33

Stress, Anxiety and Mental well-being among

Nursing students: A Descriptive-Correlational study
https://doi.org/10.37719/jhcs.2021.v3i1.oa003

KATHYRINE A. CALONG CALONG, RN, MAN JUDALYN S. COMENDADOR, RN, MAN

https://orcid.org/0000-0002-8471-6166 https://orcid.org/0000-0001-5543-1420

College of Nursing, San Beda University, Manila, Philippines

Corresponding author’s email: [email protected]

Abstract

Background: The COVID-19 pandemic has affected everyone's health and well-being and has
resulted in the shift of conventional face-to-face classes to online instruction. This has had major
negative effects on students who are facing the difficulty of online classes in terms of their physical
and mental health.

Objectives: The study determined the relationship between stress and anxiety on emotional social
and psychological well-being among nursing students.

Methods: The study utilized descriptive cross-sectional research and a purposive sample of 210
nursing students was included in the study. The data were collected from November 2020 to
December 2020. The Perceived Stress Scale (PSS-10), General Anxiety Disorders Scale (GAD-7),
and Mental Health Continuum-Short Form (MHC-SF) (which measures emotional, psychological, and
social well-being) were used to collect the necessary data. Frequency, percentage, mean, standard
deviation, and Pearson's r correlation were utilized to analyze the gathered data.

Results: The participants were shown to have a moderate level of stress (M=19.53; SD=±3.29),
moderate level of anxiety (M=14.43; SD=±7.62), and moderate mental health. Further, stress was
shown to have a significant negative correlation with emotional well-being (r= -0.218; p=0.000), social
well-being (r= -0.175; p=0.000), psychological well-being (r= -0.219; 0.000), and the over-all mental
well-being (r= -0.222, p=0.000). Also, it was noted that anxiety has a significant negative relationship
with emotional well-being (r= -0.418; p=0.000), social well-being (r= -0.280; p=0.000), psychological
well-being (r= -0.331; p=0.000) and over-all mental well-being (r= -0.362; p=0.000).
 34

Conclusion: In light of mental health concerns among nursing students, faculty and administrators
have a professional responsibility to address foreseeable psychological stressors and promote the
mental well-being of students in their institution. The protection and development of mental well-being
will allow students to maintain academic excellence and facilitate future success.

Keywords: Anxiety, COVID-19, stress, mental well-being

Introduction

I
n 2015, the United Nations Member States adopted the Sustainable Development Goals (SDGs),
also called Global Goals is established to aid humanity in grasping the optimum state of the
forthcoming years. It is designed to secure effective approaches and ensure the betterment of the
global challenges before us, as well as the challenges that await us. Ensuring healthy lives and
promoting well-being at all ages is one of the Sustainable Development Goals (SDGs) announced by
the United Nations (UN) in 2015. This has highlighted the importance of well-being as a global
academic and policy priority (United Nations, 2015). However, the current global situation is under a
constant siege against the phenomenal crisis brought by the COVID-19 pandemic which caused a
disturbance in the regularity of life in the sense of health, economy, and society.

Before the pandemic, tremendous progress was acknowledged in the improvement of health
in global settings. Increased life expectancy, as well as reduced child and maternal mortality rates,
were accomplished, however, the world must intensify its efforts to address several global issues
specifically the emerging health issues ahead of us. Therefore, adequate funding, enhancement of
health systems, improved sanitation, and reinforcement of healthcare professionals, are deemed to
be the blueprint for pursuing the sustainable development goal of promoting the health and well-being
of individuals (United Nations, 2020). The term “well-being" is agreed to be an individual's state of
physical, mental, and social health. It concerns one's frame of mind, sanity, and sense of life.
Additionally, It can also be specified as the ideal judgment and perception of life (CDC, 2018).

Currently, the COVID-19 pandemic is significantly influencing the health and well-being of
all individuals as it adds complexity to the healthcare systems. Healthcare professionals are
distressed due to excessive workload and increased susceptibility to the virus whilst the patients are
suffering from the physical and mental consequences of COVID-19. Likewise, since there is
inadequate access to healthcare facilities, people are experiencing inequality and are receiving
inadequate standards of care. Study shows that socio-economic characteristics such as income,
social class, occupation, and educational background can affect one's health outcome. In all
likelihood, the health and well-being of healthcare professionals and the public will not be fully
addressed and may yield medium and long-term consequences (Otu et al., 2020).
35

Physical classes had been suspended in the Philippines to prevent the emergence of
COVID-19 cases. In the wake of this unprecedented global phenomenon, students have shown
remarkable resilience in coping with the concept of taking courses online, establishing a "new
normal." The students took advantage of this alternative mode of instruction to remain on track and
alleviate concerns over falling behind. However, despite the convenience of online education,
distance learning has several detrimental effects on students' physical and mental health (Halupa,
2016). Researchers have raised concerns about the impact of COVID-19 on public health globally.
Several studies have shown that students are more likely to suffer from stress, anxiety, and
depression, most notably under prolonged home confinement. In addition, uncertainties, infection-
related anxiety, bereavement, financial hardship, and poor mental well-being, in general, can
adversely affect academic performance and are likely to undermine the success of online learning
(Banerjee, 2020; Deo et al., 2020; Galea et al., 2020; Kaup et al., 2020).

Higher education's universal and increasingly competitive nature has exacerbated common
academic stressors that lead to mental health problems among university students (Beiter et al.,
2015; Fawzy & Hamed, 2017). Research has found that stressors such as meeting institutional and
socio-cultural demands, coursework management, and financial commitments are sources of
depression, anxiety, and stress in university students (Elias et al., 2011). According to recent meta-
analyses, Asian university students studying nursing and medicine have a high prevalence of
depression 43% (Tung et al., 2018) and 11% (Cuttilan et al., 2016) in each group, respectively.

The onset of an outbreak and its implications for psychological distress can adversely affect
student academic success and overall mental well-being. Changing circumstances surrounding the
pandemic disrupted the learning process and created a stressful work environment where anxiety
and depression became a concern (Fawaz & Samaha, 2021). Lovric et al. (2020) found that nursing
students demonstrated poor motivation, inattention, and performance deficits following the pandemic.
Meanwhile, Alici et al. (2021) observed that fear of contracting COVID 19 is associated with elevated
anxiety, consequently affecting academic performance. According to other research (Son et al., 2020;
Majrashi et al., 2021; Thapa et al., 2021; Park & Seo, 2022), technical issues, course quality, online
learning complexities, connectivity issues, and inability to actively practice clinical skills are significant
factors contributing to stress and anxiety. As stress and anxiety intensify in times of an outbreak
detrimental to academic performance, the study aims to determine nursing students' stress and
anxiety levels and their relationship with emotional, social, and psychological well-being.

Methodology

Research design and Sampling Technique

Descriptive-cross sectional research was utilized as the design of the study and a purposive
sampling technique was used to determine the relationship between stress and anxiety on mental
 36

well-being (which includes emotional mental, and psychological well-being) among nursing students.
The data were collected from November 2020 to December 2020.

Measurement and Instrumentation

The study utilized a three-part questionnaire to gather the data needed. These include the
Perceived Stress Scale (PSS-10), General Anxiety Disorders Scale (GAD-7), and the Mental Health
Continuum-Short Form (MHC-SF).

Perceived Stress Scale (PSS-10). It was developed by Cohen et al. (1983) consisting of
10 items with five responses ranging from 0 = Never to 4 = Very often. A high score signifies a high
level of stress (0-13= low stress; 14-26= moderate stress; 27-40= high stress). The scale has a
Cronbach's alpha coefficient of 0.88.

General Anxiety Disorders Scale (GAD-7). The instrument was developed by Spitzer et
al. (2006) consisting of seven items with a 4-point Likert scale ranging from 0 = Not at all to 4 = Nearly
every day. The score can be interpreted as mild (5 to 9), moderate (14 to 15), and severe (>15). It
has a Cronbach's alpha coefficient of 0.90.

Mental Health Continuum-Short Form (MHC-SF). This was developed by Keyes et al.
(2008) and consists of 14 items which are divided into the three subscales ‘emotional well-being’
(Happiness, Interest, and Life Satisfaction), ‘social well-being’ (Social Contribution, Social Integration,
Social Actualization, Social Acceptance, and Social Coherence), and ‘psychological well-being’ (Self-
acceptance, Mastery, Positive Relations, Personal Growth, Autonomy, and Purpose in Life). In
addition, the scores on all 14 items can be averaged into a total well-being score. Items are answered
on a 6-point scale ranging from 0 (never) to 5 (almost always or always).

Procedures and Participants

Before the conduct of the study, permission was secured from the respective Deans of
selected Colleges of Nursing in Manila and Pasay City where the study was conducted. After getting
the approval, ethical clearance was secured from the San Beda University- Research Ethics Board
(SBU-ERB) with Protocol No. 2020-022. Online-based surveys were distributed to the students who
volunteered for the study.

A total of 210 nursing students were included in the study. The average age of the
participants was 20.58 (SD=3.51). There were 163 (77.62%) females and 47 (22.38%) males. The
undergraduate students included 73 (34.76%) Level 1 students, 50 (23.8%) Level 2 students, and 87
(41.44%) students. A total of 122 (58.1%) students were from a private university while 89 (41.9%)
were from a public university.
37

Data Analysis

The quantitative data gathered via Google forms was exported in Microsoft Excel format.
The data were analyzed using frequency, percentage, mean, standard deviation, and Pearson’s r
correlation.

Results

The mean stress level of the participants was 19.53 (SD=3.29) while the mean anxiety level
of the participants was 14.43 (SD=7.62). In terms of mental well-being, the mean average rating for
emotional well-being was 9.15 (3.67), the mean score for social well-being was 11.13 (6.15) and the
average rating for psychological well-being was 17.12 (7.39). The overall mental well-being means
the score was 37.40 (15.74).

Table 1. Level of stress, anxiety, and mental well-being among the participants (n=210)
Mean SD
Stress 19.53
Anxiety 14.43 ±7.62
Emotional well-being 9.15 ±3.67
Social well-being 11.13 ±6.15
Psychological well-being 17.12 ±7.39
Over-all Mental well-being 37.40 ±15.74

To determine the relationship between stress and anxiety on emotional, social, and
psychological well-being among nursing students, a Pearson's r was computed. Results revealed
that there was a significant negative correlation between stress and emotional well-being having an
r coefficient of -0.218 (p=0.000). Same findings can be noted between stress and social well-being
and stress and psychological well-being having an r coefficient of -0.175 (p=0.000) and -0.219 (0.000)
respectively. Further, a significant negative correlation was noted between stress and mental well-
being (r= -0.222, p=0.000).

Also, the relationship of anxiety to emotional well-being, social well-being, psychological

well-being, and overall mental well-being was determined. Findings revealed a significant negative
correlation between anxiety and all the measures of mental well-being which includes emotional well-
being (r= -0.418; p=0.000), social well-being (r= -0.280; p=0.000), psychological well-being (r= -0.331;
p=0.000) and over-all mental well-being (r= -0.362; p=0.000).
 38

Table 2. Correlation of measured variables

Stress Anxiety
Emotional well-being -0.218 (0.000)* -0.418 (0.000)*
Social well-being -0.175 (0.000)* -0.280 (0.000)*
Psychological well-being -0.219 (0.000)* -0.331(0.000)*
Mental well-being -0.222 (0.000)* -0.362 (0.000)*
*p value is significant at 0.01 level

Discussion

Stress is a continuously occurring phenomenon in nursing and is thought to be one of the

major causes of burnout. Among the most common causes of stress, academics are often cited as
the main contributors to which subject-related concerns, excessive workloads, and other general
difficulties associated with studying are often experienced (Pulido-Martos et al., 2012). Nursing
students are now subjected to additional stressors amid the pandemic. Every aspect of their daily
lives and functioning has dramatically changed concerning their environment, routine, and social life.
Oducado and Soriano (2021) found that nursing students held ambivalent and negative attitudes
towards online learning. Their study indicated that the new format of education was less likely to have
interactive experiences because of e-learning's perceived impersonality and lack of connection to
human experiences.

Majrashi et al. (2021) substantiate this claim, in which they report that nursing students have
a perception of lacking competence, interpersonal skills, and the capability to cope under pressure.
In their view, nursing should include real-world demonstrations and simulations in their educational
programs, particularly given the current learning environment may not impart quality skills. While
online learning can be considered to be the only viable option to date, its cost could be a substantial
financial challenge since the pandemic has left innumerable people financially strained as a result of
job losses and business closures (Burns et al., 2020; Rasdi et al., 2021). Aslan and Pekince (2021)
noted that these factors do contribute to students having higher stress levels as they cope with new
working conditions amidst seemingly unavoidable long-term stressors.

In today's unpredictable events, stress can be intensified, causing anxiety. Under long-term
stressful conditions, anxiety often occurs. In the wake of the pandemic, nurses were confronted with
multiple strains, leading to anxiety. Among them are social isolation, apprehensions about the future,
and infection concerns. This could be because nursing students are more likely than the general
population to experience psychological distress because of their familiarity with health issues
(Isralowitz et al., 2021). At the same time, having concerns about their future as registered nurses
could be closely linked to their moderate levels of anxiety (Dewart et al., 2020). Several factors may
be involved, such as being exposed to death over a long time, dread of the unknown, or uneasiness
with how they would perform their roles as registered nurses. Khoshaim et al. (2020) shared this view
39

regarding future concerns but added that academic pressure, such as managing stressful tasks and
assignments and pursuing better academic performance, may significantly influence anxiety levels
(Khoshaim et al., 2020). The reality is that, despite its perceived ease in the face of the pandemic,
this method of learning may be ineffective in the long term, particularly for courses that require skills
and firsthand experience, such as nursing.

To a certain extent, the results are consistent with other studies. As reported by Quiao et al.
(2011), the psychological well-being of nurses from China was negatively correlated with several
nursing stressors (Quiao et al., 2011). A similar finding was made by Gautam et al. (2020), where it
was also discovered that the psychological well-being of nursing students from India was linked with
their perceived stress, suggesting a negative correlation (Gautam et al., 2020). Research has been
limited on the role of stress and anxiety in nursing students' well-being, but this study contributes to
this dearth. The results revealed that Filipino nursing students have a moderate level of anxiety
(M=14.43; SD=7.62) and a moderate level of stress (M=19.53; SD=3.29). A significant negative
correlation was observed between stress and anxiety and well-being, which encompasses their
emotional, psychological, and social wellness. To date, the threat of being placed in unusual
circumstances has invoked detrimental outcomes (Savistky et al., 2020). Researchers have found
that nursing students who experience a higher degree of stress and anxiety tend to have a weaker
sense of well-being. Hence, support from faculty members should be provided to reduce the severity
of their stress and anxiety, ultimately reduce the risk of mental health issues and promote academic
success (Fitzgerald et al., 2021). By creating a nurturing environment, nursing students are more
inclined to excel academically and develop into well-rounded professionals with the competence to
provide patients with quality care (Ratanasiripong et al., 2021).

Conclusion

The study has contributed to the limited studies on mental well-being in the Philippines and
contributed to the understanding of the role of stress and anxiety on the mental well-being of
university students. With the increasing number of mental health problems among university students
worldwide, administrators and faculty members are in the best position to implement measures that
will reduce mental health problems and enhance the mental well-being of students on their campuses.
University students can become leaders in the future. Hence, improving and maintaining their
psychological well-being will aid in their academic performance in school and do better in their future
careers.

Conflict of Interest

The authors have no conflict of interest to disclose.

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Funding

This study is funded by San Beda University through its Research and Development Center,
AY 2020-2021 Research Grants.

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About the Author

Kathyrine A. Calong Calong, MA, RN, is a graduate of Bachelor of Science in Nursing from the
Metropolitan Medical Center-College of Arts, Science and Technology and received her Master of
Arts in Nursing Degree Major in Leadership and Management from Centro Escolar University. She
has worked as a staff nurse in several institutions including Metropolitan Medical Center and Manila
Medical Center. Currently, she is the Level 1 Coordinator of San Beda University-College of Nursing.
Her master’s research is focused on the caring behaviors among nurses working in Level
3 hospitals. She is pursuing her Doctor of Philosophy in Nursing Education at St. Paul University of
the Philippines Manila. She is a member of the Philippines Nurses Association and Philippine
Nursing Research Society.

Judalyn S. Comendador, MA, RN, is an experienced nurse clinician in emergency nursing

and major disaster response locally and abroad. She is also a nurse educator and had
taught in top universities in the Philippines. She is one of the pioneer leaders in nursing
education and staff development in military hospitals abroad. With skillful knowledge in
competency-based assessment and experience in multicultural nursing leadership and
management. She is currently working in San Beda University as Skills Laboratory Manager,
Lecturer, and Clinical Instructor.