Occupational stress among practicing nurses has been studied for many years, and nurses consistently report the highest levels of job stress among all health professionals (American Nurses Association, 2011; Roberts & Grubb, 2014), often manifesting as high levels of anxiety, depression, and stress-related illnesses (Mark & Smith, 2012). Preparing nurses through educational programs for such a stressful career requires insights into the stress and mental health status experienced by nursing students. Research regarding the stress experienced by nursing students has steadily increased over the past two decades, with European studies dominating and American and other international researchers contributing to this body of knowledge in recent years (Alzayyat & Al-Gamal, 2014; Chernomas & Shapiro, 2013). However, a gap exists in the literature related to how stress and selected mental health indicators differ between nursing students and the general college student population. As the shortage of nurses and the retention and successful matriculation of nursing students continues to be a health care workforce imperative, understanding stress among nursing students is essential.
The aim of this study was to compare the stress and selected mental health indicators of baccalaureate nursing students with those of students from the general student body of a university with 4-year degree programs, using the American College Health Association's (ACHA) National College Health Assessment II (NCHA-II; ACHA, 2011). The findings reported in this study represent a subset of data being collected as part of a larger, longitudinal study of nursing student health over the course of an entire nursing program.
Several studies have focused on stress in nursing students and have found that stress is experienced in higher amounts than in the general student body. Pryjmachuk and Richards (2007) reviewed studies of British nursing students and found that stress among these students was relatively high, compared with other university students. Those studies also supported suggestions that nursing students find the combination of academic and clinical demands associated with study to be major sources of stress. In addition, studies have highlighted the high levels of stress in nursing students and the disconnection in nursing student health behavior knowledge and self-application (Bryer, Cherkis, & Raman, 2013; Horneffer, 2006; Lo, 2002; de Souza, Oliviera, & Pinheiro, 2014).
With nursing demands high and supply low (Weitzel & McCahon, 2008), it is also of concern that a high level of stress in nursing education students is driving potential students away from the profession (Pryjmachuk & Richards, 2007). Some researchers have offered possible explanations for this, including it may be the status of being a college student and the stress that comes with that role, not necessarily that of being a nursing student (Pryjmachuk & Richards, 2007). In addition, nursing student populations tend to have more nontraditional students and, thus, more stressors outside of school, such as families and employment, that influence overall stress levels (Bryer et al., 2013; de Souza et al., 2014). Chernomas and Shapiro (2013) found that perceiving life as being more stressful for students in a nursing program was associated with higher stress, depression, and anxiety and that the multiple demands of personal lives and academic expectations created stress. In that study, increased stress was reflected in several quality-of-life factors, such as inadequate sleep, nutrition, and leisure time. Gibbons (2010) and Gibbons, Dempster, and Moutray (2010) sought to understand how different sources of stress might moderate or mediate well-being among nursing students. They found that self-efficacy, dispositional control, and support were important predictors of well-being and that avoidance coping was a strong predictor of adverse well-being. They found that the presence of support was beneficial, as well as the usefulness of that support, to help with student coping.
In a profession where being a role model and health promoter is paramount and where resilience for longevity in the profession is necessary, the importance of a nurse's own health-promoting behaviors cannot be underestimated. Considering that nurses are experiencing higher stress and sickness rates than the general population and other health care workers, it is important to determine where the stress and health problems begin in a nurse's career. Are these experiences only a function of employment, or are they characteristics of stress and poor health maintenance and promotion evident during prelicensure educational programs? The purpose of this study was to answer the research questions, “Do prelicensure, baccalaureate nursing students experience more stress, anxiety, depression and selected health problems and illnesses than other college students?” and “Do prelicensure, baccalaureate nursing students differ from other college students in the type of life events or circumstances as being difficult to handle?”
It was hypothesized that undergraduate nursing students would report more anxiety and depression than general undergraduate students. In addition, it was hypothesized that nursing students would report more stress and thus more stress-related issues and illnesses (e.g., sleep disturbances, upper respiratory tract infections, migraines) than general undergraduate students.
After receiving institutional review board approval to conduct the study, volunteers from a prelicensure nursing student program and from the general student population were recruited to participate in the study. All student volunteers understood that participation was voluntary and that there was no penalty or reward for participating or not participating in the study. Completion and submission of the survey indicated consent to participate.
The participants in this study were two samples of undergraduate college students from a mid-sized university in the southwestern United States, with approximately 6,474 undergraduate students enrolled. From an undergraduate nursing program with 488 students enrolled, 156 undergraduate nursing students participated (83% female, 15% male, 2% unknown), with an average age of 24.09 years (SD = 7.2 years). Seventy-six undergraduate students from the general student body population participated (50% female, 46% male, 4% unknown), with an average age of 22.13 years (SD = 4.22 years). The 156 undergraduate nursing students were statistically significantly older than the general undergraduate student body by 2 years (SE = .781, p = .011). The sample selected as representative of the student body was not statistically different from the general undergraduate student body on the variables of gender or racial diversity, with the undergraduate population reporting as 60.8% White and the representative sample reporting as 68% White. The nursing student sample reported as 75.6% White, which was significantly less diverse than the undergraduate student body, χ2(1) = 13.1124, p = .0003. Eighty-eight percent of students in both samples were upperclassmen (0% first year, 12% second year).
The NCHA-II (ACHA, 2011) was used for the assessment. The survey is an 11-page Scantron® booklet, with more than 300 questions pertaining to the various health states and practices of students. The survey was originally developed in 1998 as part of a national effort to gauge the health of college students in the United States, using the Centers for Disease Control and Prevention's National College Health Risk Behavior Survey, among several other assessments. Reliability analyses of the original NCHA-II findings revealed consistent standardized alphas and average inter-item correlation coefficients when compared with the National College Health Risk Behavior Survey (ACHA, 2003). For the purpose of this study, questions 30 through 37 of the section of the NCHA-II related to mental health were used to answer the research questions.
Surveys were administered during the middle of the spring semester during a class meeting. Researchers (M.L.B., H.T.) were present during the administration and collected surveys from students upon completion. Completed surveys were then mailed to the ACHA's National College Health Assessment data analysis center for analysis, where they were scanned and entered into an SPSS® data form. Both the hard-copy executive summaries and the data booklet were then sent back to the researchers for additional analyses.
Results were analyzed to test the stated hypotheses using a variety of statistical techniques from the SPSS version 21 statistical package. Descriptive statistics were first used to compare participant samples. Chi-square analyses were conducted to compare observed frequencies with expected frequencies among dichotomous variables. Nonparametric statistical analyses, such as the Mann-Whitney U test, were used to compare the two student groups among ordinal variables.
As was hypothesized, nursing students reported a greater experience of stress and higher stress levels than the general student body in the past year. Using a 5-point scale of 1 (no stress) to 5 (tremendous stress), the Mann-Whitney U test was run to determine whether differences existed in the overall level of stress experienced within the past 12 months score between nursing and general students. Distributions of the scores for general students and nursing students were similar, as assessed by visual inspection. The median score was statistically significantly different between non-nursing students (median = 3) and nursing students (median = 4), U = 3302, z = −5.057, p < .001. Of note, although 6.9% of the general student body sample rated as having experienced no stress in the past 12 months, not a single nursing student rated as such. Further, the same percentage of the general student body experiencing no stress (6.9%) also rated having experienced tremendous stress (6.9%) in the past 12 months, indicating a normal distribution of stress among the student body. Nursing students exhibited a non-normal left skewed distribution, with 52.3% experiencing above-average stress and 17.6% experiencing tremendous stress.
Relating to stress in academics, as was hypothesized, nursing students reported significantly more stress impacting academics than did general students, χ2(1) = 15.144, p = .0001. In examining stress-related issues and illnesses also impacting academics, chi-square analyses indicated that nursing students had significantly more anxiety affecting academics, χ2(1) = 13.715, p = .0002, and significantly more sleep disturbances affecting academics, χ2(1) = 5.195, p = .023. Nursing students also had more stress-related issues and illnesses, such as migraines, χ2(1) = 5.412, p = .019, and upper respiratory tract infections, χ2(1) = 5.986, p = .014, which was significant at a p value of .05, but not at .01. No statistical difference was found between groups in depression affecting academics. It is also important to note that there was no statistically significant difference (p < .01) between the student groups in thinking academics were too difficult to handle.
In examining general mental health, it was evident that the study sample of nursing students experienced significantly more diagnoses and treatment for anxiety in the past 12 months than did the general student body, χ2(1) = 7.5589, p = .006. No difference was noted between the groups in the diagnoses and treatment for either depression or panic attacks. In comparing likelihood to seek treatment from a mental health professional, no difference was found between groups.
To explore possible sources of stress outside of academics, such as family, work, and athletic responsibilities, the nursing students and general students were compared on the factors of marital status and outside employment for pay. Significantly more nursing students were married than the general student body population (χ2(1) = 8.241, p = .004). The Mann-Whitney U test was run to determine whether there were differences in hours per week worked for pay between the nursing and general students. Distributions of the scores for general students and nursing students were roughly similar, as assessed by visual inspection. Median score was statistically significantly different between general student body (median = 4) and nursing students (median = 3, U = 4282.5, z = −2.189, p = .029), indicating that the general student body is actually working more hours for pay than are nursing students. Also, the general student body had significantly more college student–athletes than did the nursing student population (χ2(1) = 25.821, p < .001).
The results of the current study support several of the proposed hypotheses. Particularly, nursing students reported higher stress levels, higher stress levels affecting academics, and more stress-related symptoms, such as anxiety, migraines, and illnesses than was evident in the general student body. Because there was no difference in the two groups rating academics as being too difficult to handle, this study also further explored the additional sources of stress for nursing students.
The current study echoes the results of Bryer et al. (2013) in that the nursing student population represents more students embodying the nontraditional student characteristic set of being older and married with families (χ2(1) = 8.241, p = .004) (Jeffreys, 1998, as cited in Bryer at al., 2013), which may connote more responsibilities at home. However, the nursing students and general students did not exhibit significant differences in employment status (defined as working more than 10 hours per week for pay), with additional analyses indicating that nursing students are working fewer hours than the general student body. Also, compared with the nursing students, more of the general student body was involved in intercollegiate sports, which has been noted as particularly stressful for college students, given the time demand and role conflicts (Dubuc-Charbonneau & Durand-Bush, 2015; Galli & Reel, 2012).
A shortcoming of this study was the lack of data about whether students had children, which could be a significant responsibility and stressor (Pryjmachuk & Richards, 2007). The differences on measures of stress and mental health may be partially influenced by the differing demographic of the students versus the nursing program itself (e.g., more females than males), but as this study demonstrates, other factors may be at play, contributing to higher stress levels in nursing students than the academics, as echoed in Pryjmachuk's and Richards' (2007) study. As suggested in the literature, potential additional sources of stress and anxiety are balancing relationships with academic demands, worry about the labor market (Jesus et al., 2012), role confusion, gender discrimination, attitudes of medical personnel and patients, comparison between fellow students, differentiating between theory and practice, and worry about the problems of the practice environment (Hyoung, Ju, & Im, 2014). Regardless of cause, the current study supports the existing literature, where higher levels of stress and mental health issues are reported in nursing students, compared with the general student body.
The current study represents a small sample of nursing students in a particular region in the United States. Much of the research found in the literature is international. Further research should be conducted to determine whether the trend of nursing students' higher levels of stress, anxiety, sleep disturbances, and stress-related illnesses, compared with the general student body, is evident in other universities and geographical regions, and how similar or different nursing programs are from nation-to-nation to gauge the generalizability of such research. It is recommended that an assessment geared toward the specific responsibilities of being a nursing student, versus a general college student also be used to examine the unique experience and stressors of a nursing student compared with the general student body.
Conclusion and Future Recommendations
This study adds to the growing body of evidence that nursing school is a uniquely stressful experience, although the complete picture of the sources of stress remains unclear. Efforts to eliminate the sources of stress may be unrealistic, given the high-stakes nature of nursing work. However, assisting students to more successfully manage their stress and develop successful coping strategies may not only decrease the impact of the stress response, anxiety, and other negative health experiences but can increase resilience as they progress through their respective programs. Furthermore, including stress reduction and self-care techniques throughout the nursing curriculum may provide the necessary foundation for improving stress management in the workplace and increasing longevity and satisfaction in the profession. Additional experimental studies examining interventions that are effective in decreasing stress, anxiety, and depression, as well as related health problems, are important to add to the body of knowledge on this subject. Finally, further research is needed of the extent to which nursing students are already caring for themselves in health-promoting ways, if at all.
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