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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 7  |  Issue : 1  |  Page : 45-50

COVID-19 pandemic and nursing students: Stress, depression, and coping behaviors – An exploratory study


1 Department of Child Health Nursing, B.L.D.E.A's Shri B. M. Patil Institute of Nursing Sciences, Vijayapura, Karnataka, India
2 Department of Medical Surgical Nursing, B.L.D.E.A's Shri B. M. Patil Institute of Nursing Sciences, Vijayapura, Karnataka, India

Date of Submission28-Jul-2021
Date of Decision23-Nov-2021
Date of Acceptance25-Nov-2021
Date of Web Publication27-Jun-2022

Correspondence Address:
Prof. K Kavitha
Departments of Child Health Nursing, B.L.D.E.A's Shri B. M. Patil Institute of Nursing Sciences, Vijayapura, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/bjhs.bjhs_83_21

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  Abstract 


BACKGROUND: The COVID-19 pandemic has created a confused state of day-to-day affairs among people of all walks of life. The sudden changes in the routine classes and lack of available resources for continuing academic activities are the major sources of stress and other mental health issues among nursing students.
AIM: To determine nursing students' stressful experiences, the presence of clinical depression due to the pandemic, and coping behaviors adopted by them.
METHODOLOGY: Nonexperimental, exploratory, cross-sectional research design was used. A total of six institutions have been selected for the study. Three hundred and sixty-seven participants who fulfilled the eligibility criteria were selected by the nonprobability convenient sampling method. The tool consisted of 4 parts: (a) pro forma to elicit sociodemographic variables, (b) Impact of Event Scale-Revised (IES-R) to assess the level of stress, (c) Center for Epidemiologic Studies Depression (CES-D) to screen for features of depression, and (d) bipolar scale to measure the coping behaviors. The data were collected through an online survey.
RESULTS: Out of 367 nursing students, 318 (86.64%) were in the group of 18–22 years, and a majority (74.38%) were female. A majority of participants (30.79%) had high symptoms of posttraumatic stress disorder. A significant relationship between nursing students' stress scores with coping activities such as watching the news (B = 0.735, P < 0.05), anxiety (B = 1.326, P < 0.001), health (B = −2.891, P < 0.05), exercise (B = −1.656, P < 0.05), and faith (B = 1.150, P < 0.05).
CONCLUSION: To promote the mental health and overall well-being of nursing students, proper guidance and counseling by the teachers and mentors are needed.

Keywords: Academic, coping, counseling, COVID-19, nursing, stress, students


How to cite this article:
Kavitha K, Sikandar BJ, Joseph R. COVID-19 pandemic and nursing students: Stress, depression, and coping behaviors – An exploratory study. BLDE Univ J Health Sci 2022;7:45-50

How to cite this URL:
Kavitha K, Sikandar BJ, Joseph R. COVID-19 pandemic and nursing students: Stress, depression, and coping behaviors – An exploratory study. BLDE Univ J Health Sci [serial online] 2022 [cited 2022 Aug 16];7:45-50. Available from: https://www.bldeujournalhs.in/text.asp?2022/7/1/45/348279



The COVID-19 pandemic has brought people's lives to a mere standstill throughout the world. This huge acute and ongoing health burden has had a remarkable, unimaginable, and never felt before impact on the health-care providers as well. The term impact commonly refers to effect or influence. This effect can be both positive and negative and includes various dimensions on the individual, family, or community that is exposed to the particular circumstance. The nursing profession is valued as a caring profession that fosters the health of people from birth to death across society irrespective of caste, creed, religion, etc. Nursing graduates are prepared through an eclectic curriculum that will equip them for entry-level practice.

The COVID-19 pandemic arguably made the nursing students navigate the unprecedented curriculum and pedagogical adaptations to complete their academic requirements.[1] Some institutions have chosen in-person classes, but the majorities have restricted face-to-face interactions.[2] Most of the institutions around the world opted for online classes, but students need to be in person for completing their practicum.[3] They are not able to complete their clinical experiences and summative examinations are either canceled or postponed. Specifically, the final year students are forced to wait for entering in nursing force.[4] A Chinese study highlighted that nursing students are using immature or negative coping strategies to adapt to this pandemic-imposed academic crisis.[5] On the other hand, there is a huge shortage of nursing staff caused by the uncertainty of the pandemic situation.[6]

Stress is described as internal and external demands exceeding the coping resources of an individual.[7] It is a known fact that nursing students experience high levels of stress related to academic demands such as high stakes exams, workloads, clinical expectations, and balancing their schoolwork with their personal lives.[7] COVID-19 compounded these stressors by creating a level of fear due to lack of knowledge, potential impact on the students' health as well as their family, and the constant changes made to the delivery of the nursing curriculum. As courses moved to online platforms, those same high stakes exams brought even more stress and students began to feel isolated. The isolation and fear of the unknown also impacted students' mental health and levels of depression.

Kim et al. report that prior to the pandemic, a survey of 26,811 college students in the United States showed that about half were diagnosed or treated for anxiety, depression, or panic attacks within the past year.[8] The social isolation brought on by the pandemic has exacerbated these issues for nursing students. In a study conducted by Cruz, 8.3% of nursing students scored as having moderate levels of depression and 11% scored as severe.[9] Social distancing guidelines negatively impacted nursing students by removing them from their classmates and social support systems. Interactions were limited to virtual meeting rooms and discussion boards.

When colleges and universities transitioned from face-to-face learning to remote classrooms, most of the nursing institutions made use of virtual simulation and debriefing to replace traditional clinical experiences. Other learning alternatives were created to assist learners to achieve practicum goals. However, the students' response to changes in life and education as a result of COVID-19 may vary and need to be examined. Hence, the present study is aimed to determine nursing students' stressful experiences, the presence of clinical depression due to the pandemic, and coping behaviors adopted by them.

Objectives

  • To assess the level of stress and depression due to the COVID-19 pandemic among nursing students
  • To assess the coping behaviors used by nursing students
  • To identify associations between the stress score sociodemographic variables of nursing students.



  Methodology Top


Study design and setting

A nonexperimental, exploratory, cross-sectional research design was used to explore the experiences and coping behaviors of nursing students. Nursing students were recruited from six nursing colleges across three states in India, such as Karnataka, Maharashtra, and Gujarat. The settings were selected based on feasibility. All the six institutions (two institutions per state) selected facilitated online classes during COVID-19.

Participants

A convenience sampling method was used to recruit nursing students enrolled in the selected six colleges. A total of 400 students from six institutions were approached and 367 participated in the study. Participants indicated their consent to participate and self-reported using an online survey.

Inclusion criteria

  • Students enrolled for both undergraduate and graduate nursing
  • Both male and female students
  • Those who had online classes during the lockdown period.


Exclusion criteria

  • Students who do not have internet facilities and smartphones with them
  • The students pursuing a diploma in nursing and other certificate courses in the selected settings.


Variables

  • Research variables: Stress, coping, and depression among nursing students
  • Extraneous variables: Age, gender, religion, place of residence and socioeconomic status, anxiety level, general health condition, etc.


Tools and techniques

The tool for collecting data from study participants consisted of 4 parts:

  • Part A: Pro forma to elicit information regarding sociodemographic variables that consisted of 13 items
  • Part B: Impact of Event Scale-Revised (IES-R) to assess the level of stress due to pandemic. It is a 5-point rating scale that consisted of 22 items (Christianson and Marren, 2012; Weiss, 2007).[10],[11] The score for each item ranges from 0 (not at all) to 4 (extremely). Hence, the overall score ranges from 0 to 88. The IES-R scores may indicate posttraumatic stress disorder (PTSD); a score of zero to 23 for non-PTSD, 24–32 for low-risk PTSD, 33–36 for PTSD, and ≥37 for high-risk PTSD.[10],[11] High-risk PTSD represents a stress level, which can suppress the immune system up to 10 years postevent. The test–retest reliability score was reported as 0.89–0.94[12]
  • Part C: Center for Epidemiologic Studies-Depression (CES-D) to screen the nursing students for features of depression.[13] This scale was developed by the Center for Epidemiological studies. It is a 4-point rating scale that consisted of 20 items. The score for each item ranges from 0 (rarely) to 3 (mostly). Hence, the overall score ranges from 0 to 60. A score of 16 points or more is considered depressed. Four items need reverse coding and a reliability of >0.85 was reported
  • Part D: Bipolar scale prepared by investigators to measure the coping behaviors adapted by study participants which consisted of eight items such as exercise, binge eating, sleeping, engaging activities of daily life, engage in learning, reading holy books, engaging in social media, and use of media time. These activities are measured on a five-point continuum with opposite ends for each item.


Ethical considerations

An ethical clearance certificate was obtained from the institutional ethical committee of BLDEA's Shri B. M. Patil Institute of Nursing Sciences Vijayapur, Karnataka, India (Ref. no. 318/8/2020-21, dated 19.8.2020). This is the parent institute for all the six nursing colleges. The participants were consented before accessing the survey. The data were collected through an online survey; the anonymity of the study participants was maintained. The data were stored in a password-protected computer.

Data collection procedure

The data were collected from study participants using an online survey. The survey links were sent through WhatsApp groups and E-mails. The data were collected during the first wave of the COVID-19 Pandemic (from August to October 2020). The data were analyzed using descriptive and inferential statistics.


  Results Top


Of the 367 nursing students who participated in the survey, 318 (86.64%) were in the age group of 18–22 years, a majority (74.38%) were female, and most of them were pursuing BSc nursing program. More than half of the participants (51.4%) were confined to their hostels. Most of the students identified their religion as Hindu (79.01%) and were from middle-class families (75.74%) [Table 1].
Table 1: COVID-19 Study: Sociodemographic characteristics of study participants

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Stress levels of students were examined based on the IESR scores [Table 2]. The findings of the level of stress revealed that 113 (30.79%) out of 367 participants had high symptoms of PTSD, and 44 (11.98%) students had a moderate level of PTSD.
Table 2: IESR Scores: Level of posttraumatic stress

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The students staying in hostel premises had an increased level of stress when compared to the nonhostelites [Figure 1]. Male students had more stress scores (40%) than female students (38%).
Figure 1: Impact of Event Scale-Revised scores: Comparison of stress scores among hostelites versus nonhostelites

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Depression scores demonstrated a low positive correlation with stress scores [Figure 2]. Regression analysis showed that there was a significant relationship between nursing students' stress scores with coping activities such as watching the news (B = 0.735, P < 0.05), anxiety (B = 1.326, P < 0.001), health (B = −2.891, P < 0.05), exercise (B = −1.656, P <.05), and faith (B = 1.150, P < 0.05). Furthermore, a significant relationship was observed between coping activities and depression scores for items such as watching the news (B = 0.610, P < 0.01), anxiety (B = 0.785, P < 0.001), health (B=-1.513, P < 0.05), and activity (B = 1.150, P < 0.01) [Table 3].
Figure 2: Relationship between Stress and Depression Scores among nursing students

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Table 3: The relationship between stress, depression, and adopted coping behaviors among nursing students

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  Discussion Top


In the present study, most of the students (86.64%) were in the group of 18–22 years and the mean age of the participants was 22 ± 1.86.[7] A majority (74.38%) of the participants were females, which is consistent with the results of the previous study by Aslan et al. with 71.9% of females.[14] The increased number of female participants in the study might be because nursing is considered to be a female profession. Most of the participants (86.37%) practice the Hindu faith, which is supported by a study by Sheroun et al., which showed 81% of nursing students belonged to the Hindu religion.[15] India being a Hindu nation, this finding is not surprising.

In the present study, it was found that 30.79% of nursing students had high PTSD scores which are contradicted the finding from the previous study by Subba et al. and Tiwari et al. where the findings showed a moderate stress level among 84.1% and 97.4%, respectively.[16],[17] A Malaysian study found that 29% of university students had anxiety.[18] These variations in the level of stress scores could be due to the abrupt changes in life, study, and activities of daily life caused by lockdown and its consequences.

The present finding noted a mild positive correlation between stress scores and depression scores of nursing students. However, in contradiction, Fitzgerald and Konrad mentioned in their study that there was a strong correlation between symptoms of anxiety and stress about nursing students' academic matters.[19]

A significant correlation was noted between certain coping behaviors such as watching the news (P < 0.05), anxiety (P < 0.001), health (P < 0.05), exercise (P < 0.05), and activities of students (P < 0.01) with the stress and depression level of students; these findings are comparable with findings from researchers. Joseph et al. found that anxiety, quality of sleep, and perceived health correlated with stress scores.[20] Sheroun et al. found that there was a significant association between coping strategies and stress of students during the pandemic.[15] Savitsky et al. noted that coping strategies were significantly associated with age, gender, and religion.[21] A study by Chaudhary et al. divulged that nursing students' anxiety and depression were significantly associated with having family members with COVID-19 infection.[22] A study among university students of Bangladesh noted that factors like age and gender had an impact on anxiety and depression level of students.[23] Potentially modifiable factors such as resilience, family functioning, and spiritual support were associated with the amelioration of psychological distress of nursing students[8] Gandhi et al. have reported that psychological preparedness of nursing students, their self-efficacy, optimism, and resilience were positively correlated with each other in facing COVID-19 pandemic circumstances.[24] A Spanish study mentioned that nursing students used adoptive coping strategies to reflect on the COVID-19 context, on learning, and on strengthening the available resources.[25]

Limitations

The findings from this study may not be generalizable because of multiple reasons. The settings and the sample were conveniently selected which adds to the sampling bias. The majority were female and Hindus, and the findings may be different if more males and people from other religions participated. Furthermore, this was during the first wave of COVID-19 when India did not see a large number of patients. The results may be different if the survey is administered during the second wave when India is profoundly affected. Self-report is assumed to be a true representation; however, some may have inflated the levels or reduced them out of fear or social acceptability. The isolation imposed by the quarantine may have affected in other ways which were not captured by this survey. Some students may be on medications or have assumed negative coping such as substance use, which was not captured in this survey.


  Conclusion and Recommendations Top


Many nursing students in India are from less developed regions and low-to-middle-income families. The sudden, unexpected, and uncertain scenario of lockdown might have posed challenges to those students due to less social network and inadequate academic support. Nursing students need proper guidance, support, and counseling to adapt to this impactful circumstance. Nursing educators in particular play a major role in inculcating positive coping skills among the students. Informal mentoring may help identify at-risk students and offer support. Research on parental and financial support and interventions to plan for successful completion may help nursing students. Such endeavors may help prevent attrition and foster a healthy emerging workforce.

Acknowledgment

We extend our sincere gratitude to the principals and faculties of respective nursing colleges who motivated their students to participate in the online survey. We are very much thankful to all the nursing students who enthusiastically took up the online survey in very challenging times.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
University of California, Irvine. Coronavirus Pandemic Challenges Nursing Students. Available from: https://nursing.uci.edu/2020/04/coronavirus-nursing-students/. [Last acessed on 2020 Aug 30].  Back to cited text no. 1
    
2.
Jackson D, Bradbury-Jones C, Baptiste D, Gelling L, Morin K, Neville S, et al. Life in the pandemic: Some reflections on nursing in the context of COVID-19. J Clin Nurs 2020;29:2041-3.  Back to cited text no. 2
    
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Dewart G, Corcoran L, Thirsk L, Petrovic K. Nursing education in a pandemic: Academic challenges in response to COVID-19. Nurse Educ Today 2020;92:104471.  Back to cited text no. 3
    
4.
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5.
Huang L, Lei W, Xu F, Liu H, Yu L. Emotional responses and coping strategies in nurses and nursing students during Covid-19 outbreak: A comparative study. PLoS One. 2020 Aug 7;15(8):e0237303. doi: 10.1371/journal.pone.0237303. PMID: 32764825; PMCID: PMC7413410. Available from: https://www.medrxiv.org/content/10.1101/2020.03.05.20031898v1. [Last accessed on 2021 Mar 17].  Back to cited text no. 5
    
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Chen SC, Lai YH, Tsay SL. Nursing perspectives on impact of COVID-19. J Nurs Res 2020;28:e85.  Back to cited text no. 6
    
7.
Majrashi A, Khalil A, Nagshabandi EA, Majrashi A. Stressors and coping strategies among nursing students during the COVID-19 pandemic: Scoping review. Nurs Rep 2021;11:444-59.  Back to cited text no. 7
    
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9.
Cruz JP. Risk perceptions, fear, depression, anxiety, stress and coping among Saudi nursing students during the COVID-19 pandemic. J Ment Health 2021;30:194-201.  Back to cited text no. 9
    
10.
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11.
Weiss DS. The impact of event scale-revised. In: John P. Wilson,Terence M. Keane, editors. Assessing Psychological Trauma and PTSD: A Practitioner's Handbook. 2nd ed. New York: Guilford Press; 2007. p. 168-89.  Back to cited text no. 11
    
12.
Weiss DS, Marmar CR. The impact of event scale – Revised. In: Wilson J, Keane TM, editors. Assessing Psychological Trauma and PTSD: A Practitioner's Handbook. New York: Guilford Press; 1996. p. 399-411.  Back to cited text no. 12
    
13.
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14.
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15.
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17.
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18.
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19.
Fitzgerald A, Konrad S. Transition in learning during COVID-19: Student nurse anxiety, stress, and resource support. Nurs Forum 2021;56:298-304.  Back to cited text no. 19
    
20.
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21.
Savitsky B, Findling Y, Ereli A, Hendel T. Anxiety and coping strategies among nursing students during the COVID-19 pandemic. Nurse Educ Pract 2020;46:102809.  Back to cited text no. 21
    
22.
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23.
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24.
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25.
Roca J, Canet-Vélez O, Cemeli T, Lavedán A, Masot O, Botigué T. Experiences, emotional responses, and coping skills of nursing students as auxiliary health workers during the peak COVID-19 pandemic: A qualitative study. Int J Ment Health Nurs 2021;30:1080-92.  Back to cited text no. 25
    


    Figures

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