Journal of Psychiatric and Mental Health Nursing, 2015, 22, 590–598
The prevalence and related factors of depressive symptoms among junior college nursing students: a cross-sectional study C . - J . C H E N 1 P h D , Y. - C . C H E N 2 P h D S t u d e n t , H . - C . S U N G 3 T . - C . H S I E H 4 P h D , M . - S . L E E 5 P h D a n d C . - Y. C H A N G 6 P h D
Ph D,
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Assistant professor, Nursing, Mackay Medical College, 3Associate professor, Nursing, Tzu Chi College of Technology, 4Associate professor, Institute of Medical Sciences, Tzu Chi University, 5Professor, Curriculum Design and Human Potentials Development, National Dong-Hwa University, and 6Professor, Children Development and Family Education, Tzu Chi University, Taiwan, and 2PhD Student, Institute of Occupation Therapy, National Taiwan University, Taiwan
Keywords: cross-sectional design, depressive symptoms, factors, nursing
Accessible summary
student, quantitative
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Correspondence: H.-C. Sung
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Nursing Tzu Chi College of Technology & Taiwanese Center of Evidence-based Health Care No. 880, Sec 2, Chien-Kuo Rd
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Hualien 970 Taiwan E-mail: [email protected] Accepted for publication: 10 June 2015 doi: 10.1111/jpm.12252
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The process of nursing professional training may cause emotional stress on nursing students, potentially resulting in depressive symptoms. As the problems of nurse shortage and increase of nursing student graduates who tend not to pursue nursing career continue to exist, it is important for nursing educators to investigate the factors causing depressive symptoms, and further develop strategies to manage their stress and depressive problems. The prevalence of depressive symptoms among junior college nursing students in Taiwan is high. Grade point average, interest in nursing, interest in clinical placement, career planning after graduation, relieving stress by overeating, sleep quality, stress, and anxiety were correlated with depressive symptoms. Sleep quality, stress, and the degree of anxiety can predict the degree of depressive symptoms among young nursing students in Taiwan. Development of proper strategies to help young nursing students manage stress, anxiety, and facilitate better learning experiences tailored to their problems and needs may be helpful for alleviation or prevention of depressive symptoms.
Abstract Nursing students have particularly experienced stressful lives during nursing education. This cross-sectional study aimed to investigate depressive symptoms and related factors in junior college nursing students. A total of 625 nursing students from a junior college in Taiwan were assessed by Pittsburgh Sleep Quality Index, Adolescent Depression Inventory, Situational Anxiety Scale and the Taiwanese-Chinese version of Stress in Nursing Students Scale. The results showed that (1) the prevalence of depressive symptoms among junior college nursing students was 32.6%; (2) depressive symptoms are significantly related to grade point average, interest in nursing, interest in their clinical placement, career planning after graduation, overeating as a stress-relief strategy, sleep problems, stress, and anxiety; and (3) anxiety, sleep quality, and stress are three major variables that can significantly predict depressive symptoms. Psychological factors may influence young nursing students’ willingness to seek assistance from teachers. These factors should be considered when designing strategies to promote their emotional health and well-being. Nursing educators can plan appropriate strategies tailored to junior college nursing students’ problems and needs, which thereby may facilitate learning experience and prevent depressive symptoms.
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© 2015 John Wiley & Sons Ltd
Depressive symptoms among nursing students
Introduction Depression is the ‘cancer of the twenty-first century’ (World Health Organization, 2012). Early-onset mental disorders have become an important public health problem (Van Bergh & Van Calster 2009). An epidemiological study by Miller (2007) observed that 20% of adolescents in the United States suffered from a major depressive disorder. In Taiwan, around 22.2% of college students had suffered from depression and required professional help (John Tung Foundation 2008). Young students have previously been shown more likely to exhibit depression and anxiety (Morrison & O’Connor 2005). Nursing students have particularly experienced stressful lives during nursing education training (Shikai et al. 2009). In Greece, 43.9% of the nursing students suffered from depressive symptoms (Chrysoula et al. 2011). In Cyprus, 61.8% of nursing students suffered from depressive symptoms, with 30.9% as mild, 24.5% as moderate, 6.4% as severe level (Papazisis et al. 2014). It was reported that learning experiences and stress during clinical placement affected nursing students’ performance, emotional state, and their willingness to pursue a career in nursing (Lei et al. 2000). In Taiwan, nursing students from 5-year junior colleges constitute over half of the nursing student population, and they are the majority of newly employed nursing workforce. Similar to many Asian countries, such as China, this group of nursing students are younger, aged around 16–20 years, fresh graduates from junior high schools, with different learning and coping patterns compared to matured nursing students. Unfortunately, a survey indicated that 65.4% of nursing students in Taiwan reported that they would not choose nursing as a career after graduation due to many reasons, such as stress and unpleasant experiences during clinical placement (Lai et al. 2006). This can further devastate the nursing shortage problems in Taiwan. World Health Organization (2006) estimated a shortage of over 4.3 million nurses worldwide. As the problems of nurse shortage and increase of nursing student graduates who tend not to pursue nursing career continue to exist, it is important for nursing educators to find out the factors which may cause depressive symptoms among nursing students, and further develop strategies to effectively manage nursing students’ stress and depressive problems during their nursing education (Hsiao et al. 2012). Therefore, this study aimed to explore the problems of depressive symptoms and related factors among junior college nursing students.
Literature review Depression accounts for one million deaths from suicide each year globally (World Health Organization 2012). It © 2015 John Wiley & Sons Ltd
was reported that suicide is the third leading cause of death in the 15- to 24-year age group (Centers for Disease Control and Prevention 2013). Depression is a common mental disorder, characterized by sadness, loss of interest or pleasure, feelings of guilt or low self-worth, disturbed sleep or appetite, feelings of tiredness, and poor concentration (World Health Organization 2015a). An adolescent, defined as aged 10–19 years inclusive (World Health Organization 2015b), who suffer from depression, often exhibits physiological symptoms, including decreased appetite, weight loss, and poor sleep quality (Fava 2004). Researchers have emphasized that nursing education can be stressful for students, (e.g. Beck & Srivastava 1991); thus, nursing students can be characterized as potentially prone to depression because of their risk factors of female gender and high stress. Depression often results from severe or long-term stressful life events (Anna et al. 2010). The process of professional training for nursing students is stressful. Reeve et al. (2013) emphasized that nursing education may cause emotional stress and place pressure on students, potentially resulting in depression. Ross et al. (2005) found that stress is positively correlated with depression among nursing students in Thailand. Stressful life events are related to depression and anxiety in nursing students (Stoen et al. 2013). Nursing students experience the most pressure during clinical placement training. During this period, nursing students encounter the same pressures as nurses (Sawatzky 1998, Wang et al. 2010). A study of depression among adolescents observed higher depression levels in students with low grades (Vogel et al. 2003). This result reflects the correlation between grade point average and depression in this population. These authors also observed that the main causes of depression included academic overload and worry about the future. Chrysoula et al. (2011) observed a correlation between career planning after graduation and depressive symptoms in nursing students, whereas Furegato et al. (2008) observed a correlation between the extent to which the students enjoyed nursing or clinical practice and depression. Other factors can also influence depressive symptoms in nursing students. Wang et al. (2010) indicated that the degree to which nursing students were able to relieve pressure or engage in recreational activities correlated with depression. One study found high prevalence of depressive symptoms among young college nursing students in China, and stress from academic performance and poor perspective towards career prospect were the major factors related to depressive symptoms (Xu et al. 2014). However, studies indicated that more than 70% of adolescents with depressive disorders do not receive appropriate healthcare professional assistance (Washington 2010). 591
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There are limited studies on prevalence and correlates of depressive symptoms among young junior college nursing students in Taiwan. The majority of the junior college nursing students in Taiwan are female, fresh graduates from junior high schools, aged around 16–20 years. This population of junior college nursing students is very different from nursing students who are more mature, married, with prior work experiences in other studies (Furegato et al. 2008, Christensson et al. 2011). Thus, this study aims to examine the prevalence of depressive symptoms and to identify factors associated with depressive symptoms among junior college nursing students in Taiwan.
Methods Design The study was cross-sectional and correlational in design. The paper was prepared according to the STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) standards of reporting observational studies.
Sample and setting A total of 700 nursing students from a junior college in central Taiwan were recruited, and 625 completed the questionnaires. For multiple linear regression, 20 participants per independent variable is recommended (Feinstein 1996). The reason that the sample size rule of thumb for multiple linear regression is based on study participants rather than numbers of outcome as with logistic regression is that with linear regression all participants as having experienced the outcome can be considered (Katz 2011). Participants who have missing values on one variable are more likely to have missing values on other variables. Therefore, the number of cases that will need to be dropped will likely be less than 100 (Katz 2011). This exploratory study considered 13 variables. The required sample size is the number of variables multiplied by 20 plus 100. The predicted response rate was approximately 45%. The required sample size was estimated to be greater than 558. The inclusion criteria were (1) junior college nursing students, (2) the ability to communicate in Mandarin or Taiwanese, and (3) willingness to participate in this study. Students who had been diagnosed with hearing loss or cognitive impairment and affected their ability to participate in the study were excluded.
Instruments The questionnaire consisted of a demographic sheet, Adolescent Depression Inventory (ADI), Situational Anxiety 592
Scale, Taiwanese–Chinese Version of the Stress in Nursing Students Scale (TC-SINS), and Pittsburgh Sleep Quality Index (PSQI). ADI Adolescent Depression Inventory (ADI), developed by Taiwanese researchers (Huang & Hsu 2003), is a commonly used scale to assess depressive symptoms in adolescents or teens in Taiwan. Therefore, ADI was used in this study to assess this problem for the population of young junior college nursing students in Taiwan instead of other depression assessment tools. This scale consists of 20 questions to assess depressive symptoms based on individual experiences over the past month using a 2-point scoring system. Higher scores indicated a greater degree of depression. A total score of 7 points or less is classified as minimal, 8–12 points as mild depression; 13–18 points as moderate depression, and a total score of 19 points or more as severe depression, indicated as high risk with needs for further professional evaluation. The cut-off point is 8. This scale is easy to administer with good acceptance by users in the public health domain. The internal consistency coefficient of the scale was 0.86, and the test–retest reliability was 0.76 (Huang & Hsu 2003). Situational anxiety scale The Situational Anxiety Scale was adapted from Spielberger’s Situational Trait Anxiety Scale by Chung & Long (1984). This scale comprises 20 questions scored on a 4-point Likert scale. The lowest possible score is 20 points, and the highest possible score is 80 points. A score of 20–39 indicates a low level of anxiety, a score of 40–59 indicates a moderate level of anxiety, and a score of 60–80 indicates a high level of anxiety. This scale has a good internal consistency (α = 0.898) (Chung & Long 1984). TC-SINS The TC-SINS is a Chinese translation of the SINS by Sung et al. (2013) developed for use with the nursing students in Taiwan. The original SINS was developed by Deary et al. in 2003 to measure the perception of stress among nursing students. This scale includes 43 5-point Likert-type items and scores range from 43 to 215 points. A higher score indicates greater stress. This scale has a good internal consistency, with a Cronbach’s α > 0.7 (Deary et al. 2003, Watson et al. 2008, 2010, Salomonson et al. 2011). The TC-SINS has a Cronbach’s alpha coefficient of 0.927, reflecting good internal consistency (Sung et al. 2013). PSQI The PSQI is a self-reported questionnaire developed by Buysse et al. (1989) that has been widely used in the clinical © 2015 John Wiley & Sons Ltd
Depressive symptoms among nursing students
evaluation of sleep quality. Scores were calculated using a range of 0–3 points for each section, and the total score of the seven sections ranged from 0 to 21 points. The students with a total score less than or equal to 5 were considered good sleepers. Higher scores indicated worse sleep quality. The overall reliability coefficient of this scale (Cronbach’s α) was 0.83, the diagnostic sensitivity was 89.6%, and the specificity was 86.5% (Buysse et al. 1991, Wilcox & King 1999). In this study, the Chinese version of the PSQI was used. The internal consistency coefficient was 0.83, and the test–retest reliability was 0.85 (Wu 2004).
Data collection The survey was conducted in a junior college in central Taiwan. After the study was approved by a hospital Institutional Review Board (IRB) in Taiwan, the school’s research and development centre was contacted. Consent and approval to conduct the study were obtained from the school’s research committee. A researcher assigned a list of members in the accessible population of 2201 samples to the sampling frame and then used the multistage random sampling method of selection to choose classes and names by computer randomly. A multistage random sampling method was applied to obtain the random sample, and samples with equal probability were selected using the two-stage stratified random sampling method. The twostage sampling process selected four classes from each year of the 5 years of the junior nursing programme, and then randomly selected 35 students from each class. Potential participants were explained about the study purposes and procedures by the researcher in each class with the assistance of the school counsellor from the counselling centre. Participants who provided informed consent were recruited. A total of 625 junior college nursing students completed the questionnaires.
Data analysis The data were analysed using SPSS 15.0 for Windows (SPSS Inc., Chicago, IL). Descriptive statistics were used to analyse the participants’ demographic factors. Spearman’s rank-order correlation coefficient (rs) was performed to examine the linear relationship. The point-biserial correlation coefficient (rpb) was used for dichotomous variables. Pearson’s product-moment correlation coefficient (r) was used to determine the linear relationship between two continuous variables. A multivariable stepwise regression model was used to estimate the association between statistically significant variables. © 2015 John Wiley & Sons Ltd
Ethical consideration This study was approved by a hospital IRB in Taiwan. The participants were informed of the study’s purposes and procedures. All participants were informed their participation was voluntary, that participation in this study was not connected to the school curriculum, and that their academic outcomes would not be affected by whether they participated in the study. The participants were also informed that the questionnaires used in this study would not reveal their names and would only use serial numbers. Informed consent was obtained from each participant after the study purpose and methods had been explained.
Results A total of 700 nursing students between the ages of 16 and 20 years were recruited, and 625 nursing students completed the assessment, with a response rate of 89.2%. The participants’ mean age was 17.42 years (SD = 1.03). The majority of the participants (94.6%) were female. Of the participants, 42.6% were ranked between 11% and 25% in their class for academic performance. Over half of the participants (50.7%) reported that they liked nursing, but less than half reported that they liked their clinical placement (Table 1).
Depressive symptoms and stress in junior college nursing students Our study found that 32.6% had a score higher than or equal to 8 points on the ADI, indicating that they had depressive symptoms. Among these nursing students with depressive symptoms, there were 22.9% with mild level, 8.9% with moderate level, and 0.8% with severe level of depressive symptoms (Table 2). The mean score for the participants’ stress level (TCSINS) was 120.78 (SD = 28.47), indicating that the students had moderate levels of stress. The mean stress score in the nursing students without depressive symptoms (N = 421) was 117.69 (SD = 26.29). The mean stress score in the nursing students with depressive symptoms (N = 204) was 127.15 (SD = 28.36).
Demographic factors related to depressive symptoms Correlations were found between depressive symptoms and the following variables: ‘grade point average’ (rs = 0.104, P = 0.009), ‘interest in nursing’ (rs = −0.113, P = 0.005), and ‘interest in clinical placement’ (rs = −0.123, P = 0.002). ‘Career planning after graduation’ (rpb = 0.107, P = 0.008) and ‘stress relief strategies–overeating’ (rpb = 0.100, P = 593
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Table 1 Demographic characteristics of the participants (N = 625)
Table 3 Correlation between depressive symptoms and demographic factors
Characteristics
M
SD
Variables
rpb (P)
rs (P)
Age (years) Characteristics Gender Male Female Grade point average 2.6–4.0 1.6–2.5 1.1–1.5 0–1.0 Learning status Attending lectures on campus Clinical placement Interest in nursing Like it very much Like it Average Do not like it Dislike it very much Career planning after graduation Nursing Studying for an advanced nursing degree Studying for a non-nursing degree Undecided Stress-relief strategies Sleeping Shopping Overeating Seeking assistance from classmates Seeking assistance from teachers
17.42 N
1.03 %
– −0.055 (0.168)
−0.104** (0.009) –
34 591
5.4 94.6
167 266 128 64
26.7 42.6 20.5 10.2
– – 0.107** (0.008)
−0.113** (0.005) −0.123** (0.002) –
400 225
64.0 36.0
50 317 240 14 4
8.0 50.7 38.4 2.2 .6
Grade point average Learning status (attending lectures on campus/clinical placement) Interest in nursing Interest in clinical placement Career planning after graduation (Yes/No) Stress-relief method Sleeping (Yes/No) Shopping (Yes/No) Overeating (Yes/No) Seeking assistance from classmates (Yes/No) Seeking assistance from teachers (Yes/No)
111 353 27 134
17.8 56.5 4.3 21.4
357 268 183 480 23
27.2 20.4 14.0 36.6 1.8
Table 2 Cut-off point of the ADI to detect depression levels of the participants (N = 625) Depression level
Cut-off
N
%
Minimal Mild Moderate Severe Total
≦7 8–12 13–18 ≧19
421 143 56 5 625
67.36% 22.88% 8.96% 0.8% 100%
ADI, Adolescent Depression Inventory.
0.012) were also statistically significant, indicating that depressive symptoms are significantly related to grade point average, interest in nursing, interest in clinical placement, career planning after graduation, and the stress relief strategy of overeating (Table 3).
The correlation between depressive symptoms and sleep quality, stress, and anxiety Depressive symptoms were positively correlated with poor sleep quality, stress, and anxiety. The coefficient of determination for ‘sleep quality’ was r2 = 0.513, indicating that sleep quality could explain 51.3% of the total variation in depressive symptoms. Depressive symptoms and stressors 594
−0.004 (0.911) −0.015 (0.712) 0.100* (0.012) −0.059 (0.138)
– – – –
−0.043 (0.281)
–
rs, Spearman’s rank order correlation coefficient; rpb, Point-biserial correlation coefficient. *P < 0.05; **P < 0.01; ***P < 0.001.
Table 4 Correlation between depressive symptoms and sleep quality, stress, and anxiety Variables
r
P
r2
Sleep quality Stress Anxiety
0.716*** 0.632*** 0.730***
0.000 0.000 0.000
0.513 0.397 0.533
r2, coefficient of determination. ***P < 0.001 (two tailed).
showed a significant positive correlation, with the coefficient r = 0.632 (P = 0.000) and the coefficient of determination r2 = 0.397, indicating that stress could explain 39.7% of the total variation in depressive symptoms. Depressive symptoms and anxiety showed a significant positive correlation, with the coefficient r = 0.730 (P = 0.000) and the coefficient of determination r2 = 0.533, indicating that anxiety could explain 53.3% of the total variation in depressive symptoms (Table 4).
Predictors of depressive symptoms According to the predictive regression analysis (stepwise regression with multiple variables), the individual regression coefficients of the independent variable in each regression mode was statistically significant. In mode 1, the independent variable in the regression equation was ‘anxiety’, with an interpretive power of 29.1%; in mode 2, the independent variables in the regression equation were ‘anxiety’ and ‘sleep quality’, with a combined interpretive power (R2) of 41.5%, and the interpretative power of the independent variable ‘sleep quality’ (R2) was 12.4%. In mode 3, the independent variables in the regression © 2015 John Wiley & Sons Ltd
Depressive symptoms among nursing students
Table 5 Stepwise regression with multiple variables between depressive symptoms and sleep quality, stress, and anxiety Variable Intercept 1. Anxiety 2. Sleep quality 3. Stress
R 0.540 0.644 0.660
R2 0.291 0.415 0.435
ΔR2 0.291 0.124 0.020
F 253.423 218.465 157.961
ΔF
SE (B)
Beta (β)
Tolerance
VIF
253.423*** 130.371*** 22.033***
6.674 0.137 0.566 0.024
0.357 0.350 0.158
0.778 0.866 0.813
1.286 1.155 1.231
R, multiple correlation coefficient; R2, explanatory power of the variable; Beta, standardized regression coefficient; VIF, variance inflation factor. ***P < 0.001.
equation were ‘anxiety’, ‘sleep quality’, and ‘stressors’, which had a combined interpretive power (R2) of 43.5%; the interpretive power for the independent variable ‘stressors’ (R2) was 2%. Based on the individual predictive powers, the variables with the greatest predictive power for depressive symptoms were ‘anxiety’, ‘sleep quality’, and ‘stressors’, in descending order. The F values were 253.423 (P < 0.001), 218.465 (P < 0.001), and 157.961 (P < 0.001), respectively, all of which reached the level of significance. According to the standardized regression coefficients, the β values of the three predictive variables in the regression modes were positive (0.357, 0.350, and 0.158, respectively), indicating that their effects on depressive symptoms were positive (Table 5).
Discussion Our result showed that 32.6% of junior college nursing students in Taiwan reported high score on the ADI (8 or above), indicating that they had depressive symptoms. The prevalence of depressive symptoms is higher than that of college nursing students in China (22.9%) (Xu et al. 2014). Our result is consistent with the findings of Shikai et al. (2009) and Furegato et al. (2008), whose studies found that among young student populations, nursing students have particularly stressful lives. As mentioned earlier, the majority of nursing students in Taiwan are younger, fresh graduates from junior high schools, with different learning and coping patterns compared to matured nursing students. Asian societies have contexts different from those in the West. The average age of the nursing students in our study was 17.4 years old. Depressive symptoms may occur more commonly in this population because they were younger and less mentally resilient. The experience of taking care of the sick, interacting with patients and healthcare professionals, and dealing with death during clinical placement at a young age may have caused greater stress and psychological problems for our young junior college nursing students compared to more matured nursing students in western countries. Our study found that factors significantly associated with depressive symptoms were grade point average, inter© 2015 John Wiley & Sons Ltd
est in nursing, interest in their clinical placement, career planning after graduation, overeating as a stress-relief strategy, sleep problems, stress, and anxiety. Our study observed that grade point average had a significant negative correlation with depressive symptoms, which is consistent with the findings of Vogel et al. (2003), in which higher depression scores were associated with lower grades. Our result is also consistent with previous study conducted among young nursing students in China (Xu et al. 2014), in which academic stress was strongly associated with depressive symptoms. In our study, interest in nursing and interest in clinical placement were significantly related to depressive symptoms. This result is consistent with the findings of Furegato et al. (2008) that attending specialized courses or practice opportunities reflects the extent of students’ interest in nursing or clinical placement. This recognition and affirmation of the nursing profession helps to prevent depression. In addition, career planning after graduation was found to be correlated with depressive symptoms in our study. This finding is consistent with the findings of Chrysoula et al. (2011). Chrysoula et al. (2011) found that uncertainty regarding career planning after graduation caused more anxiety and fear and led to depression among nursing students. Consistent with previous studies (Lee & Ye 2010, Martin et al. 2010, Huang et al. 2011), our study results showed that there was strong relationship between sleep quality, stress, and anxiety with depressive symptoms. Our study results also found that sleep quality, stress, and anxiety were the major predictors of depressive symptoms among nursing students. Nursing education may cause emotional stress, and emotional stress can affect sleep quality. Poor sleep quality is also associated with the occurrence and relapse of depression and with poor treatment (Buysse et al. 2001). Furthermore, our study results related to stress level were similar to the findings of Beck and Srivastava (1991) and Ross et al. (2005), in which nursing education was shown to cause emotional stress, and potentially result in depression among nursing students. The severity of stress also has a direct predictive effect on the degree of depression. Won & Kim (2002) observed that 595
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stress can cause physical and emotional problems, such as severe anxiety, nervousness, and depression. Randle (2003) observed that in the professional education of nursing students, clinical placement is particularly likely to cause anxiety because the students lack the knowledge and experience necessary to successfully face an unfamiliar hospital environment and assume responsibility for patient care. A study by Leadbeater et al. (2012) identified a significant correlation between anxiety and depression. Our results regarding anxiety are similar to the results of Fang’s study (2011), in which a close relationship between anxiety and depression was found. Our findings are also consistent with those of Randle (2003), in which complex interpersonal relationships, heavy workloads, academic training, the physical environment of the clinical placement, and a competitive work environment were found to cause anxiety among nursing students. When anxiety becomes increasingly severe, the level of depressive symptoms increases. Sleep quality has direct power for predicting the degree of depressive symptoms among nursing students, as noted by Fava (2004), who observed that changes in mood are primarily related to sleep problems. Adolescents with depressive symptoms are more likely to suffer from insomnia. Buysse et al. (2001) also indicated that poor sleep quality is related to the occurrence, recurrence, and poor treatment efficacy of depression. Our results showed that relieving stress by overeating was associated with depressive symptoms, and is consistent with the finding of Gan et al. (2011). Eating to relieve stress is generally an unplanned activity (Rampersaud et al. 2005). Furthermore, the factor of seeking assistance from teachers is worth discussing. Our result is different from that of Washington (2010). In our study, the nursing students were younger and did not know how to actively seek assistance from teachers. Alternatively, this difference may be explained by cultural differences between eastern and western cultures. Adolescents in Taiwan tend to be more passive and less outspoken compared to those in western countries. Young nursing students in Taiwan may hesitate to seek for help and guidance when they experience stress and problems during their nursing training at school. Psychological factors may influence nursing students’ willingness to seek assistance from teachers across racial and ethnic groups. Therefore, these factors should be considered when designing strategies to promote emotional health and well-being among young nursing students. The potential limitation of this study is its crosssectional design. This design has made it difficult to make reference in regard to causality of depressive symptoms. In addition, the sample was limited to younger nursing stu596
dents in one junior college in central Taiwan, which may have introduced a bias regarding the population and limited the generalization of the study results. Future research can be expanded towards the investigation and comparisons of all nursing students including young junior college nursing students (adolescents) and university nursing students (young adults). Due to the nature of selfreported measures, the study results have to be interpreted cautiously. Furthermore, a quantitative exploration of stress and depressive symptoms among nursing students may not be sufficient to allow a comprehensive understanding of nursing students’ experiences and problems in academic settings and clinical placement; therefore, qualitative research is required to explore this phenomenon in greater detail.
Conclusion The results of this study indicate that the prevalence of depressive symptoms among junior college nursing students in Taiwan is high. Grade point average, interest in nursing, interest in clinical placement, career planning after graduation, relieving stress by overeating, sleep quality, stress, and anxiety were correlated with depressive symptoms among young nursing students. Sleep quality, stress, and the degree of anxiety can predict the degree of depressive symptoms among young nursing students in Taiwan. This study also has important implications for health promotion and disease prevention among nursing students. Nursing educators should be aware of the problems and related factors of depressive symptoms among junior college nursing students. Development of proper strategies to help young nursing students manage stress, anxiety, and facilitate better learning experiences tailored to their problems and needs may be helpful for alleviation or prevention of depressive symptoms. The efforts to help young nursing students deal with stress and prevent depressive symptoms may promote the completion of nursing education programmes and inspire them to remain in a nursing career after graduation.
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Conflicts of interest All authors have no personal or financial conflicts of interest to declare. © 2015 John Wiley & Sons Ltd
Depressive symptoms among nursing students
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© 2015 John Wiley & Sons Ltd
The prevalence and related factors of depressive symptoms among junior college nursing students: a cross-sectional study C . - J . C H E N 1 P h D , Y. - C . C H E N 2 P h D S t u d e n t , H . - C . S U N G 3 T . - C . H S I E H 4 P h D , M . - S . L E E 5 P h D a n d C . - Y. C H A N G 6 P h D
Ph D,
1
Assistant professor, Nursing, Mackay Medical College, 3Associate professor, Nursing, Tzu Chi College of Technology, 4Associate professor, Institute of Medical Sciences, Tzu Chi University, 5Professor, Curriculum Design and Human Potentials Development, National Dong-Hwa University, and 6Professor, Children Development and Family Education, Tzu Chi University, Taiwan, and 2PhD Student, Institute of Occupation Therapy, National Taiwan University, Taiwan
Keywords: cross-sectional design, depressive symptoms, factors, nursing
Accessible summary
student, quantitative
•
Correspondence: H.-C. Sung
•
Nursing Tzu Chi College of Technology & Taiwanese Center of Evidence-based Health Care No. 880, Sec 2, Chien-Kuo Rd
•
Hualien 970 Taiwan E-mail: [email protected] Accepted for publication: 10 June 2015 doi: 10.1111/jpm.12252
•
The process of nursing professional training may cause emotional stress on nursing students, potentially resulting in depressive symptoms. As the problems of nurse shortage and increase of nursing student graduates who tend not to pursue nursing career continue to exist, it is important for nursing educators to investigate the factors causing depressive symptoms, and further develop strategies to manage their stress and depressive problems. The prevalence of depressive symptoms among junior college nursing students in Taiwan is high. Grade point average, interest in nursing, interest in clinical placement, career planning after graduation, relieving stress by overeating, sleep quality, stress, and anxiety were correlated with depressive symptoms. Sleep quality, stress, and the degree of anxiety can predict the degree of depressive symptoms among young nursing students in Taiwan. Development of proper strategies to help young nursing students manage stress, anxiety, and facilitate better learning experiences tailored to their problems and needs may be helpful for alleviation or prevention of depressive symptoms.
Abstract Nursing students have particularly experienced stressful lives during nursing education. This cross-sectional study aimed to investigate depressive symptoms and related factors in junior college nursing students. A total of 625 nursing students from a junior college in Taiwan were assessed by Pittsburgh Sleep Quality Index, Adolescent Depression Inventory, Situational Anxiety Scale and the Taiwanese-Chinese version of Stress in Nursing Students Scale. The results showed that (1) the prevalence of depressive symptoms among junior college nursing students was 32.6%; (2) depressive symptoms are significantly related to grade point average, interest in nursing, interest in their clinical placement, career planning after graduation, overeating as a stress-relief strategy, sleep problems, stress, and anxiety; and (3) anxiety, sleep quality, and stress are three major variables that can significantly predict depressive symptoms. Psychological factors may influence young nursing students’ willingness to seek assistance from teachers. These factors should be considered when designing strategies to promote their emotional health and well-being. Nursing educators can plan appropriate strategies tailored to junior college nursing students’ problems and needs, which thereby may facilitate learning experience and prevent depressive symptoms.
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© 2015 John Wiley & Sons Ltd
Depressive symptoms among nursing students
Introduction Depression is the ‘cancer of the twenty-first century’ (World Health Organization, 2012). Early-onset mental disorders have become an important public health problem (Van Bergh & Van Calster 2009). An epidemiological study by Miller (2007) observed that 20% of adolescents in the United States suffered from a major depressive disorder. In Taiwan, around 22.2% of college students had suffered from depression and required professional help (John Tung Foundation 2008). Young students have previously been shown more likely to exhibit depression and anxiety (Morrison & O’Connor 2005). Nursing students have particularly experienced stressful lives during nursing education training (Shikai et al. 2009). In Greece, 43.9% of the nursing students suffered from depressive symptoms (Chrysoula et al. 2011). In Cyprus, 61.8% of nursing students suffered from depressive symptoms, with 30.9% as mild, 24.5% as moderate, 6.4% as severe level (Papazisis et al. 2014). It was reported that learning experiences and stress during clinical placement affected nursing students’ performance, emotional state, and their willingness to pursue a career in nursing (Lei et al. 2000). In Taiwan, nursing students from 5-year junior colleges constitute over half of the nursing student population, and they are the majority of newly employed nursing workforce. Similar to many Asian countries, such as China, this group of nursing students are younger, aged around 16–20 years, fresh graduates from junior high schools, with different learning and coping patterns compared to matured nursing students. Unfortunately, a survey indicated that 65.4% of nursing students in Taiwan reported that they would not choose nursing as a career after graduation due to many reasons, such as stress and unpleasant experiences during clinical placement (Lai et al. 2006). This can further devastate the nursing shortage problems in Taiwan. World Health Organization (2006) estimated a shortage of over 4.3 million nurses worldwide. As the problems of nurse shortage and increase of nursing student graduates who tend not to pursue nursing career continue to exist, it is important for nursing educators to find out the factors which may cause depressive symptoms among nursing students, and further develop strategies to effectively manage nursing students’ stress and depressive problems during their nursing education (Hsiao et al. 2012). Therefore, this study aimed to explore the problems of depressive symptoms and related factors among junior college nursing students.
Literature review Depression accounts for one million deaths from suicide each year globally (World Health Organization 2012). It © 2015 John Wiley & Sons Ltd
was reported that suicide is the third leading cause of death in the 15- to 24-year age group (Centers for Disease Control and Prevention 2013). Depression is a common mental disorder, characterized by sadness, loss of interest or pleasure, feelings of guilt or low self-worth, disturbed sleep or appetite, feelings of tiredness, and poor concentration (World Health Organization 2015a). An adolescent, defined as aged 10–19 years inclusive (World Health Organization 2015b), who suffer from depression, often exhibits physiological symptoms, including decreased appetite, weight loss, and poor sleep quality (Fava 2004). Researchers have emphasized that nursing education can be stressful for students, (e.g. Beck & Srivastava 1991); thus, nursing students can be characterized as potentially prone to depression because of their risk factors of female gender and high stress. Depression often results from severe or long-term stressful life events (Anna et al. 2010). The process of professional training for nursing students is stressful. Reeve et al. (2013) emphasized that nursing education may cause emotional stress and place pressure on students, potentially resulting in depression. Ross et al. (2005) found that stress is positively correlated with depression among nursing students in Thailand. Stressful life events are related to depression and anxiety in nursing students (Stoen et al. 2013). Nursing students experience the most pressure during clinical placement training. During this period, nursing students encounter the same pressures as nurses (Sawatzky 1998, Wang et al. 2010). A study of depression among adolescents observed higher depression levels in students with low grades (Vogel et al. 2003). This result reflects the correlation between grade point average and depression in this population. These authors also observed that the main causes of depression included academic overload and worry about the future. Chrysoula et al. (2011) observed a correlation between career planning after graduation and depressive symptoms in nursing students, whereas Furegato et al. (2008) observed a correlation between the extent to which the students enjoyed nursing or clinical practice and depression. Other factors can also influence depressive symptoms in nursing students. Wang et al. (2010) indicated that the degree to which nursing students were able to relieve pressure or engage in recreational activities correlated with depression. One study found high prevalence of depressive symptoms among young college nursing students in China, and stress from academic performance and poor perspective towards career prospect were the major factors related to depressive symptoms (Xu et al. 2014). However, studies indicated that more than 70% of adolescents with depressive disorders do not receive appropriate healthcare professional assistance (Washington 2010). 591
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There are limited studies on prevalence and correlates of depressive symptoms among young junior college nursing students in Taiwan. The majority of the junior college nursing students in Taiwan are female, fresh graduates from junior high schools, aged around 16–20 years. This population of junior college nursing students is very different from nursing students who are more mature, married, with prior work experiences in other studies (Furegato et al. 2008, Christensson et al. 2011). Thus, this study aims to examine the prevalence of depressive symptoms and to identify factors associated with depressive symptoms among junior college nursing students in Taiwan.
Methods Design The study was cross-sectional and correlational in design. The paper was prepared according to the STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) standards of reporting observational studies.
Sample and setting A total of 700 nursing students from a junior college in central Taiwan were recruited, and 625 completed the questionnaires. For multiple linear regression, 20 participants per independent variable is recommended (Feinstein 1996). The reason that the sample size rule of thumb for multiple linear regression is based on study participants rather than numbers of outcome as with logistic regression is that with linear regression all participants as having experienced the outcome can be considered (Katz 2011). Participants who have missing values on one variable are more likely to have missing values on other variables. Therefore, the number of cases that will need to be dropped will likely be less than 100 (Katz 2011). This exploratory study considered 13 variables. The required sample size is the number of variables multiplied by 20 plus 100. The predicted response rate was approximately 45%. The required sample size was estimated to be greater than 558. The inclusion criteria were (1) junior college nursing students, (2) the ability to communicate in Mandarin or Taiwanese, and (3) willingness to participate in this study. Students who had been diagnosed with hearing loss or cognitive impairment and affected their ability to participate in the study were excluded.
Instruments The questionnaire consisted of a demographic sheet, Adolescent Depression Inventory (ADI), Situational Anxiety 592
Scale, Taiwanese–Chinese Version of the Stress in Nursing Students Scale (TC-SINS), and Pittsburgh Sleep Quality Index (PSQI). ADI Adolescent Depression Inventory (ADI), developed by Taiwanese researchers (Huang & Hsu 2003), is a commonly used scale to assess depressive symptoms in adolescents or teens in Taiwan. Therefore, ADI was used in this study to assess this problem for the population of young junior college nursing students in Taiwan instead of other depression assessment tools. This scale consists of 20 questions to assess depressive symptoms based on individual experiences over the past month using a 2-point scoring system. Higher scores indicated a greater degree of depression. A total score of 7 points or less is classified as minimal, 8–12 points as mild depression; 13–18 points as moderate depression, and a total score of 19 points or more as severe depression, indicated as high risk with needs for further professional evaluation. The cut-off point is 8. This scale is easy to administer with good acceptance by users in the public health domain. The internal consistency coefficient of the scale was 0.86, and the test–retest reliability was 0.76 (Huang & Hsu 2003). Situational anxiety scale The Situational Anxiety Scale was adapted from Spielberger’s Situational Trait Anxiety Scale by Chung & Long (1984). This scale comprises 20 questions scored on a 4-point Likert scale. The lowest possible score is 20 points, and the highest possible score is 80 points. A score of 20–39 indicates a low level of anxiety, a score of 40–59 indicates a moderate level of anxiety, and a score of 60–80 indicates a high level of anxiety. This scale has a good internal consistency (α = 0.898) (Chung & Long 1984). TC-SINS The TC-SINS is a Chinese translation of the SINS by Sung et al. (2013) developed for use with the nursing students in Taiwan. The original SINS was developed by Deary et al. in 2003 to measure the perception of stress among nursing students. This scale includes 43 5-point Likert-type items and scores range from 43 to 215 points. A higher score indicates greater stress. This scale has a good internal consistency, with a Cronbach’s α > 0.7 (Deary et al. 2003, Watson et al. 2008, 2010, Salomonson et al. 2011). The TC-SINS has a Cronbach’s alpha coefficient of 0.927, reflecting good internal consistency (Sung et al. 2013). PSQI The PSQI is a self-reported questionnaire developed by Buysse et al. (1989) that has been widely used in the clinical © 2015 John Wiley & Sons Ltd
Depressive symptoms among nursing students
evaluation of sleep quality. Scores were calculated using a range of 0–3 points for each section, and the total score of the seven sections ranged from 0 to 21 points. The students with a total score less than or equal to 5 were considered good sleepers. Higher scores indicated worse sleep quality. The overall reliability coefficient of this scale (Cronbach’s α) was 0.83, the diagnostic sensitivity was 89.6%, and the specificity was 86.5% (Buysse et al. 1991, Wilcox & King 1999). In this study, the Chinese version of the PSQI was used. The internal consistency coefficient was 0.83, and the test–retest reliability was 0.85 (Wu 2004).
Data collection The survey was conducted in a junior college in central Taiwan. After the study was approved by a hospital Institutional Review Board (IRB) in Taiwan, the school’s research and development centre was contacted. Consent and approval to conduct the study were obtained from the school’s research committee. A researcher assigned a list of members in the accessible population of 2201 samples to the sampling frame and then used the multistage random sampling method of selection to choose classes and names by computer randomly. A multistage random sampling method was applied to obtain the random sample, and samples with equal probability were selected using the two-stage stratified random sampling method. The twostage sampling process selected four classes from each year of the 5 years of the junior nursing programme, and then randomly selected 35 students from each class. Potential participants were explained about the study purposes and procedures by the researcher in each class with the assistance of the school counsellor from the counselling centre. Participants who provided informed consent were recruited. A total of 625 junior college nursing students completed the questionnaires.
Data analysis The data were analysed using SPSS 15.0 for Windows (SPSS Inc., Chicago, IL). Descriptive statistics were used to analyse the participants’ demographic factors. Spearman’s rank-order correlation coefficient (rs) was performed to examine the linear relationship. The point-biserial correlation coefficient (rpb) was used for dichotomous variables. Pearson’s product-moment correlation coefficient (r) was used to determine the linear relationship between two continuous variables. A multivariable stepwise regression model was used to estimate the association between statistically significant variables. © 2015 John Wiley & Sons Ltd
Ethical consideration This study was approved by a hospital IRB in Taiwan. The participants were informed of the study’s purposes and procedures. All participants were informed their participation was voluntary, that participation in this study was not connected to the school curriculum, and that their academic outcomes would not be affected by whether they participated in the study. The participants were also informed that the questionnaires used in this study would not reveal their names and would only use serial numbers. Informed consent was obtained from each participant after the study purpose and methods had been explained.
Results A total of 700 nursing students between the ages of 16 and 20 years were recruited, and 625 nursing students completed the assessment, with a response rate of 89.2%. The participants’ mean age was 17.42 years (SD = 1.03). The majority of the participants (94.6%) were female. Of the participants, 42.6% were ranked between 11% and 25% in their class for academic performance. Over half of the participants (50.7%) reported that they liked nursing, but less than half reported that they liked their clinical placement (Table 1).
Depressive symptoms and stress in junior college nursing students Our study found that 32.6% had a score higher than or equal to 8 points on the ADI, indicating that they had depressive symptoms. Among these nursing students with depressive symptoms, there were 22.9% with mild level, 8.9% with moderate level, and 0.8% with severe level of depressive symptoms (Table 2). The mean score for the participants’ stress level (TCSINS) was 120.78 (SD = 28.47), indicating that the students had moderate levels of stress. The mean stress score in the nursing students without depressive symptoms (N = 421) was 117.69 (SD = 26.29). The mean stress score in the nursing students with depressive symptoms (N = 204) was 127.15 (SD = 28.36).
Demographic factors related to depressive symptoms Correlations were found between depressive symptoms and the following variables: ‘grade point average’ (rs = 0.104, P = 0.009), ‘interest in nursing’ (rs = −0.113, P = 0.005), and ‘interest in clinical placement’ (rs = −0.123, P = 0.002). ‘Career planning after graduation’ (rpb = 0.107, P = 0.008) and ‘stress relief strategies–overeating’ (rpb = 0.100, P = 593
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Table 1 Demographic characteristics of the participants (N = 625)
Table 3 Correlation between depressive symptoms and demographic factors
Characteristics
M
SD
Variables
rpb (P)
rs (P)
Age (years) Characteristics Gender Male Female Grade point average 2.6–4.0 1.6–2.5 1.1–1.5 0–1.0 Learning status Attending lectures on campus Clinical placement Interest in nursing Like it very much Like it Average Do not like it Dislike it very much Career planning after graduation Nursing Studying for an advanced nursing degree Studying for a non-nursing degree Undecided Stress-relief strategies Sleeping Shopping Overeating Seeking assistance from classmates Seeking assistance from teachers
17.42 N
1.03 %
– −0.055 (0.168)
−0.104** (0.009) –
34 591
5.4 94.6
167 266 128 64
26.7 42.6 20.5 10.2
– – 0.107** (0.008)
−0.113** (0.005) −0.123** (0.002) –
400 225
64.0 36.0
50 317 240 14 4
8.0 50.7 38.4 2.2 .6
Grade point average Learning status (attending lectures on campus/clinical placement) Interest in nursing Interest in clinical placement Career planning after graduation (Yes/No) Stress-relief method Sleeping (Yes/No) Shopping (Yes/No) Overeating (Yes/No) Seeking assistance from classmates (Yes/No) Seeking assistance from teachers (Yes/No)
111 353 27 134
17.8 56.5 4.3 21.4
357 268 183 480 23
27.2 20.4 14.0 36.6 1.8
Table 2 Cut-off point of the ADI to detect depression levels of the participants (N = 625) Depression level
Cut-off
N
%
Minimal Mild Moderate Severe Total
≦7 8–12 13–18 ≧19
421 143 56 5 625
67.36% 22.88% 8.96% 0.8% 100%
ADI, Adolescent Depression Inventory.
0.012) were also statistically significant, indicating that depressive symptoms are significantly related to grade point average, interest in nursing, interest in clinical placement, career planning after graduation, and the stress relief strategy of overeating (Table 3).
The correlation between depressive symptoms and sleep quality, stress, and anxiety Depressive symptoms were positively correlated with poor sleep quality, stress, and anxiety. The coefficient of determination for ‘sleep quality’ was r2 = 0.513, indicating that sleep quality could explain 51.3% of the total variation in depressive symptoms. Depressive symptoms and stressors 594
−0.004 (0.911) −0.015 (0.712) 0.100* (0.012) −0.059 (0.138)
– – – –
−0.043 (0.281)
–
rs, Spearman’s rank order correlation coefficient; rpb, Point-biserial correlation coefficient. *P < 0.05; **P < 0.01; ***P < 0.001.
Table 4 Correlation between depressive symptoms and sleep quality, stress, and anxiety Variables
r
P
r2
Sleep quality Stress Anxiety
0.716*** 0.632*** 0.730***
0.000 0.000 0.000
0.513 0.397 0.533
r2, coefficient of determination. ***P < 0.001 (two tailed).
showed a significant positive correlation, with the coefficient r = 0.632 (P = 0.000) and the coefficient of determination r2 = 0.397, indicating that stress could explain 39.7% of the total variation in depressive symptoms. Depressive symptoms and anxiety showed a significant positive correlation, with the coefficient r = 0.730 (P = 0.000) and the coefficient of determination r2 = 0.533, indicating that anxiety could explain 53.3% of the total variation in depressive symptoms (Table 4).
Predictors of depressive symptoms According to the predictive regression analysis (stepwise regression with multiple variables), the individual regression coefficients of the independent variable in each regression mode was statistically significant. In mode 1, the independent variable in the regression equation was ‘anxiety’, with an interpretive power of 29.1%; in mode 2, the independent variables in the regression equation were ‘anxiety’ and ‘sleep quality’, with a combined interpretive power (R2) of 41.5%, and the interpretative power of the independent variable ‘sleep quality’ (R2) was 12.4%. In mode 3, the independent variables in the regression © 2015 John Wiley & Sons Ltd
Depressive symptoms among nursing students
Table 5 Stepwise regression with multiple variables between depressive symptoms and sleep quality, stress, and anxiety Variable Intercept 1. Anxiety 2. Sleep quality 3. Stress
R 0.540 0.644 0.660
R2 0.291 0.415 0.435
ΔR2 0.291 0.124 0.020
F 253.423 218.465 157.961
ΔF
SE (B)
Beta (β)
Tolerance
VIF
253.423*** 130.371*** 22.033***
6.674 0.137 0.566 0.024
0.357 0.350 0.158
0.778 0.866 0.813
1.286 1.155 1.231
R, multiple correlation coefficient; R2, explanatory power of the variable; Beta, standardized regression coefficient; VIF, variance inflation factor. ***P < 0.001.
equation were ‘anxiety’, ‘sleep quality’, and ‘stressors’, which had a combined interpretive power (R2) of 43.5%; the interpretive power for the independent variable ‘stressors’ (R2) was 2%. Based on the individual predictive powers, the variables with the greatest predictive power for depressive symptoms were ‘anxiety’, ‘sleep quality’, and ‘stressors’, in descending order. The F values were 253.423 (P < 0.001), 218.465 (P < 0.001), and 157.961 (P < 0.001), respectively, all of which reached the level of significance. According to the standardized regression coefficients, the β values of the three predictive variables in the regression modes were positive (0.357, 0.350, and 0.158, respectively), indicating that their effects on depressive symptoms were positive (Table 5).
Discussion Our result showed that 32.6% of junior college nursing students in Taiwan reported high score on the ADI (8 or above), indicating that they had depressive symptoms. The prevalence of depressive symptoms is higher than that of college nursing students in China (22.9%) (Xu et al. 2014). Our result is consistent with the findings of Shikai et al. (2009) and Furegato et al. (2008), whose studies found that among young student populations, nursing students have particularly stressful lives. As mentioned earlier, the majority of nursing students in Taiwan are younger, fresh graduates from junior high schools, with different learning and coping patterns compared to matured nursing students. Asian societies have contexts different from those in the West. The average age of the nursing students in our study was 17.4 years old. Depressive symptoms may occur more commonly in this population because they were younger and less mentally resilient. The experience of taking care of the sick, interacting with patients and healthcare professionals, and dealing with death during clinical placement at a young age may have caused greater stress and psychological problems for our young junior college nursing students compared to more matured nursing students in western countries. Our study found that factors significantly associated with depressive symptoms were grade point average, inter© 2015 John Wiley & Sons Ltd
est in nursing, interest in their clinical placement, career planning after graduation, overeating as a stress-relief strategy, sleep problems, stress, and anxiety. Our study observed that grade point average had a significant negative correlation with depressive symptoms, which is consistent with the findings of Vogel et al. (2003), in which higher depression scores were associated with lower grades. Our result is also consistent with previous study conducted among young nursing students in China (Xu et al. 2014), in which academic stress was strongly associated with depressive symptoms. In our study, interest in nursing and interest in clinical placement were significantly related to depressive symptoms. This result is consistent with the findings of Furegato et al. (2008) that attending specialized courses or practice opportunities reflects the extent of students’ interest in nursing or clinical placement. This recognition and affirmation of the nursing profession helps to prevent depression. In addition, career planning after graduation was found to be correlated with depressive symptoms in our study. This finding is consistent with the findings of Chrysoula et al. (2011). Chrysoula et al. (2011) found that uncertainty regarding career planning after graduation caused more anxiety and fear and led to depression among nursing students. Consistent with previous studies (Lee & Ye 2010, Martin et al. 2010, Huang et al. 2011), our study results showed that there was strong relationship between sleep quality, stress, and anxiety with depressive symptoms. Our study results also found that sleep quality, stress, and anxiety were the major predictors of depressive symptoms among nursing students. Nursing education may cause emotional stress, and emotional stress can affect sleep quality. Poor sleep quality is also associated with the occurrence and relapse of depression and with poor treatment (Buysse et al. 2001). Furthermore, our study results related to stress level were similar to the findings of Beck and Srivastava (1991) and Ross et al. (2005), in which nursing education was shown to cause emotional stress, and potentially result in depression among nursing students. The severity of stress also has a direct predictive effect on the degree of depression. Won & Kim (2002) observed that 595
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stress can cause physical and emotional problems, such as severe anxiety, nervousness, and depression. Randle (2003) observed that in the professional education of nursing students, clinical placement is particularly likely to cause anxiety because the students lack the knowledge and experience necessary to successfully face an unfamiliar hospital environment and assume responsibility for patient care. A study by Leadbeater et al. (2012) identified a significant correlation between anxiety and depression. Our results regarding anxiety are similar to the results of Fang’s study (2011), in which a close relationship between anxiety and depression was found. Our findings are also consistent with those of Randle (2003), in which complex interpersonal relationships, heavy workloads, academic training, the physical environment of the clinical placement, and a competitive work environment were found to cause anxiety among nursing students. When anxiety becomes increasingly severe, the level of depressive symptoms increases. Sleep quality has direct power for predicting the degree of depressive symptoms among nursing students, as noted by Fava (2004), who observed that changes in mood are primarily related to sleep problems. Adolescents with depressive symptoms are more likely to suffer from insomnia. Buysse et al. (2001) also indicated that poor sleep quality is related to the occurrence, recurrence, and poor treatment efficacy of depression. Our results showed that relieving stress by overeating was associated with depressive symptoms, and is consistent with the finding of Gan et al. (2011). Eating to relieve stress is generally an unplanned activity (Rampersaud et al. 2005). Furthermore, the factor of seeking assistance from teachers is worth discussing. Our result is different from that of Washington (2010). In our study, the nursing students were younger and did not know how to actively seek assistance from teachers. Alternatively, this difference may be explained by cultural differences between eastern and western cultures. Adolescents in Taiwan tend to be more passive and less outspoken compared to those in western countries. Young nursing students in Taiwan may hesitate to seek for help and guidance when they experience stress and problems during their nursing training at school. Psychological factors may influence nursing students’ willingness to seek assistance from teachers across racial and ethnic groups. Therefore, these factors should be considered when designing strategies to promote emotional health and well-being among young nursing students. The potential limitation of this study is its crosssectional design. This design has made it difficult to make reference in regard to causality of depressive symptoms. In addition, the sample was limited to younger nursing stu596
dents in one junior college in central Taiwan, which may have introduced a bias regarding the population and limited the generalization of the study results. Future research can be expanded towards the investigation and comparisons of all nursing students including young junior college nursing students (adolescents) and university nursing students (young adults). Due to the nature of selfreported measures, the study results have to be interpreted cautiously. Furthermore, a quantitative exploration of stress and depressive symptoms among nursing students may not be sufficient to allow a comprehensive understanding of nursing students’ experiences and problems in academic settings and clinical placement; therefore, qualitative research is required to explore this phenomenon in greater detail.
Conclusion The results of this study indicate that the prevalence of depressive symptoms among junior college nursing students in Taiwan is high. Grade point average, interest in nursing, interest in clinical placement, career planning after graduation, relieving stress by overeating, sleep quality, stress, and anxiety were correlated with depressive symptoms among young nursing students. Sleep quality, stress, and the degree of anxiety can predict the degree of depressive symptoms among young nursing students in Taiwan. This study also has important implications for health promotion and disease prevention among nursing students. Nursing educators should be aware of the problems and related factors of depressive symptoms among junior college nursing students. Development of proper strategies to help young nursing students manage stress, anxiety, and facilitate better learning experiences tailored to their problems and needs may be helpful for alleviation or prevention of depressive symptoms. The efforts to help young nursing students deal with stress and prevent depressive symptoms may promote the completion of nursing education programmes and inspire them to remain in a nursing career after graduation.
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Conflicts of interest All authors have no personal or financial conflicts of interest to declare. © 2015 John Wiley & Sons Ltd
Depressive symptoms among nursing students
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