sleep duration, sleep efficiency, sleep disturbance, use of sleep medication, and daytime dysfunction. A PSQI score of ≥ 7 is generally considered to indicate poor sleep quality [ 15 , 40 , 41 ]. The internal consistency coefficient of the scale in this study was 0.754.

Anxiety in older adults was measured using the Self-Rating Anxiety Scale (SAS). The scale consists of 20 items and is rated on a 4-point scale. An SAS score of 50 or more is considered to be indicative of anxiety symptoms [ 42 ]. The internal consistency coefficient of this scale in this study was 0.831.

Trait coping style

Negative coping was measured using the Trait Coping Style Questionnaire (TCSQ). The scale consists of 20 questions in 2 dimensions—negative coping and positive coping—and is rated on a 5-point scale. The negative coping and positive coping scores are the sum of the scores for each item in the corresponding dimensions. A positive total score indicates a predominantly positive attitude toward coping with events, whereas a negative score indicates a predominantly negative coping style [ 43 , 44 ]. Only the negative coping dimension of the scale, which has an internal consistency coefficient of 0.929, was selected in this study.

Statistical analysis

The variables in the study were descriptively analyzed using the mean, standard deviation, frequency (n), and constituent ratio (%), and difference tests were conducted using t-tests and the Kruskal-Wallis H test. Spearman’s correlation was used to analyze whether there were correlations between sleep quality and the variables. Finally, a multiple-mediator structural equation model was constructed to analyze the effects of anxiety and negative coping on the relationship between sleep quality and childhood adversity, and the bootstrap method was applied to verify the mediating effect. After the initial establishment of the model, we evaluated the fit degree of the structural equation model and adjusted the model via calculating indicators such as standardized root-mean-square residual (SRMR ≤ 0.08), root-mean-square error of approximation (RMSEA ≤ 0.08), goodness of fit index (GFI ≥ 0.90), comparative fit index (CFI ≥ 0.90), normed fit index (NFI ≥ 0.90) according to the studies by Wen and Kang [ 45 , 46 ]. Data were analyzed using SPSS 25.0 and AMOS 24.0 software, and a P value < 0.05 was considered to be statistically significant. The bootstrap CI was set to 95%, and the bootstrap sample size was 5000. If the 95% CI interval does not contain 0, it indicates a significant mediating effect.

Research results

Comparison of the general information and sleep quality scores of the study participants.

A total of 3,873 older adults were included in this study. The mean participant age was 72.84 ± 6.13 years, ranging from a minimum of 65 years to a maximum of 99 years. The mean PISQ score was 6.94 ± 3.88, and older adults with poor sleep quality (PSQI score ≥ 7) accounted for 48.15%. The mean ACE score was 2.09 ± 1.16, the mean SAS score was 44.13 ± 9.84, and the mean TCSQ negative coping score was 21.88 ± 8.23.

The results of univariate analysis showed that among the different gender populations, women had poorer sleep quality and a statistically significantly higher PSQI score than men at 7.44 ± 3.98 (t = 8.845, p < 0.001). The PSQI score increased with age: that of adults aged 80 years and older was 7.32 ± 4.01, and the difference was statistically significant (H = 11.125, p = 0.004). Regarding the groups with different educational levels, the highest PSQI score was found among illiteracy individuals (7.39 ± 4.01), with a statistically significant difference (H = 39.885, p < 0.001). Sleep quality varied among older adults with different marital statuses, and the worst sleep quality was found in widowed older adults, with a PSQI score of 7.52 ± 4.00, which presented a statistically significant difference (H = 39.582, p < 0.001). Older adults living alone had the worst sleep quality with a statistically significantly different PSQI score of 7.46 ± 3.90 (H = 20.904, p < 0.001). Older adults with chronic diseases had poor sleep quality with a statistically significantly different PSQI score of 7.4 ± 3.95 (t=-8.83, p < 0.001) (Table 1 ).

Association of sleep quality with childhood adversity, anxiety, and negative coping in rural older adults

The relevant analysis results indicated that the PSQI score was positively correlated with the ACE score ( r = 0.092, P < 0.01). The PSQI score was positively correlated with the SAS score and negative coping score ( r = 0.279 and r = 0.239, respectively; both P < 0.01). The ACE score was positively correlated with the SAS score and negative coping score ( r = 0.217 and r = 0.133, respectively; both P < 0.01). There was also a positive correlation between the SAS score and negative coping score ( r = 0.351, P < 0.01) (Table 2 ).

Analysis of mediating effects

Goodness-of-fit indices and path coefficients for the theoretical model of older adults’ sleep quality.

Based on the results of the above analyses, a structural equation model was constructed with childhood adversity as the independent variable, anxiety and negative coping as the mediating variables, and sleep quality as the dependent variable. The final model was screened according to the following model fitting indices: SRMR = 0.05, RMSEA = 0.06, GFI = 0.97, CFI = 0.90 and NFI = 0.89. The results of the fitting indices indicated that the model was well fitted. The differences in each of the standardized path coefficients in the model were statistically significant (all P < 0.05) (Fig. 1 ).

Serial mediation models for childhood adversity, anxiety, negative coping and sleep quality

Bootstrap test of the theoretical model of older adults’ sleep quality

Table 3 demonstrates the results of structural modeling: (1) The total effect value of childhood adversity on sleep quality was 0.208 (95% CI: 0.146, 0.270), with a direct effect value of 0.066 (95% CI: 0.006, 0.130), accounting for 31.73% of the total effect, and a total indirect effect value of 0.142 (95% CI: 0.119, 0.170), accounting for 68.27% of the total effect. (2) The mediating effect of anxiety on the association between childhood adversity and sleep quality was significant, with a path effect value of 0.096 (95% CI: 0.078, 0.119), accounting for 46.15% of the total effect. (3) The mediating effect of negative coping on the association between childhood adversity on sleep quality was significant, with a path effect value of 0.024 (95% CI: 0.014, 0.037), accounting for 11.54% of the total effect. (4) The multiple mediating effects of anxiety and negative coping on the association between childhood adversity on sleep quality were also significant, with a pathway effect value of 0.022 (95% CI: 0.017, 0.028), accounting for 10.58% of the total effect (Table 3 ).

Current status and influencing factors of sleep quality in older adults

The proportion of older adults with poor sleep quality (PSQI score ≥ 7) was 48.15%, which is similar to the results of previous studies [ 15 , 16 ]. Due to gradual aging, the sleep-wake cycle of the older adults is disordered, and the efficiency of the circadian rhythm mechanism is reduced, which leads to changes in their sleep duration, sleep architecture, and sleep depth [ 12 ]. Furthermore, the occurrence of a variety of sleep problems such as sleep disruption, early sleep onset, and early awakening [ 47 , 48 , 49 ], result in a general decline in the sleep quality of older adults. We also found that gender, educational level, marital status, residency status, and chronic diseases were influencing factors of sleep quality. First, women have poorer sleep quality than men, which is in accordance with the established viewpoint [ 50 , 51 ]. Poor sleep quality and an increased risk of sleep disorders in older women may be due to the following reasons: (1) women are at a disadvantage in terms of socioeconomic factors, such as education and personal income [ 52 ]; (2) women are more susceptible to somatic [ 53 ] and psychiatric [ 54 , 55 ] disorders than men; and (3) women experience changes in secreted reproductive hormones [ 56 ]. Second, differences in sleep quality among older adults with different educational levels may be due to the fact that well-educated older adults have a higher sense of wellness and are more likely to access healthcare knowledge, which in turn leads to a better sleep state [ 57 ]. Third, the poorer sleep quality in widowed older adults and those living alone than in others may be related to loneliness and lack of social support leading to mood disorders, which in turn may cause reduced sleep efficiency and quality [ 58 ]. Finally, having a chronic disease is also a risk factor for poor sleep quality in older adults, which may be related to the physical discomfort caused by chronic diseases, the side effects of medications, and the associated financial pressure and psychological burden [ 59 ].

Direct effect of childhood adversity on sleep quality in older adults

The present study found that childhood adversity had a direct effect on sleep quality. Early life experiences, such as abuse, poverty, or the death of a parent, can affect sleep not only in childhood and adolescence but also in adulthood [ 60 , 61 ]. Childhood is an important phase for significant development of the hypothalamic-pituitary-adrenal (HPA) axis and the brain [ 58 ], and adverse events experienced during childhood can lead to long-term changes in the HPA axis response to stress (e.g., hyperactivity) and interfere with normal neurodevelopment in childhood and adolescence [ 62 ], increasing the risk of developing psychiatric disorders such as depression and post-traumatic stress disorder, which indirectly affect sleep in adulthood [ 63 ]. In addition, people exposed to ACEs are more likely to adopt unhealthy lifestyles and behaviors [ 64 , 65 ], and these changes may directly affect the sleep-wake cycle and lead to sleep problems.

Mediating effect of anxiety between childhood adversity and sleep quality in older adults

Sleep problems are not only a precursor but also a consequence of mental illness [ 66 , 67 ]. Our study found that anxiety could partially explain the relationship between childhood adversity and sleep disorders. Extensive studies have confirmed that exposure to adverse experiences in early life can increase an individual’s risk of developing psychiatric disorders such as anxiety and depression [ 68 , 69 ]. Anxiety is thus associated with a variety of sleep problems, with higher levels of anxiety corresponding to more severe sleep disorders [ 25 , 70 , 71 ]. Furthermore, anxiety has been found to mediate the effects of childhood adversity on sleep quality. For example, Amarneh found that elevated levels of anxiety sensitivity may explain the relationship between child maltreatment and adult sleep disorders among psychiatric hospitalizations [ 72 ]. Haimov found that COVID-19-related anxiety mediated the association between the number of childhood adversities and adult sleep quality [ 73 ]. The findings of our study further support the mediating role of anxiety on the effects of childhood adversity on sleep quality in older adults, suggesting that actively intervening in older adults’ anxiety states may mitigate the effects of childhood adversity on their sleep quality.

Mediating effect of negative coping between childhood adversity and sleep quality in older adults

Our results also identified a significant mediating effect of negative coping in the action of childhood adversity on sleep quality. Individuals’ exposure to environmental stressors early in life can compromise their adaptive coping strategies [ 74 ] and thus further affect sleep [ 75 ]. This result can be explained by the theory of stress. This theory states that when facing stressful events, people may take measures to disengage from threatening stimuli and generate associated thoughts and emotions (i.e., reducing activity and sleeping longer to minimize exposure to the stressor and the associated maladaptive emotions and thoughts) as well as adopt emotion-focused coping (i.e., regulating emotional responses to problems). However, such approaches may increase alertness and thus produce physiological arousal, disrupting or reducing sleep, which in turn affects sleep quality [ 76 ].

Finally, we founded that childhood adversity affected sleep quality in older adults through anxiety and negative coping. As mentioned above, stressful life events in childhood are associated with an increased risk of anxiety disorders in adulthood. Under the influence of such negative emotions, individuals are more inclined to adopt negative coping, which in turn affects the sleep quality in older adults. The above results facilitate a deeper understanding of the relationships among childhood adversity, anxiety, negative coping, and sleep quality and provide clues for exploring the potential mechanisms of how childhood adversity affects sleep quality in older adults.

Research limitations

In this study, the theoretical structural equation model fit the data well and provided an epidemiologic basis for the associations among childhood adversity, anxiety, negative coping, and sleep quality. However, there are several limitations. First, the results for the main variables in this study were obtained via self-report from the respondents and thus may be subject to unavoidable recall bias. Second, this study utilized a cross-sectional research design, which does not allow for a more precise determination of the causal relationship between variables. Third, this study explored the relationship between ACEs and PSQI scores but did not determine a dose-response relationship or whether different types of childhood adversities have different effects on sleep quality. Finally, the effects of drugs (such as antidepressants and anti-inflammatory drugs) on sleep quality were ignored in this study.

To sum up, anxiety and negative coping not only had direct effects on sleep quality but also played mediating roles in the association between childhood adversity and sleep quality, with a chained multiple mediating effect. These findings suggest that timely intervention for anxiety symptoms and negative coping states in older adults may mitigate the negative impact of childhood adversity on sleep quality.

Data availability

The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.

Abbreviations

Adverse Childhood Experiences

the revised Chinese-version Pittsburgh Sleep Quality Index

Self-Rating Anxiety Scale

Trait Coping Style Questionnaire

Structural equation modelling

confidence interval

root mean square error of approximation

the hypo-thalamic pituitary adrenal axis

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Acknowledgements

We thank the responsible person of local health work, all participants and the staff of data reduction for their cooperation.

This work was funded by the research projects of “Investigation on health status and risk factors of the elderly over 65 years old in Deyang City” (No.301021062) of Chengdu University of Traditional Chinese Medicine.

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Chengwei Lin

Hospital of Chengdu University of Traditional Chinese Medicine, Deyang Integrated Traditional Chinese and Western Medicine Hospital, Deyang, 618000, China

Centre for Aging Health Service of Deyang City, Deyang, 618000, China

Xueyan Zhou

Health Commission of Deyang City, Deyang, 618000, China

Sichuan Provincial Health Information Center, Chengdu, 610015, Sichuan, China

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YQ Z, CW L and HW L were responsible for conception and design of the study. L L, XY Z and Y X were involved in recruiting the participants. YQ Z and CW L did the statistical analysis and were involved in manuscript preparation and drafting the article.J Y , MX X, and XL Z were involved in editing and revising the manuscript. CC Z and L Y were responsible for the critical revision of the manuscript. All authors have contributed to and have approved the final manuscript.

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The current study was conducted according to the guidelines of the Declaration of Helsinki, approved by the Medical Ethics Committee of the Affiliated Hospital of Chengdu University of Chinese Medicine (Approval no.2023KL-011). All the participants completed informed consent forms before recruitment to the study. For illiterate participants their guardians (usually immediate family members, for example, son, daughter, son and daughter in law etc.) gave written informed consent for participation in the study. The ethics committee had approved the methods of giving consent.

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Zhang, Y., Lin, C., Li, H. et al. The relationship between childhood adversity and sleep quality among rural older adults in China: the mediating role of anxiety and negative coping. BMC Psychiatry 24 , 346 (2024). https://doi.org/10.1186/s12888-024-05792-2

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The impact of nursing interventions on the rehabilitation outcome of patients after lumbar spine surgery

Jun Liang 1 , 2 ,
Liyan Wang 1 , 2 ,
Jialu Song 1 , 2 ,
Yu Zhao 1 , 2 ,
Keyan Zhang 1 , 2 ,
Xia Zhang 1 , 2 ,
Cailing Hu 1 , 2 &
Dong Tian 1 , 2

BMC Musculoskeletal Disorders volume 25 , Article number: 354 ( 2024 ) Cite this article

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This study aimed to investigate the impact of nursing interventions on the rehabilitation outcomes of patients after lumbar spine surgery and to provide effective references for future postoperative care for patients undergoing lumbar spine surgery.

The study included two groups: a control group receiving routine care and an observation group receiving additional comprehensive nursing care. The comprehensive care encompassed postoperative rehabilitation, pain, psychological, dietary management, and discharge planning. The Visual Analogue Scale (VAS), Oswestry Disability Index (ODI), Short-Form 36 (SF-36) Health Survey, self-rating depression scale (SDS) and self-rating anxiety scale(SAS) were used to assess physiological and psychological recovery. Blood albumin, haemoglobin, neutrophil counts, white blood cell counts, red blood cell counts, inflammatory markers (IL-6, IL-10, and IFN-γ) were measured, and the incidence of postoperative adverse reactions was also recorded.

Patients in the observation group exhibited significantly improved VAS, ODI, SF-36, SDS and SAS scores assessments post-intervention compared to the control group ( P < 0.05). Moreover, levels of IL-6, IL-10, and IFN-γ were more favorable in the observation group post-intervention ( P < 0.05), indicating a reduction in inflammatory response. There was no significant difference in the incidence of postoperative adverse reactions between the groups ( P > 0.05), suggesting that the comprehensive nursing interventions did not increase the risk of adverse effects.

Comprehensive nursing interventions have a significant impact on the postoperative recovery outcomes of patients with LSS, alleviating pain, reducing inflammation levels, and improving the overall quality of patient recovery without increasing the patient burden. Therefore, in clinical practice, it is important to focus on comprehensive nursing interventions for patients with LSS to improve their recovery outcomes and quality of life.

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Introduction

Lumbar spinal stenosis (LSS) is a common spinal disease in clinical orthopaedics that is characterized by narrowing of the spinal canal, leading to compression of the nerve roots and spinal cord and resulting in a series of symptoms [ 1 ]. LSS is considered a developmental disease that has a weak association with age, although the incidence of LSS in individuals older than 60 years is quite high [ 2 ]. LSS is prone to recurrence and clinically manifests with symptoms such as low back pain, sciatica, and lower limb weakness [ 3 ]. Severe cases can lead to urinary incontinence, muscle atrophy, and difficulty walking. Currently, lumbar fusion surgery is the main treatment method for lumbar spinal diseases, including lumbar spinal stenosis, although minimally invasive decompression surgery is becoming increasingly common. Compared to traditional surgical methods, lumbar fusion surgery has the advantages of better stability, preservation of intervertebral disc function, and reduced risk of complications [ 4 ]. Therefore, postoperative nursing interventions for this disease have become a new topic of research interest [ 5 , 6 , 7 ]. This study aimed to investigate the impact of nursing interventions on the rehabilitation outcomes of patients after lumbar spine surgery and to provide effective references for future postoperative care for patients undergoing lumbar spine surgery.

Materials and methods

Basic information.

Eighty patients with LSS treated at Shanxi Bethune Hospital of Shanxi Medical Academy from January 2023 to November 2023 were selected. The Shanxi Bethune Hospital’s institutional ethical review board approved this study, and all patients’ families provided written informed consent. All patients underwent lumbar fusion surgery. Using the random number table method, the patients were divided into a control group and an observation group, with 40 patients in each group. Both the control group and the observation group included 21 males and 19 females. There were no significant differences between the two groups in terms of age, sex, height, weight, American Society of Anesthesiologists (ASA) classification, or other data (Table 1 ).

The inclusion criteria were as follows:

Met the diagnostic criteria for lumbar spine diseases according to the “Clinical Diagnosis and Treatment Guidelines for Orthopedics [ 8 ]”.

Age between 18 and 65 years, ASA Grade I to II, required lumbar spine surgery based on their diagnosis.

No significant abnormalities in the results of preoperative routine blood tests or liver and kidney function tests.

No contraindications for anaesthesia or surgery.

The exclusion criteria were as follows:

Patients with significant organ dysfunction.

Patients with infectious diseases.

Patients with neurological or psychiatric disorders.

Patients who were allergic to the drugs used for anaesthesia.

Patients with severe cerebrovascular disease, heart disease, increased intracranial pressure, or elevated eye pressure.

Nursing methods

The control group of 40 patients received routine nursing care, which included advising the patients’ families about the process and timeline of postoperative recovery; providing appropriate pain relief medication under the guidance of a doctor according to the patients’ level of pain to alleviate postoperative pain [ 9 ]; guiding patients to gradually start activities such as getting out of bed and walking on the second day after surgery but avoiding strenuous activities and heavy lifting; and offering appropriate dietary guidance according to the patient’s condition, such as a low-fat, high-protein, high-fibre diet. The nurses of the control group patients recorded and regularly organized the patients’ daily data according to the study protocol.

In addition to routine care, patients in the observation group received comprehensive nursing care, which included postoperative pain management [ 10 ], postoperative exercise management, postoperative emotional management, and postoperative dietary management. Each patient was assigned to a dedicated nurse who recorded detailed daily data, including daily physical recovery status. The specific nursing content is described below.

Postoperative Rehabilitation Management.

After lumbar spine surgery, patients may undergo a period of rehabilitation. Lumbar spine surgery can cause physical and psychological burdens and stress to patients, and they are likely to face complications, such as deep vein thrombosis and pneumonia. Rehabilitation management can reduce the occurrence of complications through appropriate position adjustments, breathing training, bed transfer, and mobility training [ 11 ].

Before starting rehabilitation training, nurses provided guidance to patients on postoperative precautions, correct postures, position adjustments, avoidance of overexertion and incorrect movements. From the third day after surgery until discharge, patients were assisted by nurses to walk before breakfast, lunch, and dinner for 10 min each time, three times a day; the specifics were adjusted based on the patient’s situation [ 12 ]. Beginning on the fifth day after surgery, patients performed supine sit-ups with the nurses’ assistance. Patients placed their hands at their sides, and then nurses gently lifted the patients’ hips, forming a bridge shape with the body, which was held for 1–3 s before lowering; this exercise was repeated 5–10 times. Beginning on the seventh day after surgery, patients performed side-lying leg lifts with the nurses’ assistance. The patient lay on one side, supporting their head with one hand and placing the other hand in front for support, as nurses gently lifted the patient’s waist, lifted the upper leg as high as possible, and slowly lowered it [ 13 ] ; this exercise was repeated 10 times for each side. Two weeks after surgery, patients performed sit-ups with the nurses’ assistance, lying supine with their feet flat on the bed and their hands crossed over the chest or behind the ears. Then, the nurses gently lifted the patient’s waist, using the abdominal muscles to lift the upper body forwards as close to the knees as possible, and then slowly lowered it; this exercise was repeated 10–15 times. Nurses adjusted the exercises according to the patient’s condition and tolerance and taught them the correct posture, position, and movement techniques to help them avoid overexertion and incorrect movements, reducing the risk of further injury or damage to the lumbar spine [ 14 ].

Postoperative Pain Management.

According to medical orders, nurses used pain relief techniques, such as cold compresses, hot compresses, massage, and electrotherapy, to alleviate patients’ pain. Nurses regularly observed patients’ pain conditions and record detailed information about pain characteristics, intensity, duration, etc., so that doctors could adjust the pain relief treatment plan. In addition, nurses provided education and guidance to patients and their families about postoperative pain management, including how to correctly use pain relief medications, how to apply pain relief techniques, and how to observe and record pain conditions.

Postoperative Psychological Management.

After lumbar fusion surgery, patients may face uncertainties in postoperative recovery and worries about the results of the surgery, which may trigger anxiety and fear. Additionally, after lumbar fusion surgery, patients may experience changes in quality of life, such as dependence on others, limited mobility, and work impact, which can negatively affect patients’ psychological state and self-esteem [ 15 ]. Therefore, nurses provided psychological interventions and resources to help patients cope with and adapt to the surgery and recovery process.

Nurses assessed patients’ psychological states through interviews and observations, determining whether patients exhibit anxiety, fear, depression, or other psychological issues. Nurses provided patients and their families with detailed information and education about the surgery and recovery process, which helped them understand the purpose, process, and expected effects of the surgery, alleviating anxiety and fear, and listened to patients’ needs and emotional expressions to provide emotional support and comfort. Nurses used different psychological intervention techniques, such as cognitive-behavioural therapy, relaxation training, and mindfulness exercises, to help patients adjust their negative thoughts and emotions and improve their coping abilities; nurses also regularly followed up with patients to understand changes in their psychological state and recovery progress, and promptly identify and address psychological issues. Moreover, nurses collaborated with mental health professionals to provide necessary counselling and treatment resources to help patients deal with psychological problems [ 16 ].

Postoperative Dietary Management.

After lumbar spine surgery, patients’ wounds need to heal, and they face issues such as limited mobility and constipation. Therefore, good dietary management can provide sufficient nutrients to promote wound healing and tissue repair, improving patients’ recovery outcomes and quality of life [ 17 ].

Before managing the postoperative diet, the nursing staff conducted a comprehensive assessment of patients, including understanding their dietary preferences, food allergy history, nutritional status, and oral health status, to develop a personalized dietary management plan. Based on the assessment results, nursing staff provided a nutritionally balanced diet that included sufficient protein, vitamins, minerals, and carbohydrates to meet patients’ energy needs and promote wound healing. The nursing staff provided small and frequent meals, controlling the quantity and frequency of food intake to avoid overeating, which can lead to weight gain and indigestion. In postoperative dietary management, nursing staff provided easily digestible food, including low-fat and low-fibre foods such as cooked vegetables, tenderly cooked meat, and fish, to reduce the gastrointestinal burden. Patients’ weight changes, nutritional intake, digestive issues, etc., were closely observed so that the dietary management plan could be adjusted in a timely manner.

Postoperative Discharge Management.

Nurses provided detailed postdischarge guidance to patients the day before discharge, including precautions during the postoperative recovery period, dietary adjustments, and medication management, so that patients and their families clearly understood the postoperative precautions and could manage themselves and recover correctly. Nurses reminded patients to rest, allocate time for activities and work reasonably and avoid long periods of standing that could burden the waist. In addition, nurses maintained constant contact with patients through interviews and phone calls and recorded patients’ daily vital signs and lumbar spine recovery status within one month after discharge.

Nurses also emphasized to patients the prohibition on bending, carrying, or lifting heavy objects. Patients were told to avoid engaging in high-intensity and heavy labour to prevent damage to the postoperative lumbar spine. Nurses provided positive psychological support and encouragement to patients after discharge, helping them adjust their emotions and strengthen their confidence in recovery. They also reminded patients to stay warm and avoid overexerting the waist.

Observation indicators

The visual analogue scale (VAS) was used to assess pain before and 1 month after surgery in both groups of patients; on this scale, 0 is no pain, 1–3 is mild pain, 4–6 is moderate pain, and 7–10 is severe pain [ 18 ]. The Oswestry Disability Index (ODI) was used to evaluate functional recovery before and 1 month after surgery in both groups of patients [ 19 ] ; the ODI includes items on self-care ability in daily life (washing, dressing, etc.), ability to lift heavy objects, walking, sexual life, social activities, and travel (outings). Each item has 6 possible answers, scored from 0 to 5, with 0 indicating no pain and 5 indicating extreme pain and the most severe disability. The scoring method was as follows: actual score/50 (highest possible score) × 100%. If one question was not answered, then the scoring method was calculated as follows: actual score/45 (highest possible score) × 100%. Higher scores indicated more severe functional impairment. The Short-Form 36 (SF-36) Health Survey was administered before and 1 month after surgery in both groups of patients. The SF-36 is a brief self-administered questionnaire that generates scores across 8 dimensions of health: physical functioning (PF; 10 items), general health (GH; 5 items), role limitations due to physical health problems (role physical, RP; 4 items), bodily pain (BP; 2 items), social functioning (SF; 2 items), vitality (VT; 4 items), role limitations due to emotional problems (role emotional, RE; 3 items), and mental health (MH; 5 items). For each domain, a score ranging from 0 to 100 was assigned, with a higher score indicating better health [ 20 ]. Self-rating depression scale (SDS) scores were determined before and 1 month after surgery in both groups of patients. The SDS contains 20 items that reflect subjective feelings of depression. Answers are rated on a 4-point Likert scale (from 1, “no or a little of the time,” to 4, “most of the time or all the time”), and the scale includes 10 symptom-positive items and 10 symptom-negative items [ 21 ]. Self-rating anxiety scale (SAS) scores were determined before and 1 month after surgery in both groups of patients. The SAS is also composed of 20 items and is rated on a 4-point Likert scale (from 1, “no or a little of the time,” to 4, “most of the time or all the time”). Higher scores reflect more severe anxiety symptoms [ 22 ]. Blood albumin, red blood cell counts and haemoglobin levels were compared before surgery, 1 day and 1 month after surgery in both groups of patients; blood was sampled using vacuum methods and analysed using the bromocresol green and cyanide methods, respectively. Neutrophil counts and white blood cell counts, were compared before and 1 month after surgery in both groups of patients; blood was sampled using vacuum methods and analysed using an automatic blood cell analyser. IL-6, IL-10, and IFN-γ levels were compared before and 1 month after surgery in both groups of patients; blood was sampled using vacuum methods and analysed using flow cytometry. Blood samples were collected at the same time as those for routine blood tests and did not require additional invasive procedures. Statistics on the incidence of adverse reactions within 48 h after surgery were calculated in both groups of patients; the main adverse reactions included pressure ulcers, pulmonary infection, venous thrombosis (determined by ultrasound), urinary system infection, neutrophilia (more than 7.5 × 10 9 /L), and leucocytosis (more than 10 × 10 9 /L). The occurrence of delayed wound healing was assessed in both groups.

Statistical analysis

Count data are expressed as a percentage and were analysed using the χ2 test. The measurement data are expressed as the mean value ± standard deviation. Paired t tests were used to compare the results before and after the intervention. Independent samples t tests were used to compare the results between the two groups except red blood cells, haemoglobin and blood albumin, for the three outcomes, analysis of variance was conducted. A P value less than 0.05 was considered to indicate statistical significance.

Comparison of general information between the two groups of patients

There were no statistically significant differences between the two groups of patients in terms of sex, age, height, weight, ASA I or ASA II ( P > 0.05) (Table 1 ).

VAS and ODI scores

Table 2 shows the VAS and ODI scores, which indicated that compared with the preoperative conditions, both nursing strategies clearly lowered the VAS-leg score, VAS-back score and ODI 1 month after surgery ( p < 0.05). Compared with those in the control group, the decreases in scores in the observation group were significantly greater.

SF-36, SAS and SDS results

Table 3 shows the results of the SF-36, SAS and SDS, which indicated that compared with the preoperative conditions, both nursing strategies clearly lowered the SAS and SDS scores and increased the scores of all 8 domains of the SF-36 1 month after surgery ( p < 0.05). Compared with those of the control group, the decrease in the SAS and SDS scores for the observation group was significantly greater, and the increase in the scores for 6 domains of the SF-36, except the RE and MH domains, for the observation group were obviously greater.

Blood test results

Tables 4 and 5 shows the blood test results, which showed that compared with the preoperative conditions or 1 day after surgery, both nursing strategies clearly lowered the IL-6, IL-10 and IFN-γ levels and increased the blood albumin, red blood cell and haemoglobin levels 1 month after surgery ( p < 0.05). Compared with those in the control group, the decreases in the levels of IL-6, IL-10 and IFN-γ in the observation group were significantly greater, and the increase in the level of blood albumin in the observation group was obviously greater, with the not significant trend for red blood cell count and haemoglobin level.

Comparison of adverse reactions occurring within 48 h after surgery between the two groups of patients (%)

There were no significant differences in the occurrence of adverse reactions within 48 h after surgery between the control group and the observation group ( P > 0.05) (Table 6 ). In addition, no patients in either group experienced delayed wound healing.

Lumbar fusion can effectively restore normal lumbar function in LSS patients, but the necessity of postoperative bed rest causes various types of psychological and physical discomfort to patients. Therefore, postoperative nursing care interventions are crucial for patient recovery [ 23 ]. In this study, the observation group received comprehensive nursing care interventions based on routine care for LSS, including postoperative rehabilitation management, postoperative pain management, postoperative psychological management, postoperative dietary management, and postoperative discharge management, which offered nursing interventions from psychological and physiological perspectives to help alleviate pain and improve postoperative recovery outcomes in patients. This approach provides thorough and personalized nursing to patients. Although some studies have suggested that after lumbar decompression, physical therapy intervention does not significantly affect clinical outcomes, as measured by patient‑reported outcomes and surgical outcomes [ 24 , 25 ], numerous approaches aimed at improving nursing quality, such as brain storming, world café, and management by objectives, have been created since the World Health Organization has defined quality nursing as a patient-oriented, fair, convenient, effective, highly efficient, safe and acceptable model of nursing [ 26 ]. Studies have shown that personalized nursing that involves the application of a scientific, systemic and standardized nursing program and plan is effective for postoperative rehabilitation [ 27 , 28 ]. In addition, intimate and comprehensive nursing also contributes to communication and relationships between patients and nurses, which is beneficial for improving the quality of nursing and the outcome of surgery [ 29 , 30 , 31 ].

The results also supported the efficacy of comprehensive nursing. After receiving comprehensive nursing interventions, patients in the observation group had better scores on the VAS, ODI, SAS, SDS, and 6 of the 8 domains of the SF-36 than did patients in the control group ( P < 0.05). The study results indicate that comprehensive nursing care interventions based on routine care can significantly impact patients’ postoperative psychological and physiological conditions, enhancing postoperative recovery outcomes. Blood albumin, red blood cell count and haemoglobin are three common outcomes used to assess nutrient conditions, and our results suggested no significant results for the later two outcomes; however, both nursing methods clearly improved nutrient conditions compared with preoperative conditions, which suggested a positive effect of the comprehensive nursing method. The differences in neutrophil and white blood cell counts between the two groups were not clear; however, we used more microscopic outcomes to compare inflammatory conditions. The measurement of cytokine levels is important for predicting postoperative complications and inflammation severity. For example, increases in IL-6 and IFN-γ levels are associated with sepsis and wound disruption [ 32 , 33 ], while the IL-10 concentration can be used to determine the occurrence of postoperative complications such as atrial fibrillation [ 34 ]. In this study, after nursing interventions, the levels of IL-6, IL-10, and IFN-γ in the observation group were improved compared with those in the control group ( P < 0.05), suggesting that comprehensive nursing interventions, especially in dietary management and pain management, can reduce patients’ levels of inflammatory factors and improve patient recovery. However, both groups received non-steroid anti-inflammatory drug, which may influence the results. The lack of delayed wound healing in patients also suggested the high efficacy of comprehensive nursing. In addition, a comparison of the incidence of adverse reactions within 48 h after surgery in both groups found no significant difference between the two groups after receiving nursing interventions ( P > 0.05), indicating that not only did comprehensive nursing interventions improve several positive health indicators, but they also did not negatively impact the risk of postoperative adverse reactions in patients.

There were two major limitations in our study. First, the number of included patients was small, and the follow-up duration was short, which may influence the results. Second, there are many perioperative factors that may all influence the different outcomes in the two groups; we investigated only the nursing field, which may cause bias.

In summary, this study demonstrated that comprehensive nursing interventions have a significant impact on the postoperative recovery outcomes of patients with LSS, alleviating pain, reducing inflammation levels, and improving the overall quality of patient recovery without increasing the patient burden. Therefore, in clinical practice, it is important to focus on comprehensive nursing interventions for patients with LSS to improve their recovery outcomes and quality of life. Further studies with more included patients are needed to verify our results.

Data availability

All data generated or analysed during this study are included in this published article.

Abbreviations

American Society of Anesthesiologists

bodily pain

general health

lumbar spinal stenosis

and mental health

Oswestry Disability Index

physical functioning

role physical

self-rating anxiety scale

self-rating depression scale

social functioning

Short-Form 36

visual analogue scale

role emotional

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Department of Orthopaedic Surgery, Shanxi Bethune Hospital,Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, No. 99, Longcheng Street, Taiyuan city, Shanxi Province , 030032, China

Jun Liang, Liyan Wang, Jialu Song, Yu Zhao, Keyan Zhang, Xia Zhang, Cailing Hu & Dong Tian

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Jun Liang: designed research, analyzed data, wrote and checked paper. Liyan Liang: analyzed data, checked paper. Jialu Song: analyzed data, checked paper. Yu Zhao: collected data, analyzed data. Keyan Zhang: collected data, analyzed data. Xia Zhang: collected data, analyzed data. Cailing Hu: collected data, analyzed data. Dong Tian: designed research, supported research, checked paper.

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Liang, J., Wang, L., Song, J. et al. The impact of nursing interventions on the rehabilitation outcome of patients after lumbar spine surgery. BMC Musculoskelet Disord 25 , 354 (2024). https://doi.org/10.1186/s12891-024-07419-9

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Study: Pressure to be “perfect” causing burnout for parents, mental health concerns for their children

New data finds stress, anxiety and depression spike for those feeling the weight of a “culture of achievement”

Is the status of “perfect parent” attainable?

Researchers leading a national dialogue about parental burnout from The Ohio State University College of Nursing and the university’s Office of the Chief Wellness Officer say “no,” and a new study finds that pressure to try to be “perfect” leads to unhealthy impacts on both parents and their children.

The survey of more than 700 parents nationwide from June 15 – July 28, 2023 is summarized in the new report, “The Power of Positive Parenting: Evidence to Help Parents and Their Children Thrive.” The data shows that:

Fifty-seven percent (57%) of parents self-reported burnout.
Parental burnout is strongly associated with internal and external expectations, including whether one feels they are a good parent, perceived judgment from others, time to play with their children, the relationship with their spouse and keeping a clean house.
The more free play time that parents spend with their children and the lighter the load of structured extracurricular activities, the fewer mental health issues in their children (i.e. anxiety, depression, OCD, ADHD, bipolar disorder).
Parents’ mental health and behaviors strongly impact their children’s mental health. If their children have a mental health disorder, parents report a higher level of burnout and a greater likelihood for them to insult, criticize, scream at, curse at and/or physically harm their children (i.e. repeated spanking). Higher levels of self-reported parental burnout and harsh parenting practices are associated with more mental health problems in children.

Kate Gawlik , DNP, APRN-CNP, FAANP, FNAP, FAAN, one of the lead researchers on the study who pursues this research based on her experience as a working mother of four, said the illusion and expectations of “perfect parenting” can be deflating.

“I think social media has just really tipped the scales,” said Gawlik, an associate clinical professor at the Ohio State College of Nursing. “You can look at people on Instagram or you can even just see people walking around, and I always think, ‘How do they do that? How do they seem to always have it all together when I don't?’

“We have high expectations for ourselves as parents; we have high expectations for what our kids should be doing. Then on the flipside, you're comparing yourself to other people, other families, and there's a lot of judgment that goes on. And whether it's intended or not, it's still there.”

Data from the study shows that force of expectations from what Gawlik calls a “culture of achievement” leads to burnout (a state of physical and emotional exhaustion), which in turn leads to other, potentially debilitating issues.

“When parents are burned out, they have more depression, anxiety and stress, but their children also do behaviorally and emotionally worse,” said Bernadette Melnyk , PhD, APRN-CNP, FAANP, FNAP FAAN, vice president for health promotion and chief wellness officer at Ohio State and Helene Fuld Health Trust professor of evidence-based practice at the College of Nursing. “So it's super important to face your true story if you're burning out as a parent and do something about it for better self-care.”

Gawlik and Melnyk’s new report brings critical updates to their initial study in 2022, which measured working parent burnout during the height of the COVID-19 pandemic. Gawlik and Melnyk created a first-of-its-kind Working Parent Burnout Scale, a 10-point survey that allows parents to measure their burnout in real time and use evidence-based solutions to help.

That scale is included in the new report, along with new guidance on positive parenting strategies, techniques and tips to form deeper connections with one’s children.

“Positive parenting is when you give your children a lot of love and warmth, but you also provide structure and guidance in their life,” Melnyk explained. “You gently teach them consequences of behaviors. So that is a much better goal to shoot for being a positive parent than a perfect parent.”

Among the strategies:

Connection and active listening
Catching, checking and changing negative thoughts into positive ones
Readjusting expectations for the parent and the child
Reflecting and acting on priorities

“If maybe you're prioritizing making sure your house is spotless all the time, but then you don't feel like you have time to go for a walk every night with your children, maybe you need to reorganize or find a way to make both of those things work,” Gawlik suggested.

Melnyk said these evidence-based approaches can help calm what she calls a “public health epidemic” of parental burnout.

“Parents do a great job caring for their children and everybody else, but they often don't prioritize their own self-care,” Melnyk said. “As parents, we can't keep pouring from an empty cup. If children see their parents taking good self-care, the chances are they're going to grow up with that value as well. It has a ripple effect to the children and to the entire family.”

“As one parent told me,” Gawlik added, “‘I would much rather have a happy kid than a perfect kid.’”

Media coverage of this story:

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IMAGES

(PDF) Stress, Depression, and Anxiety among Undergraduate Nursing Students
(PDF) Effects of Anxiety on Health and Well-being of the Individuals
Anxiety Nursing Diagnosis Care Plan
(PDF) Effectiveness of aromatherapy in reducing test anxiety among
(PDF) Strategies to Reduce Nursing Student Test Anxiety: A Literature
(PDF) A qualitative study of patients’ views on anxiety and depression

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ANXIETY DISORDERS #nursing #psychology #medicalstudent #nurse
Psychological Safety in Nursing: A Personal Account of Resilience in the Face of Trauma
Stress ,Anxiety and coping
Racism in Nursing Research
Notes Of Anxiety Disorder in Mental Health Nursing (Psychiatric) in Hindi
Help And Support For Anxiety ✔️

COMMENTS

Treatment of anxiety disorders in clinical practice: a critical overview of recent systematic evidence
Eligible articles were systematic reviews (with or without meta-analysis), which evaluated treatment effectiveness of either nonbiological or biological interventions for anxiety disorders. Retrieved articles were summarized as an overview. We assessed methods, quality of evidence, and risk of bias of the articles.
Anxiety (Nursing)
Fear is an automatic neurophysiological state of alarm characterized by a fight or flight response to a cognitive appraisal of present or imminent danger (real or perceived). Anxiety is linked to fear and manifests as a future-oriented mood state that consists of a complex cognitive, affective, physiological, and behavioral response system associated with preparation for the anticipated events ...
Anxiety, perceived stress and coping strategies in nursing students: a
Research on stress levels among health professionals is an issue of current interest that merits concern [].This is not only due to the many causes of intrinsic stress referred by healthcare professionals, but also because it is worth considering the negative and chronic effects of stress over time [].In nursing, the subject of stress has received much attention in the literature, and ...
Treatment of Anxiety Disorders in Primary Care: What Nurse
Introduction. Anxiety disorders are the most common mental illnesses in the United States and are highly prevalent in the primary care setting, where 70% of all mental health services are provided (Jetty et al., 2021).Approximately 31% to 32% of adolescents and adults experience an anxiety disorder during their lifetime (National Institute of Mental Health [NIMH], 2024), impairing quality of ...
Nursing Process Addressing the Focus "Anxiety": A Scoping Review
From the total of articles located, 165 were included. The nursing diagnosis "anxiety" can be considered a parent diagnosis, from which other children diagnoses are derived. Data that lead to nursing diagnoses in the anxiety domain can be divided into cognitive and somatic data.
Reducing stress, anxiety and depression in undergraduate nursing
These levels of stress and anxiety in nursing students were found to be higher than the general student body (Bartlett et al., 2016). ... The first stage of the search strategy was a search of relevant research articles from two databases (MEDLINE and the Cumulative Index to Nursing and Allied Health Literature [CINAHL]) to appraise and refine ...
Risks of treated anxiety, depression, and insomnia among nurses: A
Introduction. Nursing has been acknowledged to be a stressful occupation with a high prevalence of distress and stress-related burnout [1-3].The high level of occupational stress and burnout among nurses can lead to behavioral health problems and psychiatric morbidity, including insomnia [4-6], anxiety [7-10], depression [7, 10-14], and substance use [15-17].
(PDF) Anxiety: a concept analysis
For nursing, a clear understanding of anxiety is conducive to clinical nursing practice and research. Under the guidance of the Walker and Avant method, this article conducts a concept analysis of ...
Stress, anxiety, depression and sleep disturbance among healthcare
The outbreak of SARS-CoV-2, which causes COVID-19, has significantly impacted the psychological and physical health of a wide range of individuals, including healthcare professionals (HCPs). This umbrella review aims provide a quantitative summary of meta-analyses that have investigated the prevalence of stress, anxiety, depression, and sleep disturbance among HCPs during the COVID-19 pandemic ...
Anxiety and depression among nursing students during the COVID‐19
The Journal of Clinical Nursing publishes research and developments relevant to all areas of nursing practice- community, geriatric, mental health, pediatric & more. Abstract Aims and Objectives To determine the prevalence and levels of anxiety and depression symptoms among nursing students during the coronavirus lockdown, and to examine ...
Effects of Relaxation Therapy on Anxiety Disorders: A Systematic Review
Articles included in the systematic review were published before April 2016, and found through a search of the computer-based Cochrane Library, Pubmed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFo, KoreaMed, and Research Information Sharing Service (RISS).
Reducing Nursing Student Anxiety in the Clinical Setting: An ...
ns. METHOD An integrative review was undertaken following guidelines by Whittemore and Knafl. The search was limited to articles published from 1999 to 2018 to increase the likelihood that they included the generations of students currently most prevalent in nursing programs, millennials and generation Z. RESULTS Most researchers (17 studies) supported their interventions as somewhat effective ...
Effectiveness of nursing Intervention on anxiety,... : Medicine
intervention. One hundred thirty six patients with acute coronary intervention were randomly divided into the experimental group (n = 68) and the control group (n = 68). The experimental group received nursing intervention measures, and control group received routine nursing. We measured the depression, anxiety score of the 2 groups before and after nursing and multiple regressions was to ...
Depression and anxiety prevalence in nursing staff during th ...
Figure. The World Health Organization declared COVID-19 a pandemic on March 11, 2020, as the novel virus spread rapidly across the globe. 1 As the number of COVID-19 cases grew, the US experienced a parallel increase in mental health crisis, with rates of depression and anxiety tripling. 2 Recent studies suggest that healthcare workers are at a higher risk for experiencing depression and ...
Navigating Nursing Student Anxiety: A Conceptual Model
Nursing students experience high rates of anxiety (Gurková & Zeleníková, 2018; Mills et al., 2020; Wedgeworth, 2016) but little is known about the relationship between anxiety and the learning environment. This study intended to explore and better understand what components of the learning environment are impacted by or impact anxiety.
Anxiety disorders
Anxiety disorders form the most common group of mental disorders and generally start before or in early adulthood. Core features include excessive fear and anxiety or avoidance of perceived threats that are persistent and impairing. Anxiety disorders involve dysfunction in brain circuits that respond to danger. Risk for anxiety disorders is influenced by genetic factors, environmental factors ...
Nursing students' stressors and coping strategies during their first
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 ...
Strategies to Reduce Nursing Student Test Anxiety: A Literature Review
Faculty members should consider using the test anxiety reduction interventions described in this article. Priorities for future research include studying the effects of test anxiety reduction interventions on examination grades. ... The effect of guided reflection on test anxiety in nursing students. Nursing and Midwifery Studies, 2, 16-20.
Validation of depression, anxiety, and stress scales (DASS-21 ...
The Depression, Anxiety and Stress Scale (DASS-21), an introductory scale used to identify common mental disorders (CMDs) among adults, was validated across cultures in Asian populations; nevertheless, its capacity for screening these disorders may be limited for some specified groups, including nursing students. This study attempted to investigate the psychometric scale's unique features of ...
Analysis of Anxiety or Depression and Long-term Mortality Among
Key Points. Question Is depression or anxiety associated with increased long-term mortality among patients after out-of-hospital cardiac arrest?. Findings In this cohort study using claims from the Korean National Health Insurance Service database, 2373 patients with out-of-hospital cardiac arrest were followed up for up to 14 years. . Patients diagnosed with depression or anxiety had an ...
The relationship between childhood adversity and sleep quality among
Background Studies have revealed the effects of childhood adversity, anxiety, and negative coping on sleep quality in older adults, but few studies have focused on the association between childhood adversity and sleep quality in rural older adults and the potential mechanisms of this influence. In this study, we aim to evaluate sleep quality in rural older adults, analyze the impact of adverse ...
The impact of nursing interventions on the rehabilitation outcome of
Blood test results. Tables 4 and 5 shows the blood test results, which showed that compared with the preoperative conditions or 1 day after surgery, both nursing strategies clearly lowered the IL-6, IL-10 and IFN-γ levels and increased the blood albumin, red blood cell and haemoglobin levels 1 month after surgery (p < 0.05). Compared with those in the control group, the decreases in the ...
Study: Pressure to be "perfect" causing burnout for parents, mental
New data finds stress, anxiety and depression spike for those feeling the weight of a "culture of achievement" Is the status of "perfect parent" attainable? Researchers leading a national dialogue about parental burnout from The Ohio State University College of Nursing and the university's Office of the Chief Wellness Officer say "no," and a new study finds that pressure to try ...

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