depression case study for nursing students

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Patient Case Presentation

Ms. A. M. is a 23 year old biracial female who arrives to her primary care clinic for her annual physical. Ms A.M. has had a 15lb weight gain since her last visit. She complains of feelings of guilt and sadness with her parents’ recent divorce. Patient states she is not sleeping well and feels that she cannot concentrate during her nursing orientation classes. When asked about her interpersonal relationships, she states that she just ended her two-year relationship with her boyfriend and she states that she hasn’t been able to meet new friends or keep up with current friendships.

Past Medical/Surgical History

• Asthma diagnosed at age 8
• Hypothyroidism diagnosed at age 16

Pertinent Family History

• Older sister with suicide attempt 3 years prior.
• Father diagnosed with Bipolar II in his thirties, currently taking medication.
• Mother alive and healthy at age 54
• Uncle with history of substance abuse

Pertinent Social History

• recently graduated college and is starting her career as a nurse at a large teaching hospital on the intensive care unit
• parents recently divorced
• moving out on her own for the first time

Nursing students and depressive symptomatology: an observational study in University of Palermo

Mental Illness

ISSN : 2036-7465

Article publication date: 29 November 2019

Issue publication date: 6 December 2019

Depression is a common and serious medical illness, considered as a public health issue because it interferes with the interpersonal, social and professional functioning of the individual, and its frequency is constantly increasing. According to a recent review, approximately 34 per cent of nursing students had experienced depression worldwide. The university period may represent a moment in which the mental well-being of students is subjected to stress with a relative predisposition to the development of diseases related to mood disorders. The purpose of this study is to estimate the prevalence and examine the socio-demographic correlates of depressive symptomatology.

Design/methodology/approach

In April 2019, a questionnaire was administered to all the nursing students of University of Palermo of the three years of course, accompanied by informed consent. Multivariable logistic regression was performed. The statistical significance level chosen for all analyses was 0.05. The results were analyzed using the STATA statistical software version 14. Results are expressed as adjusted odds ratio (aOR) with 95 per cent confidence intervals.

The sample consists of 493 students who completed the questionnaire, and the average age of the sample participants is 21.88 years. The multivariable logistic regression model shows that the risk to have depressive symptomatology is significantly associated with the following independent variables: female gender (aOR 1.91), being single (aOR 1.87), second year of study (aOR 1.94), third year of study (aOR 1.92), not performing regular physical activity (aOR 1.78) and perceived low health status (aOR 3.08).

Originality/value

This study shows that belonging to the female gender, being further along in the years of study, having a chronic illness and perceiving a low state of health are all factors that can increase the risk of developing the symptoms of depression; rather, regular physical activity, friendship and romantic relationships can be considered factors protecting them from the risk of falling into depression that can undermine both the study and work performance. Certainly, it is important to analyze all the involved variables to improve the global health not only of the nursing students but of all the students.

• Female gender
• Health status
• Mood disorders
• Nursing students

Santangelo, O.E. , Provenzano, S. , Giordano, D. , Alagna, E. , Armetta, F. , Gliubizzi, C. , Terranova, A. , D'Anna, G. , Barresi, D. , Grigis, D. , Genovese, C. , Squeri, R. and Firenze, A. (2019), "Nursing students and depressive symptomatology: an observational study in University of Palermo", Mental Illness , Vol. 11 No. 2, pp. 25-31. https://doi.org/10.1108/MIJ-10-2019-0006

Emerald Publishing Limited

Copyright © 2019, Omar Enzo Santangelo, Sandro Provenzano, Domiziana Giordano, Enrico Alagna, Francesco Armetta, Claudia Gliubizzi, Antonio Terranova, Giuseppe D’Anna, Dalila Barresi, Dimple Grigis, Cristina Genovese, Raffaele Squeri and Alberto Firenze.

Published by Emerald Publishing Limited. This article is published under the Creative Commons Attribution (CC BY 4.0) licence. Anyone may reproduce, distribute, translate and create derivative works of this article (for both commercial and non-commercial purposes), subject to full attribution to the original publication and authors. The full terms of this licence may be seen at: http://creativecommons.org/licences/by/4.0/legalcode

Introduction

Depression (major depressive disorder) is a common and serious medical illness, considered a public health issue. It interferes with the interpersonal, social and professional functioning of the individual and causes feelings of sadness and loss of energy, initiative and interest in activities once enjoyed. Furthermore, depression may lead to feeling worthless or guilty, difficulty in thinking, concentrating or making decisions, lack of self-care, changes in appetite (weight loss or gain unrelated to dieting), slowed movements and speech, insomnia or hypersomnia and thoughts of death or suicide. Depression is the most common mental disorder in the general population, with a frequency between 3 and 5 per cent, according to the World Health Organization (WHO), and this frequency is steadily increasing. The aggregate point, one-year and lifetime prevalence of depression are 12.9, 7.2 and 10.8 per cent, respectively ( Lim et al. , 2018 ). The Epidemiologic Catchment Area Study, driven by National Institute of Mental Health, has estimated an annual incidence of major depression of 1.10 per cent in men and 1.98 per cent in women. According to WHO, by 2020, major depression will be at second place, after ischemic coronaropathy, for disability adjusted life years, that represents the lost years of healthy life, both for premature death and for disability ( WHO, 2009 ; Murray and Lopez, 1997 ). Depression, indeed, is strongly linked with higher rates of morbidity, mortality and also suicide. This disorder can affect all ages, even if the age at which the first symptoms appear is commonly around 15-29 years old ( Chen et al. , 2019 ). The university period, in particular, may represent a moment in which the mental well-being of students is subjected to stress with relative predisposition to the development of diseases related to mood disorders ( Santangelo et al. , 2018 ).

Indeed, the university brings big changes in to students’ life. The pace of life becomes more intense, the workload of studies is increased, and often the geographical distance of the family may provoke feelings such as disappointment, irritability, anxiety and impatience during graduation ( Fernandes et al. , 2018 ; Ibrahim et al. , 2013 ; Provenzano et al. , 2018 ; Santangelo et al. , 2019 ; Santangelo et al. , 2018 ). Such situations are, in many cases, anxiety factors and possible triggers for depression. A high prevalence of depression in university students is observed, on average 30.6 per cent, while for the population in general, this prevalence corresponds to 9 per cent ( Fernandes et al. , 2018 ). In particular, when compared with other university students, nursing students have additional factors that may cause or contribute to depressive symptoms, such as disinterest in the nurse course, a low-grade point average, worry about future placement, workload, study assignments, fear of unknown conditions, handling technical equipment, mistakes with patients in clinical practices and situations in which they must deal with the imminence of death ( Chen et al. , 2019 ; Fernandes et al. , 2018 ). Many studies have confirmed that nursing students have a high risk of depressive symptoms and depression. According to a recent review, approximately 34.0 per cent of nursing students had experienced depression worldwide ( Tung et al. , 2018 ). Depressive disorders can lead to the onset of a reduction of academic achievement and abuse of alcoholic beverages ( Eisenberg et al. , 2009 ). Moreover, studies have shown that depression is among the strongest risk factors for suicide attempt in nursing students ( Aradilla-Herrero et al. , 2014 ). Data from longitudinal studies show that these symptoms persist for a long period of time if students do not receive appropriate help ( Newbury-Birch et al. , 2002 ). Therefore, it is necessary to identify valid and protracted approaches that aim to help nursing students deal with depressive symptoms and depression.

The objective of our study was to estimate the prevalence and examine the socio-demographic correlates of depressive symptomatology within the student population of the degree course in nursing at the University of Palermo to focus attention on the mental and behavioral disorders of this population, to improve the quality of life and to prevent the future development of diseases.

Materials and methods

This study was approved by the Ethical Committee of the University Hospital “P. Giaccone” of Palermo, Minutes No. 02/2019 (15. Studio A.D.A.3) of February 18, 2019. In the month of April 2019, a survey was provided to all the nursing students of University of Palermo of the three years of course, accompanied by informed consent. In the first section of the questionnaire, personal information was requested, relating to the course of study undertaken, job, chronic illnesses, the perception of the economic and health status and voluptuous habits. In the second part of the survey, the Quick Inventory of Depressive Symptomatology Self-Report (QIDS-SR16) questionnaire was administered, a self-report tool that allows evaluation of the severity of depressive symptomatology by administering 16 items with 4 possible answers to which a score ranging from 0 to 3 is attributed. The QIDS-SR16 is derived from the 30-item Inventory of Depressive Symptomatology, which has seen many years of use at the University of Texas Southwestern Medical School ( Rush et al. , 2003 ).

Questions in the QIDS-SR16 include: sleep disturbance (initial, middle and late insomnia or hypersomnia), sad mood, decrease/increase in appetite/weight, concentration, self-criticism, suicidal ideation, interest, energy/fatigue and psychomotor agitation/retardation. Based on the score, the subjects are assigned to one of the following categories: (0-5) no depressive symptomatology, (6-10) mild, (11-15) moderate, (16-20) severe and (≥21) very severe depressive symptomatology.

The variable “age” was subsequently dichotomized in <22 years and ≥22 years because the average age of the sample participants was 21.88 years. For all qualitative variables, absolute and relative frequencies have been calculated; categorical variables were analyzed by Pearson’s chi-square test ( x 2 ). Multivariable logistic regression was performed, considering it as a dependent variable “depressive symptomatology moderate-severe-very severe.” To evaluate the role of the variables in the first section of the questionnaire, the covariates to be included into the final model were selected using a stepwise backward selection process, with a univariate p -value <0.25 as the main criterion ( Hosmer and Lemeshow, 1989 ). The statistical significance level chosen for all analyses was 0.05. The results were analyzed using the STATA statistical software version 14 ( StataCorp, 2015 ). Results are expressed as adjusted odds ratio (aOR) with 95 per cent confidence intervals (CI).

The sample size consists of 493 students who agreed to the informed consent and completed the questionnaire. Only five third-year students did not complete the questionnaire, two of them refused consent and three were not traceable. The average age of the sample participants is 21.88 years (standard deviation ± 3.38), 67.55 per cent of the interviewees are women, 99.59 per cent were born in Italy, 71.60 per cent are single, 40.57 per cent report to attend the first year of study, 30.83 per cent attend the second year of study and 28.60 are in the third year of study. In all 39.55 per cent were off-site students, 78.50 per cent live with their families, 7.30 per cent report that they currently have a job, 77.28 per cent report a low perceived economic status, 29.41 per cent currently smoke, 59.23 per cent do not exercise regularly, 26.57 per cent report a low perceived health status and 11.77 per cent of the interviewees show a moderate severe anxiety symptomatology ( Table I ). Regarding bivariate analysis, statistically significant differences were found for the following variables: “gender?”, “are you a student off-site or in-site or commuter students?”, “do you perform regular physical activity?”, “perceived health status”, and “do you have chronic illnesses?” ( Table II ). Table III shows aOR. A multivariable logistic regression model was used based on 493 observations. Each independent variable has been adjusted for all the other independent variables. The analysis shows that the risk to have depressive symptomatology (moderate, severe or very severe) is significantly associated with the following independent variables: female gender (aOR 1.91, 95 per cent CI 1.05-3.48, p = 0.035); being single at the time of study (aOR 1.87, 95 per cent CI 1.02-3.44, p = 0.044); second year of study (aOR 1.94, 95 per cent CI 1.03-3.65, p = 0.042); third year of study (aOR 1.92, 95 per cent CI 1.03-3.59, p = 0.040); not performing regular physical activity (aOR 1.78, 95 per cent CI 1.02-3.11, p = 0.044) and perceived low health status (aOR 3.08, 95 per cent CI 1.80-5.25, p < 0.001).

“What a stress!” “What anxiety!” “What a depression!” The boys often use these exclamations, in many cases as a simple interlayer, in others as a real expression of emotional malaise. In Italy there are about 800,000 depressed young people: an international survey conducted by Sodexo (2019) , a company that deals with services aimed at improving the quality of life, shows that more than 4,000 young Italian university students are most dissatisfied with their lives. Among the main concerns of young people are the workload and too many commitments ( Johnson et al. , 2018 ). More and more young people manifest personality disorders, lack of attention, listlessness, anxiety, depression and obsessive manias, and the phenomenon unfortunately seems to be increasing in recent years. The depressive symptomatology among students today represents an extremely important problem that can influence and compromise both academic performance and also work performance ( Santangelo et al. , 2018 ). Juvenile depression is constantly growing and it is assumed that in 2030, it will be the most widespread chronic disease among the very young population ( Crouch et al. , 2019 ; Werner-Seidler et al. , 2017 ). A very important fact that makes one think: why are young people so depressed? Unhappiness in young people is the consequence of the contemporary lifestyle. From our study conducted on a total of 493 students, of which 32.45 per cent are males (160), 67.55 per cent are females (333) and 40.16 per cent (198) are younger than 22 years and 59.84 per cent (295) are over the age of 22, it emerges that female individuals suffer from depressive symptoms more than male subjects. In fact, according to the data emerging from the multivariate logistic regression ( Table III ), female individuals have a 1.91 times greater risk than male subjects of being suffering from depressive disorder (moderate, severe or really severe). In adolescence and in adulthood, major depressive disorder occurs more commonly in women, with a ratio of 2:1 compared to males ( APA [American Psychological Association], 2019 ). The female preponderance in depression seems to begin around puberty, suggesting a probable link of the disorder to the woman’s generative period. Serretti et al. (2004) also confirms this fact, citing the fact that numerous studies have revealed a greater involvement in depressive states, especially between the ages of 15 and 30. As shown in the literature ( Pulkki-Råback et al. , 2012 ), being single at the time of study predisposes to a greater risk of depressive symptomatology (aOR 1.87). The data present in the literature ( Chernomas and Shapiro, 2013 ), however, leave many possibilities for interpretation open. For example, according to a hypothesis provided by a team of researchers, friendships and romantic relationships would provide relief from stress and increase the level of self-esteem of children, guaranteeing the development of effective interpersonal skills. The direct result of this would be the increase in the coping skills of young people in difficult situations ( Provenzano et al. , 2018 ). Years of university studies can upset the mental well-being of students, making them vulnerable to the damaging effects of many stressors, in many cases reducing academic performance, as reported in literature and academic sources ( Chernomas and Shapiro, 2013 ). Students later in the study years, second year (aOR 1.94) and third year (aOR 1.92), have a greater risk of developing severe and very severe depressive symptoms. Performing regular physical activity decreases the risk of suffering from depression (aOR 1.78). One aspect that is not immediately thought of when talking about the benefits of exercise is its link with mental health. Moving in fact helps to prevent depression too. It is an aspect that should not be underestimated and that makes the movement an important tool both in a preventive way and for the treatment of depressive states ( Atkins, 2017 ). The WHO recalls the benefits of physical activity on whole well-being, mind and body, which recommends 150 min of physical activity per week, aerobic and mild to moderate, for adults up to 65 years. Now new evidence on the close link between movement and mental well-being comes from an international study which was also attended by the University of New South Wales in Sydney (Australia) and published in the American Journal of Psychiatry . Regular exercise, at any intensity, has been associated with a reduction in the risk of depression ( Andersson et al. , 2015 ). The researchers collected data on physical activity levels and depressive symptoms in 33.908 Norwegian adults. It was found that 12 per cent of cases of depression could have been prevented if participants had only taken an hour of physical activity a week. In addition, those who reported being sedentary were 44 per cent more likely to develop depression than those who said they would engage in physical activity one to two hours a week. With physical exercise the body releases a series of neurotransmitters, first of all the endorphins, which are associated with a feeling of well-being and are activated by brain mechanisms modulated by physical activity ( Italian Ministry of Health, 2019 ). Finally, individuals who perceive a lower health status have a greater risk of developing depressive symptoms (aOR 3.08). Depression is a condition associated with suffering and disability and constitutes a significant source of direct and indirect costs. In adolescence, the presence of depressive symptomatology is a frequent and often serious condition, which can be associated with a low perception of the status of health, socio-economic status or the presence of diseases ( Han et al. , 2019 ).

Conclusions

Systematic review and meta-analysis show that a high-pooled prevalence of depression was reported among nursing students ( Tung et al. , 2018 ). Sleep disturbance (initial, middle and late insomnia or hypersomnia), sad mood, decrease/increase in appetite/weight, concentration, self-criticism and psychomotor agitation/retardation until suicidal ideation are only some of the sensations characterizing depressive status, with a different weight depending on the severity, that we tried to analyze. Our study, carried out on nursing students of the University of Palermo, also tried to identify the copious variables associated with this status, variables that have to be known to intervene and prevent the important consequences that can manifest in young people who are depressed. Being female, further ahead in the year of study, having chronic illness and perceiving low health status are factors that can increase the risk to develop depressive symptoms. On the contrary, performing regular physical activity, friendship and romantic relations can be helpful to face with more positivity the problems and difficulties that young students can bump into during their academic career, protecting them from the risk of falling into depression that can undermine both study and work performances, with direct and indirect costs. Certainly it is important to be able to recognize all the signs that can reveal a suffering mental status, to not confuse a serious psychiatric syndrome, as depression is, with a simple bad mood. This would enable us to analyze all the variables involved to improve the global health not only of the nursing students, but also of the nurses that they would become and, as consequence, of their patients. In conclusion, this study shows that the high prevalence of depression among the students can be mitigated only with continual efforts by the education institutions and further research.

Acknowledgement

Funding : None.

Competing interests: None declared.

Ethical approval: This study was approved by the Ethical Committee of the University Hospital “P. Giaccone” of Palermo, Minutes No. 02/2019 (15. Studio A.D.A.3) of February 18, 2019.

Author’s contribution statement: Sandro Provenzano, Omar E. Santangelo, Domiziana Giordano and Alberto Firenze conceived, designed, coordinated and supervised the research project. Sandro Provenzano and Omar E. Santangelo performed the data quality control, optimized the informatics database, performed the statistical analyses and evaluated the results. Sandro Provenzano, Omar E. Santangelo, Domiziana Giordano, Enrico Alagna, Francesco Armetta, Claudia Gliubizzi, Dalila Barresi, Dimple Grigis, Alberto Firenze, Antonio Terranova, Giuseppe D’Anna, Cristina Genovese and Raffaele Squeri wrote the manuscript. All authors read and approved the final manuscript.

Submission declaration: The submission has not been previously published.

Description of the sample

Stepwise backward selection process with a univariate p -value < 0.25 as the main criterion. aOR are presented. Each independent variable is adjusted for all the other independent variables. Based on 493 observations

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Stress, Depression, and Anxiety among Undergraduate Nursing Students

Admission to a professional program marks the beginning of fulfilling a career goal. However, the rigors of professional education can be demanding. Stress, depression, and anxiety (SDA) can interfere with learning, affect academic performance, and impair clinical practice performance. Studies report a general increase in the severity of and extent of mental health problems among college/university students. The literature regarding nursing students’ mental health distress identifies academic and personal sources of stress and coping efforts, with emphasis on the stress and anxiety associated with clinical practice. This cross-sectional descriptive exploratory study investigated levels of SDA among nursing students in 3 years of a university-based program. The association between quality of life indicators including known stressors, such as financial concerns and balance between school and personal life, and SDA was also investigated. Through an online survey, 437 participants from one mid-western Canadian undergraduate nursing program completed the Depression Anxiety Stress Scales and provided data on quality of life indicators and demographic information. Participants also were invited to provide narrative data about their experiences with SDA. This article will present significant findings including: levels of SDA; comparisons between our sample and a normative sample on the dimensions of SDA; and the results of multiple regression analysis identifying significant predictors of each dimension. Themes from the qualitative comments from 251 of the participants were identified and added depth and clarity to the quantitative findings. The predominant themes represented were: perceptions of clinical practice, coping, personal issues, and balancing school, work, and personal life. Implications and recommendations for curriculum design, ensuring students understand program expectations prior to admission, and enhancing accessibility to mental health/support services need to be considered.

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Depression Nursing Diagnosis and Nursing Care Plan

Last updated on April 29th, 2023 at 11:58 pm

Depression Nursing Care Plans Diagnosis and Interventions

Depression NCLEX Review and Nursing Care Plans

Depression is a mood disorder wherein the patient experiences a persistent feeling of loneliness and loss of interest which is otherwise different from usual episodes of sadness.

This disorder greatly affects the person’s thinking, emotions, and behavior, consequently affecting how he/she performs activities of daily living.

Also called major depressive disorder or clinical depression, this mood disorder will require a long-term and comprehensive treatment plan to prevent the development to a more serious and debilitating psychiatric condition.

Signs and Symptoms of Depression

• Feelings of sadness, emptiness, hopelessness
• Angry outbursts
• Easy irritability
• May appear withdrawn, avoids socializations
• Loss of interest in most normal activities such as hobbies
• Sleep disturbances (difficulty sleeping or too much sleeping)
• Lack of energy
• Discrepancies in eating habits (either overeating loss of appetite)
• Restlessness and anxiety
• Sluggish thinking, speaking
• Feelings of worthlessness, particularly from past failures
• Cognitive discrepancies (such as difficulty concentrating or memory faults)
• Suicidal thoughts
• Unexplained aches and pains  

Types of Depression

The types of depression according to specifiers include:

1. Anxious distress – A type of depression characterized by having feelings of losing control.  

2. Mixed features – A subtype with features of depression and mania .

3. Melancholic features – Another subtype wherein the patient experiences severe depression and lacking enthusiasm in activities of daily living.

4. Atypical features – Another subtype wherein the patient can be temporarily lifted from depressed moods through happy events, increased appetite, and sensitivity to rejection.

5. Psychotic features – A depression subtype with accompanying delusions or hallucinations.

6. Catatonia – A form of depression characterized by unpurposeful and uncontrollable movement (such as Fixed posturing)

7. Peripartum onset – A subtype encountered during pregnancy or weeks after giving birth (postpartum)

8. Seasonal pattern – A subtype with the changes in season and the amount of exposure to sunlight. 

Causes and Risk Factors of Depression

The causes of depression vary, but they can be clustered through the following:

• Biological differences. Depressed patients tend to have changes in the biologic structure of their brains.
• Changes in brain chemistry. Neurotransmitters are essential chemicals responsible for the communications between neurons in the brain. Changes in the levels of these chemicals play a vital role in the mood stability of the patient and the effect of treatment for depression.
• Hormonal imbalance. Some hormones may trigger changes in a patient’s mood. Such instances can occur for women on post-partum, people on birth control medications, or on patients with thyroid problems.
• Inherited traits. Patients whose relatives or family members have experienced depression are more prone to develop its symptoms.

The risk factors of depression are enumerated below:

• Depression usually begins during teens, in the 20’s or 30’s, but can occur at any age
• More commonly diagnosed in women than men
• Certain personality traits (such as pessimism, low self-esteem)
• Traumatic events (such as history of sexual abuse, financial problems, accidents)
• Familial history of depression, bipolar disorder , or suicide
• Being lesbian, gay, bisexual, or transgender with poor psychosocial support
• History of mental health disorders (such as eating disorders)
• Substance abuse (such as alcohol, drugs)
• Chronic or debilitating illness (such as cancer, heart disease)
• Medications (such as sleeping pills and birth control medications)

Complications of Depression

• Excess weight that can lead to heart disease and diabetes mellitus
• Pain or actual illness
• Substance abuse
• Anxiety attacks, social phobias
• Interpersonal problems (such as problems in family dynamics)
• Social isolation
• Suicide ideations or suicide
• Self-harm or mutilation
• Premature death brought about by co-morbidities

Diagnosis for Depression

• Physical exam – to evaluate baseline health of the patient. Some causes of depression may be due to underlying conditions (such as heart disease)
• Blood tests – to determine the baseline physical health of the patient. An example of which is thyroid function tests in which changes in the levels could indicate thyroid disease.
• Psychiatric evaluation – a professional evaluation to determine and profile the baseline psychological health of the patient by assessing behaviors, moods, thoughts, and feelings, etc. 
• DSM 5 – The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) will be utilized to properly identify and classify the depression.

Treatment for Depression

Treating depression involves the following therapeutic regimens:

• Medications. Prescribed drugs are given as first line treatment for depression for it acts on the neurotransmitters in a patient’s brain. Examples of the drug classes used for clinical depression are:
• Selective serotonin reuptake inhibitors (SSRI)
• Serotonin-norepinephrine reuptake inhibitors (SNRI)
• Atypical depressants
• Tricyclic depressants
• Monoamine Oxidase Inhibitors (MAOI)

2. Psychotherapy. Also known as talk therapy, psychotherapy is utilized to explore depression and other related issues of the patient with the help of a certified mental health physician called a psychiatrist. Some types of psychotherapy include Cognitive Behavioral Therapy (CBT) or interpersonal therapy which aims to develop resilience to stressful situations.

3. Admission to a mental health care facility. In instances where depression is severe, causing for the patient to inflict harm, patients are institutionalized for further management. Being surrounded and monitored by healthcare workers will mitigate the violent tendencies of the depressed patient.

Other treatment options. If medications and psychotherapy proved to be ineffective in treating depression, some drastic procedures are done to address the condition, which may include:

4. Electroconvulsive therapy (ECT) – involves passing of electrical currents to the brain with the goal of impacting the functions of the neuron and effects of neurotransmitters.

5. Transcranial magnetic stimulation (TMS) – a procedure which makes use of brief magnetic impulses sent to the brain to stimulate the neurons involved in mood regulation.

Nursing Diagnosis for Depression

Nursing care plan for depression 1.

Nursing Diagnosis : Disturbed Thought Process related to biochemical/ neurophysical imbalance secondary to depression as evidenced by impaired insight and judgment, poor decision-making skills, difficulty handling complex tasks, confusion and disorientation, inability to do activities of daily living (ADLs) as normal

Desired Outcome: The patient will be able to regain appropriate mental and physical functioning.

Nursing Care Plan for Depression 2

Nursing Diagnosis: Impaired Social Interaction related to social isolation secondary to clinical depression as evidenced by withdrawal from group gatherings or social events, anxiety , impaired perception, inability to meet basic needs and role expectations

Desired Outcome: The patient will demonstrate improved social interaction by increased participation in social events.

Nursing Care Plan for Depression 3

Risk for Self-directed Violence

Nursing Diagnosis: Risk for Self-directed Violence related to loneliness, social isolation, helplessness, hopelessness, anhedonia, severe personality disorder, psychosis or substance abuse secondary to depression possibly evidenced by suicidal behavior (ideation, attempts, plan and available means), previous attempts of violence, having a suicidal plan that is clear and specific (lethal method and available means), having the energy to carry out the suicidal plan when depression begins to lift.

Desired Outcomes : 

• The patient will seek help when encountering self-destructive impulses.
• The patient will demonstrate a behavioral manifestation of absent depression.
• The patient will demonstrate satisfaction with social circumstances and attainment of life goals
• The patient will not inflict harm on herself/ himself or to others.
• The patient will identify at least 2-3 people he/she can seek out for support and emotional guidance whenever he/she is feeling self-destructive prior to discharge.
• The patient will identify support and support groups with whom he/she is in contact within a month.
• The patient will verbalize that he/she wants to live.
• The patient will demonstrate compliance to medication or treatment plan within the next 2 weeks.
• The patient will start constructing plans for the future.
• The patient will demonstrate alternative ways in dealing with negative feelings and emotional stress.

Nursing Care Plan for Depression 4

Chronic Low Self-Esteem

Nursing Diagnosis: Chronic Low Self-Esteem related to feelings of shame and guilt, biochemical or neurophysiological imbalances, impaired cognitive self-appraisal, unrealistic expectation of self, and repeated past failure secondary to depression as possibly evidenced by inability to recognize one’s own achievement, negative view of self and abilities, repeated expression of worthlessness, rejection of a positive feedback, verbalization of self-negating statements, and evaluation of oneself as unable to deal with events.

Desired Outcomes: 

• The patient will express belief in himself/herself.
• The patient will maintain his/her self-esteem.
• The patient will show a zeal for life and the ability to enjoy the current moment.
• By the end of the day, the patient will have identified one or two strengths.
• The patient will have identified two unreasonable self-expectations and will have reformulated more realistic life objectives with the nurse by the end of the day.
• The patient will select 3 judgmental adjectives that he/she uses to describe himself/herself (e.g., “I am lazy”) and replace them with objective terms (e.g., “I do not feel inspired to”).
• The patient will keep a daily load and rate his/her feelings of guilt, humiliation, and self-hatred on a scale of 1 to 10 (1 being the lowest, 10 being the highest).
• On a scale of 1 to 10, the patient will report diminished feelings of guilt, shame, and self-hatred (1 being the lowest, 10 being the highest).
• The patient will show that he or she can change unrealistic self-expectations.
• Patient will describe four positive attributes in a factual and nonjudgmental manner, as well as two areas in which he or she wishes to improve.

Nursing Care Plan for Depression 5

Spiritual Distress

Nursing Diagnosis : Spiritual Distress related to death or dying of self or others, chronic illness of self or others, life changes, lack of purpose in life, pain , and self-alienation, or sociocultural deprivation secondary to depression as evidenced by expression of intense feelings of guilt, hopelessness and helplessness, expression of being abandoned by or having anger towards God, expressing concern with the meaning of life or death or belief systems, expression of  lack of hope, meaning, or purpose in life, forgiveness of self, peach, serenity, and acceptance, inability to pray, express previous state of creativity or participate in religious activities, lack of interest in art, questioning the meaning of one’s own existence, refusion to interact with families, friends or religious leaders and searching for a spiritual source of strength.

• The patient will feel a sense of belongingness as he/she shares their thoughts, feelings, and beliefs with others.
• The patient will experience a sense of inner self-connection.
• The patient will take part in spiritual rites and rites of passage.
• Within three days, the patient will share with the nurse two items that have given meaning to his or her life in the past.
• Within three days, the patient will speak with a nurse or a spiritual leader about spiritual problems and concerns.
• For one week, the patient will keep a journal of his or her thoughts and feelings.
• The patient will express that he or she feels forgiven.
• The patient will express a desire to return to previous creative endeavors.
• The patient will verbalize that previous spiritual practices provided solace to him/her.

Other possible nursing diagnosis:

• Powerlessness / Hopelessness
• Self-care Deficit

Nursing References

Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020).  Nursing diagnoses handbook: An evidence-based guide to planning care . St. Louis, MO: Elsevier.  Buy on Amazon

Gulanick, M., & Myers, J. L. (2022).  Nursing care plans: Diagnoses, interventions, & outcomes . St. Louis, MO: Elsevier. Buy on Amazon

Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018).  Medical-surgical nursing: Concepts for interprofessional collaborative care . St. Louis, MO: Elsevier.  Buy on Amazon

Silvestri, L. A. (2020).  Saunders comprehensive review for the NCLEX-RN examination . St. Louis, MO: Elsevier.  Buy on Amazon

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Psychological Distress, Depression, and Anxiety in Nursing Students: A Longitudinal Study

Affiliations.

• 1 Department of Public Health, Akdeniz University Faculty of Medicine, Antalya 07058, Turkey.
• 2 Department of Public Health Nursing, Akdeniz University Faculty of Nursing, Antalya 07058, Turkey.
• PMID: 36900639
• PMCID: PMC10001336
• DOI: 10.3390/healthcare11050636

The aim of this longitudinal study is to determine how stressful life events, psychological distress, depressive symptoms, and anxiety change in a cohort of students from one nursing faculty during the education process and to document the factors related to psychological distress, depressive symptoms, and anxiety during the fourth year of education. The General Health Questionnaire (GHQ-12), the Beck Depression Inventory (BDI), and the State-Trait Anxiety Inventory (STAI) were applied to students within the faculty of nursing within the first week of the 2018-2019 academic year. All students were asked to answer a questionnaire measuring their possible stressful life events (first timepoint). The process was repeated for the same students again in the fourth year (second timepoint). The changes between the two timepoints were examined. Nursing students' GHQ-12 and STAI scores and averages increased significantly from first timepoint to second timepoint ( p < 0.05). There was a significant increase in the prevalence of depressive symptoms for the ≥21 cut-off point of BDI in the fourth year of the study cohort. A significant increase in perceived stress levels between the two timepoints was also found for numerous stressful life events. As a result of linear regression, "dissatisfaction with major" was found as a determinant on all scale scores. The psychological indicators increased significantly in nursing students during their education. Interventions to reduce stress, anxiety, and psychological distress are needed to improve the mental health status of nursing students.

Keywords: anxiety; depressive symptoms; longitudinal study; nursing students; perceived stress; psychological distress.

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Case Studies

Case 5: denise.

Denise, a 19-year-old woman, has been admitted informally to an acute mental health ward; this is Denise's first admission. Denise was being treated for depression by her GP; prior to her admission Denise attempted to kill herself by cutting her wrists. Subsequently a short admission was arranged with the aim of devising a comprehensive care package.

After speaking about the circumstances leading up to her suicide attempt Denise became increasingly tearful and distressed, and started demanding to see a doctor. After being told that the doctor was on their way and would arrive in about 10 minutes, Denise became angry demanding medication to calm her down; she then proceeded to run towards the ward's doors shouting that she wanted to go home. At that moment the doctor arrived on the ward and Denise also immediately calmed down.

During the assessment process Denise disclosed that being angry if she did not get her way was not unusual for her. She also mentioned that she felt awful after these bouts of anger. She described herself as a "terrible person who was out of control" and she just wanted to die. After assessing Denise the nurse started to formulate a plan of care.

(a) What type of psychological interventions would the nurse consider implementing?

Show Answer

• Build a collaborative and therapeutic relationship based on a person-centred approach.
• Normalise an individual's experiences of mental distress.
• Take a "strengths approach".
• Maintain safety and effectively manage challenging behaviours.
• Explore the individual's capacity to change.
• Modify thought processes – identify, challenge and replace negative thoughts.
• Focus on the individual controlling and regulating their behaviour – promoting and enhancing healthy ways of coping.
• Prevent social isolation and promote social functioning.
• Focus on relapse prevention – early warning signs and self-monitoring of symptoms.
• Signpost to self-help and relevant support groups.
• Therapeutically support recovery.

(b) Currently Denise has been admitted informally to the ward. Due to Denise's impulse control difficulties this may change. On this basis what does the nurse professionally need to know when managing Denise's legal status?

• Understand and apply current legislation in a way that protects Denise.
• Act in accordance with the law, relevant ethical and regulatory frameworks, and also take into account local protocols/policies.
• Respect and uphold Denise's rights
• Know when to actively share personal information with others when the interests of safety and protection override the need for confidentiality.

(c) Denise is subsequently diagnosed with a "borderline personality disorder". What other types of personality disorders are there?

• Cluster A – paranoid, schizoid and schizotypal.
• Cluster B – antisocial (type: dissocial), borderline (type: emotionally unstable), histrionic, and narcissistic (not included in types).
• Cluster C – avoidant (type: anxious), dependent, obsessive-compulsive (type: anankastic).
• paranoid – suspicious and excessively sensitive;
• schizoid – emotional coldness, little interest in other people;
• schizotypal – odd beliefs and unusual appearance;
• borderline – instability of mood, impulsive;
• histrionic – excessive attention seeking;
• narcissistic – grandiose and arrogant;
• antisocial – disregard of self and others;
• avoidant – feelings of inadequacy;
• dependent – submissive behaviour;
• 0bsessive-compulsive – a preoccupation with orderliness.

(d) What specific psychological interventions would the nurse deliver?

• boundary setting;
• promoting healthy ways of coping;
• motivational interviewing and pre-therapy work;
• delivering specific therapeutic approaches/therapies.

(e) How could the nurse learn from their experiences of working with Denise?

• identifying and describing the experiences;
• examining the experiences in depth and teasing out the key issues;
• critically processing the issues;
• learning from the experiences by implementing future actions that improve the nurse's practice.

Denise has now been on the ward for over 6 months. Each time discharge has been arranged Denise self-harms or threatens suicide. Denise has now agreed to go to a therapeutic community, a place has been secured and Denise is now engaging in pre-therapy work.

(a) What other treatments besides a therapeutic community are recommended for individuals diagnosed with a borderline personality disorder?

• cognitive behaviour therapy – group and individual;
• behavioural approaches;
• mentalisation-based approaches;
• dialectic behaviour therapy.

(b) While working with Denise the primary nurse has found the relationship at times to be quite stressful. What are the signs of stress?

• sleep problems;
• loss of appetite;
• difficulty concentrating;
• constantly feeling anxious;
• feeling irritable and/or angry;
• having repeating thoughts;
• avoiding certain situations and/or people;
• an increased use of alcohol;
• muscle tension.

(c) What strategies could the nurse use to manage their stress?

• engage in physical activity;
• engage in something that makes them laugh;
• learn relaxation and/or deep breathing techniques;
• take control of the situation;
• seek support and talk;
• problem solve;
• eat a healthily diet;
• drink plenty of water;
• be mindful.

(d) What process should be utilised as a way to support the primary nurse to improve their practice?

Correct answer: A common method of systematically reflecting on practice is through the clinical supervision, which is a formal activity where a clinical supervisor facilitates the nurse to reflect upon their practice and identify strategies that focus on improving their practice.

Consider Chapters 20, 34 and 37.

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• NICE Guidance
• Conditions and diseases
• Mental health, behavioural and neurodevelopmental conditions

Common mental health problems: identification and pathways to care

Clinical guideline [CG123] Published: 25 May 2011

This guideline has been stood down. All of the recommendations are now covered in other NICE guidelines, or are out of date and no longer relevant to clinical practice.

For guidance on common mental health problems, see our guidelines on:

• Depression in adults
• Depression in adults with a chronic physical health problem
• Depression in children and young people
• Generalised anxiety disorder and panic disorder in adults
• Obsessive-compulsive disorder and body dysmorphic disorder
• Social anxiety disorder

• Open access
• Published: 14 May 2024

Developing a survey to measure nursing students’ knowledge, attitudes and beliefs, influences, and willingness to be involved in Medical Assistance in Dying (MAiD): a mixed method modified e-Delphi study

• Jocelyn Schroeder 1 ,
• Barbara Pesut 1 , 2 ,
• Lise Olsen 2 ,
• Nelly D. Oelke 2 &
• Helen Sharp 2  

BMC Nursing volume  23 , Article number:  326 ( 2024 ) Cite this article

Metrics details

Medical Assistance in Dying (MAiD) was legalized in Canada in 2016. Canada’s legislation is the first to permit Nurse Practitioners (NP) to serve as independent MAiD assessors and providers. Registered Nurses’ (RN) also have important roles in MAiD that include MAiD care coordination; client and family teaching and support, MAiD procedural quality; healthcare provider and public education; and bereavement care for family. Nurses have a right under the law to conscientious objection to participating in MAiD. Therefore, it is essential to prepare nurses in their entry-level education for the practice implications and moral complexities inherent in this practice. Knowing what nursing students think about MAiD is a critical first step. Therefore, the purpose of this study was to develop a survey to measure nursing students’ knowledge, attitudes and beliefs, influences, and willingness to be involved in MAiD in the Canadian context.

The design was a mixed-method, modified e-Delphi method that entailed item generation from the literature, item refinement through a 2 round survey of an expert faculty panel, and item validation through a cognitive focus group interview with nursing students. The settings were a University located in an urban area and a College located in a rural area in Western Canada.

During phase 1, a 56-item survey was developed from existing literature that included demographic items and items designed to measure experience with death and dying (including MAiD), education and preparation, attitudes and beliefs, influences on those beliefs, and anticipated future involvement. During phase 2, an expert faculty panel reviewed, modified, and prioritized the items yielding 51 items. During phase 3, a sample of nursing students further evaluated and modified the language in the survey to aid readability and comprehension. The final survey consists of 45 items including 4 case studies.

Systematic evaluation of knowledge-to-date coupled with stakeholder perspectives supports robust survey design. This study yielded a survey to assess nursing students’ attitudes toward MAiD in a Canadian context.

The survey is appropriate for use in education and research to measure knowledge and attitudes about MAiD among nurse trainees and can be a helpful step in preparing nursing students for entry-level practice.

Peer Review reports

Medical Assistance in Dying (MAiD) is permitted under an amendment to Canada’s Criminal Code which was passed in 2016 [ 1 ]. MAiD is defined in the legislation as both self-administered and clinician-administered medication for the purpose of causing death. In the 2016 Bill C-14 legislation one of the eligibility criteria was that an applicant for MAiD must have a reasonably foreseeable natural death although this term was not defined. It was left to the clinical judgement of MAiD assessors and providers to determine the time frame that constitutes reasonably foreseeable [ 2 ]. However, in 2021 under Bill C-7, the eligibility criteria for MAiD were changed to allow individuals with irreversible medical conditions, declining health, and suffering, but whose natural death was not reasonably foreseeable, to receive MAiD [ 3 ]. This population of MAiD applicants are referred to as Track 2 MAiD (those whose natural death is foreseeable are referred to as Track 1). Track 2 applicants are subject to additional safeguards under the 2021 C-7 legislation.

Three additional proposed changes to the legislation have been extensively studied by Canadian Expert Panels (Council of Canadian Academics [CCA]) [ 4 , 5 , 6 ] First, under the legislation that defines Track 2, individuals with mental disease as their sole underlying medical condition may apply for MAiD, but implementation of this practice is embargoed until March 2027 [ 4 ]. Second, there is consideration of allowing MAiD to be implemented through advanced consent. This would make it possible for persons living with dementia to receive MAID after they have lost the capacity to consent to the procedure [ 5 ]. Third, there is consideration of extending MAiD to mature minors. A mature minor is defined as “a person under the age of majority…and who has the capacity to understand and appreciate the nature and consequences of a decision” ([ 6 ] p. 5). In summary, since the legalization of MAiD in 2016 the eligibility criteria and safeguards have evolved significantly with consequent implications for nurses and nursing care. Further, the number of Canadians who access MAiD shows steady increases since 2016 [ 7 ] and it is expected that these increases will continue in the foreseeable future.

Nurses have been integral to MAiD care in the Canadian context. While other countries such as Belgium and the Netherlands also permit euthanasia, Canada is the first country to allow Nurse Practitioners (Registered Nurses with additional preparation typically achieved at the graduate level) to act independently as assessors and providers of MAiD [ 1 ]. Although the role of Registered Nurses (RNs) in MAiD is not defined in federal legislation, it has been addressed at the provincial/territorial-level with variability in scope of practice by region [ 8 , 9 ]. For example, there are differences with respect to the obligation of the nurse to provide information to patients about MAiD, and to the degree that nurses are expected to ensure that patient eligibility criteria and safeguards are met prior to their participation [ 10 ]. Studies conducted in the Canadian context indicate that RNs perform essential roles in MAiD care coordination; client and family teaching and support; MAiD procedural quality; healthcare provider and public education; and bereavement care for family [ 9 , 11 ]. Nurse practitioners and RNs are integral to a robust MAiD care system in Canada and hence need to be well-prepared for their role [ 12 ].

Previous studies have found that end of life care, and MAiD specifically, raise complex moral and ethical issues for nurses [ 13 , 14 , 15 , 16 ]. The knowledge, attitudes, and beliefs of nurses are important across practice settings because nurses have consistent, ongoing, and direct contact with patients who experience chronic or life-limiting health conditions. Canadian studies exploring nurses’ moral and ethical decision-making in relation to MAiD reveal that although some nurses are clear in their support for, or opposition to, MAiD, others are unclear on what they believe to be good and right [ 14 ]. Empirical findings suggest that nurses go through a period of moral sense-making that is often informed by their family, peers, and initial experiences with MAID [ 17 , 18 ]. Canadian legislation and policy specifies that nurses are not required to participate in MAiD and may recuse themselves as conscientious objectors with appropriate steps to ensure ongoing and safe care of patients [ 1 , 19 ]. However, with so many nurses having to reflect on and make sense of their moral position, it is essential that they are given adequate time and preparation to make an informed and thoughtful decision before they participate in a MAID death [ 20 , 21 ].

It is well established that nursing students receive inconsistent exposure to end of life care issues [ 22 ] and little or no training related to MAiD [ 23 ]. Without such education and reflection time in pre-entry nursing preparation, nurses are at significant risk for moral harm. An important first step in providing this preparation is to be able to assess the knowledge, values, and beliefs of nursing students regarding MAID and end of life care. As demand for MAiD increases along with the complexities of MAiD, it is critical to understand the knowledge, attitudes, and likelihood of engagement with MAiD among nursing students as a baseline upon which to build curriculum and as a means to track these variables over time.

Aim, design, and setting

The aim of this study was to develop a survey to measure nursing students’ knowledge, attitudes and beliefs, influences, and willingness to be involved in MAiD in the Canadian context. We sought to explore both their willingness to be involved in the registered nursing role and in the nurse practitioner role should they chose to prepare themselves to that level of education. The design was a mixed-method, modified e-Delphi method that entailed item generation, item refinement through an expert faculty panel [ 24 , 25 , 26 ], and initial item validation through a cognitive focus group interview with nursing students [ 27 ]. The settings were a University located in an urban area and a College located in a rural area in Western Canada.

Participants

A panel of 10 faculty from the two nursing education programs were recruited for Phase 2 of the e-Delphi. To be included, faculty were required to have a minimum of three years of experience in nurse education, be employed as nursing faculty, and self-identify as having experience with MAiD. A convenience sample of 5 fourth-year nursing students were recruited to participate in Phase 3. Students had to be in good standing in the nursing program and be willing to share their experiences of the survey in an online group interview format.

The modified e-Delphi was conducted in 3 phases: Phase 1 entailed item generation through literature and existing survey review. Phase 2 entailed item refinement through a faculty expert panel review with focus on content validity, prioritization, and revision of item wording [ 25 ]. Phase 3 entailed an assessment of face validity through focus group-based cognitive interview with nursing students.

Phase I. Item generation through literature review

The goal of phase 1 was to develop a bank of survey items that would represent the variables of interest and which could be provided to expert faculty in Phase 2. Initial survey items were generated through a literature review of similar surveys designed to assess knowledge and attitudes toward MAiD/euthanasia in healthcare providers; Canadian empirical studies on nurses’ roles and/or experiences with MAiD; and legislative and expert panel documents that outlined proposed changes to the legislative eligibility criteria and safeguards. The literature review was conducted in three online databases: CINAHL, PsycINFO, and Medline. Key words for the search included nurses , nursing students , medical students , NPs, MAiD , euthanasia , assisted death , and end-of-life care . Only articles written in English were reviewed. The legalization and legislation of MAiD is new in many countries; therefore, studies that were greater than twenty years old were excluded, no further exclusion criteria set for country.

Items from surveys designed to measure similar variables in other health care providers and geographic contexts were placed in a table and similar items were collated and revised into a single item. Then key variables were identified from the empirical literature on nurses and MAiD in Canada and checked against the items derived from the surveys to ensure that each of the key variables were represented. For example, conscientious objection has figured prominently in the Canadian literature, but there were few items that assessed knowledge of conscientious objection in other surveys and so items were added [ 15 , 21 , 28 , 29 ]. Finally, four case studies were added to the survey to address the anticipated changes to the Canadian legislation. The case studies were based upon the inclusion of mature minors, advanced consent, and mental disorder as the sole underlying medical condition. The intention was to assess nurses’ beliefs and comfort with these potential legislative changes.

Phase 2. Item refinement through expert panel review

The goal of phase 2 was to refine and prioritize the proposed survey items identified in phase 1 using a modified e-Delphi approach to achieve consensus among an expert panel [ 26 ]. Items from phase 1 were presented to an expert faculty panel using a Qualtrics (Provo, UT) online survey. Panel members were asked to review each item to determine if it should be: included, excluded or adapted for the survey. When adapted was selected faculty experts were asked to provide rationale and suggestions for adaptation through the use of an open text box. Items that reached a level of 75% consensus for either inclusion or adaptation were retained [ 25 , 26 ]. New items were categorized and added, and a revised survey was presented to the panel of experts in round 2. Panel members were again asked to review items, including new items, to determine if it should be: included, excluded, or adapted for the survey. Round 2 of the modified e-Delphi approach also included an item prioritization activity, where participants were then asked to rate the importance of each item, based on a 5-point Likert scale (low to high importance), which De Vaus [ 30 ] states is helpful for increasing the reliability of responses. Items that reached a 75% consensus on inclusion were then considered in relation to the importance it was given by the expert panel. Quantitative data were managed using SPSS (IBM Corp).

Phase 3. Face validity through cognitive interviews with nursing students

The goal of phase 3 was to obtain initial face validity of the proposed survey using a sample of nursing student informants. More specifically, student participants were asked to discuss how items were interpreted, to identify confusing wording or other problematic construction of items, and to provide feedback about the survey as a whole including readability and organization [ 31 , 32 , 33 ]. The focus group was held online and audio recorded. A semi-structured interview guide was developed for this study that focused on clarity, meaning, order and wording of questions; emotions evoked by the questions; and overall survey cohesion and length was used to obtain data (see Supplementary Material 2  for the interview guide). A prompt to “think aloud” was used to limit interviewer-imposed bias and encourage participants to describe their thoughts and response to a given item as they reviewed survey items [ 27 ]. Where needed, verbal probes such as “could you expand on that” were used to encourage participants to expand on their responses [ 27 ]. Student participants’ feedback was collated verbatim and presented to the research team where potential survey modifications were negotiated and finalized among team members. Conventional content analysis [ 34 ] of focus group data was conducted to identify key themes that emerged through discussion with students. Themes were derived from the data by grouping common responses and then using those common responses to modify survey items.

Ten nursing faculty participated in the expert panel. Eight of the 10 faculty self-identified as female. No faculty panel members reported conscientious objector status and ninety percent reported general agreement with MAiD with one respondent who indicated their view as “unsure.” Six of the 10 faculty experts had 16 years of experience or more working as a nurse educator.

Five nursing students participated in the cognitive interview focus group. The duration of the focus group was 2.5 h. All participants identified that they were born in Canada, self-identified as female (one preferred not to say) and reported having received some instruction about MAiD as part of their nursing curriculum. See Tables  1 and 2 for the demographic descriptors of the study sample. Study results will be reported in accordance with the study phases. See Fig.  1 for an overview of the results from each phase.

Fig. 1  Overview of survey development findings

Phase 1: survey item generation

Review of the literature identified that no existing survey was available for use with nursing students in the Canadian context. However, an analysis of themes across qualitative and quantitative studies of physicians, medical students, nurses, and nursing students provided sufficient data to develop a preliminary set of items suitable for adaptation to a population of nursing students.

Four major themes and factors that influence knowledge, attitudes, and beliefs about MAiD were evident from the literature: (i) endogenous or individual factors such as age, gender, personally held values, religion, religiosity, and/or spirituality [ 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 ], (ii) experience with death and dying in personal and/or professional life [ 35 , 40 , 41 , 43 , 44 , 45 ], (iii) training including curricular instruction about clinical role, scope of practice, or the law [ 23 , 36 , 39 ], and (iv) exogenous or social factors such as the influence of key leaders, colleagues, friends and/or family, professional and licensure organizations, support within professional settings, and/or engagement in MAiD in an interdisciplinary team context [ 9 , 35 , 46 ].

Studies of nursing students also suggest overlap across these categories. For example, value for patient autonomy [ 23 ] and the moral complexity of decision-making [ 37 ] are important factors that contribute to attitudes about MAiD and may stem from a blend of personally held values coupled with curricular content, professional training and norms, and clinical exposure. For example, students report that participation in end of life care allows for personal growth, shifts in perception, and opportunities to build therapeutic relationships with their clients [ 44 , 47 , 48 ].

Preliminary items generated from the literature resulted in 56 questions from 11 published sources (See Table  3 ). These items were constructed across four main categories: (i) socio-demographic questions; (ii) end of life care questions; (iii) knowledge about MAiD; or (iv) comfort and willingness to participate in MAiD. Knowledge questions were refined to reflect current MAiD legislation, policies, and regulatory frameworks. Falconer [ 39 ] and Freeman [ 45 ] studies were foundational sources for item selection. Additionally, four case studies were written to reflect the most recent anticipated changes to MAiD legislation and all used the same open-ended core questions to address respondents’ perspectives about the patient’s right to make the decision, comfort in assisting a physician or NP to administer MAiD in that scenario, and hypothesized comfort about serving as a primary provider if qualified as an NP in future. Response options for the survey were also constructed during this stage and included: open text, categorical, yes/no , and Likert scales.

Phase 2: faculty expert panel review

Of the 56 items presented to the faculty panel, 54 questions reached 75% consensus. However, based upon the qualitative responses 9 items were removed largely because they were felt to be repetitive. Items that generated the most controversy were related to measuring religion and spirituality in the Canadian context, defining end of life care when there is no agreed upon time frames (e.g., last days, months, or years), and predicting willingness to be involved in a future events – thus predicting their future selves. Phase 2, round 1 resulted in an initial set of 47 items which were then presented back to the faculty panel in round 2.

Of the 47 initial questions presented to the panel in round 2, 45 reached a level of consensus of 75% or greater, and 34 of these questions reached a level of 100% consensus [ 27 ] of which all participants chose to include without any adaptations) For each question, level of importance was determined based on a 5-point Likert scale (1 = very unimportant, 2 = somewhat unimportant, 3 = neutral, 4 = somewhat important, and 5 = very important). Figure  2 provides an overview of the level of importance assigned to each item.

Ranking level of importance for survey items

After round 2, a careful analysis of participant comments and level of importance was completed by the research team. While the main method of survey item development came from participants’ response to the first round of Delphi consensus ratings, level of importance was used to assist in the decision of whether to keep or modify questions that created controversy, or that rated lower in the include/exclude/adapt portion of the Delphi. Survey items that rated low in level of importance included questions about future roles, sex and gender, and religion/spirituality. After deliberation by the research committee, these questions were retained in the survey based upon the importance of these variables in the scientific literature.

Of the 47 questions remaining from Phase 2, round 2, four were revised. In addition, the two questions that did not meet the 75% cut off level for consensus were reviewed by the research team. The first question reviewed was What is your comfort level with providing a MAiD death in the future if you were a qualified NP ? Based on a review of participant comments, it was decided to retain this question for the cognitive interviews with students in the final phase of testing. The second question asked about impacts on respondents’ views of MAiD and was changed from one item with 4 subcategories into 4 separate items, resulting in a final total of 51 items for phase 3. The revised survey was then brought forward to the cognitive interviews with student participants in Phase 3. (see Supplementary Material 1 for a complete description of item modification during round 2).

Phase 3. Outcomes of cognitive interview focus group

Of the 51 items reviewed by student participants, 29 were identified as clear with little or no discussion. Participant comments for the remaining 22 questions were noted and verified against the audio recording. Following content analysis of the comments, four key themes emerged through the student discussion: unclear or ambiguous wording; difficult to answer questions; need for additional response options; and emotional response evoked by questions. An example of unclear or ambiguous wording was a request for clarity in the use of the word “sufficient” in the context of assessing an item that read “My nursing education has provided sufficient content about the nursing role in MAiD.” “Sufficient” was viewed as subjective and “laden with…complexity that distracted me from the question.” The group recommended rewording the item to read “My nursing education has provided enough content for me to care for a patient considering or requesting MAiD.”

An example of having difficulty answering questions related to limited knowledge related to terms used in the legislation such as such as safeguards , mature minor , eligibility criteria , and conscientious objection. Students were unclear about what these words meant relative to the legislation and indicated that this lack of clarity would hamper appropriate responses to the survey. To ensure that respondents are able to answer relevant questions, student participants recommended that the final survey include explanation of key terms such as mature minor and conscientious objection and an overview of current legislation.

Response options were also a point of discussion. Participants noted a lack of distinction between response options of unsure and unable to say . Additionally, scaling of attitudes was noted as important since perspectives about MAiD are dynamic and not dichotomous “agree or disagree” responses. Although the faculty expert panel recommended the integration of the demographic variables of religious and/or spiritual remain as a single item, the student group stated a preference to have religion and spirituality appear as separate items. The student focus group also took issue with separate items for the variables of sex and gender, specifically that non-binary respondents might feel othered or “outed” particularly when asked to identify their sex. These variables had been created based upon best practices in health research but students did not feel they were appropriate in this context [ 49 ]. Finally, students agreed with the faculty expert panel in terms of the complexity of projecting their future involvement as a Nurse Practitioner. One participant stated: “I certainly had to like, whoa, whoa, whoa. Now let me finish this degree first, please.” Another stated, “I'm still imagining myself, my future career as an RN.”

Finally, student participants acknowledged the array of emotions that some of the items produced for them. For example, one student described positive feelings when interacting with the survey. “Brought me a little bit of feeling of joy. Like it reminded me that this is the last piece of independence that people grab on to.” Another participant, described the freedom that the idea of an advance request gave her. “The advance request gives the most comfort for me, just with early onset Alzheimer’s and knowing what it can do.” But other participants described less positive feelings. For example, the mature minor case study yielded a comment: “This whole scenario just made my heart hurt with the idea of a child requesting that.”

Based on the data gathered from the cognitive interview focus group of nursing students, revisions were made to 11 closed-ended questions (see Table  4 ) and 3 items were excluded. In the four case studies, the open-ended question related to a respondents’ hypothesized actions in a future role as NP were removed. The final survey consists of 45 items including 4 case studies (see Supplementary Material 3 ).

The aim of this study was to develop and validate a survey that can be used to track the growth of knowledge about MAiD among nursing students over time, inform training programs about curricular needs, and evaluate attitudes and willingness to participate in MAiD at time-points during training or across nursing programs over time.

The faculty expert panel and student participants in the cognitive interview focus group identified a need to establish core knowledge of the terminology and legislative rules related to MAiD. For example, within the cognitive interview group of student participants, several acknowledged lack of clear understanding of specific terms such as “conscientious objector” and “safeguards.” Participants acknowledged discomfort with the uncertainty of not knowing and their inclination to look up these terms to assist with answering the questions. This survey can be administered to nursing or pre-nursing students at any phase of their training within a program or across training programs. However, in doing so it is important to acknowledge that their baseline knowledge of MAiD will vary. A response option of “not sure” is important and provides a means for respondents to convey uncertainty. If this survey is used to inform curricular needs, respondents should be given explicit instructions not to conduct online searches to inform their responses, but rather to provide an honest appraisal of their current knowledge and these instructions are included in the survey (see Supplementary Material 3 ).

Some provincial regulatory bodies have established core competencies for entry-level nurses that include MAiD. For example, the BC College of Nurses and Midwives (BCCNM) requires “knowledge about ethical, legal, and regulatory implications of medical assistance in dying (MAiD) when providing nursing care.” (10 p. 6) However, across Canada curricular content and coverage related to end of life care and MAiD is variable [ 23 ]. Given the dynamic nature of the legislation that includes portions of the law that are embargoed until 2024, it is important to ensure that respondents are guided by current and accurate information. As the law changes, nursing curricula, and public attitudes continue to evolve, inclusion of core knowledge and content is essential and relevant for investigators to be able to interpret the portions of the survey focused on attitudes and beliefs about MAiD. Content knowledge portions of the survey may need to be modified over time as legislation and training change and to meet the specific purposes of the investigator.

Given the sensitive nature of the topic, it is strongly recommended that surveys be conducted anonymously and that students be provided with an opportunity to discuss their responses to the survey. A majority of feedback from both the expert panel of faculty and from student participants related to the wording and inclusion of demographic variables, in particular religion, religiosity, gender identity, and sex assigned at birth. These and other demographic variables have the potential to be highly identifying in small samples. In any instance in which the survey could be expected to yield demographic group sizes less than 5, users should eliminate the demographic variables from the survey. For example, the profession of nursing is highly dominated by females with over 90% of nurses who identify as female [ 50 ]. Thus, a survey within a single class of students or even across classes in a single institution is likely to yield a small number of male respondents and/or respondents who report a difference between sex assigned at birth and gender identity. When variables that serve to identify respondents are included, respondents are less likely to complete or submit the survey, to obscure their responses so as not to be identifiable, or to be influenced by social desirability bias in their responses rather than to convey their attitudes accurately [ 51 ]. Further, small samples do not allow for conclusive analyses or interpretation of apparent group differences. Although these variables are often included in surveys, such demographics should be included only when anonymity can be sustained. In small and/or known samples, highly identifying variables should be omitted.

There are several limitations associated with the development of this survey. The expert panel was comprised of faculty who teach nursing students and are knowledgeable about MAiD and curricular content, however none identified as a conscientious objector to MAiD. Ideally, our expert panel would have included one or more conscientious objectors to MAiD to provide a broader perspective. Review by practitioners who participate in MAiD, those who are neutral or undecided, and practitioners who are conscientious objectors would ensure broad applicability of the survey. This study included one student cognitive interview focus group with 5 self-selected participants. All student participants had held discussions about end of life care with at least one patient, 4 of 5 participants had worked with a patient who requested MAiD, and one had been present for a MAiD death. It is not clear that these participants are representative of nursing students demographically or by experience with end of life care. It is possible that the students who elected to participate hold perspectives and reflections on patient care and MAiD that differ from students with little or no exposure to end of life care and/or MAiD. However, previous studies find that most nursing students have been involved with end of life care including meaningful discussions about patients’ preferences and care needs during their education [ 40 , 44 , 47 , 48 , 52 ]. Data collection with additional student focus groups with students early in their training and drawn from other training contexts would contribute to further validation of survey items.

Future studies should incorporate pilot testing with small sample of nursing students followed by a larger cross-program sample to allow evaluation of the psychometric properties of specific items and further refinement of the survey tool. Consistent with literature about the importance of leadership in the context of MAiD [ 12 , 53 , 54 ], a study of faculty knowledge, beliefs, and attitudes toward MAiD would provide context for understanding student perspectives within and across programs. Additional research is also needed to understand the timing and content coverage of MAiD across Canadian nurse training programs’ curricula.

The implementation of MAiD is complex and requires understanding of the perspectives of multiple stakeholders. Within the field of nursing this includes clinical providers, educators, and students who will deliver clinical care. A survey to assess nursing students’ attitudes toward and willingness to participate in MAiD in the Canadian context is timely, due to the legislation enacted in 2016 and subsequent modifications to the law in 2021 with portions of the law to be enacted in 2027. Further development of this survey could be undertaken to allow for use in settings with practicing nurses or to allow longitudinal follow up with students as they enter practice. As the Canadian landscape changes, ongoing assessment of the perspectives and needs of health professionals and students in the health professions is needed to inform policy makers, leaders in practice, curricular needs, and to monitor changes in attitudes and practice patterns over time.

Availability of data and materials

The datasets used and/or analysed during the current study are not publicly available due to small sample sizes, but are available from the corresponding author on reasonable request.

Abbreviations

British Columbia College of Nurses and Midwives

Medical assistance in dying

Nurse practitioner

Registered nurse

University of British Columbia Okanagan

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JS received a student traineeship through the Principal Research Chairs program at the University of British Columbia Okanagan.

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Schroeder, J., Pesut, B., Olsen, L. et al. Developing a survey to measure nursing students’ knowledge, attitudes and beliefs, influences, and willingness to be involved in Medical Assistance in Dying (MAiD): a mixed method modified e-Delphi study. BMC Nurs 23 , 326 (2024). https://doi.org/10.1186/s12912-024-01984-z

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Associations between Stress, Anxiety, Depression and Sleep Quality among Healthcare Students

Monira alwhaibi.

1 Medication Safety Research Chair, College of Pharmacy, King Saud University, Riyadh 11149, Saudi Arabia

2 Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh 11149, Saudi Arabia

Noha A Al Aloola

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The corresponding author will provide the datasets used and analyzed during the current work upon reasonable request.

Objectives: Stress, anxiety, and depression among students have many negative health consequences and may predispose students to poor sleep quality; therefore, this research aimed to investigate the perceived stress, anxiety, and depression and their relation to the level of sleep quality among healthcare students. Methods: A cross-sectional study using a validated survey was conducted among Saudi healthcare students from different regions during the period from 26 September 2022 to 30 October 2022. The Pittsburgh Sleep Quality Index (PSQI) was utilized to assess sleep quality. PSPP Statistical Analysis Software version 1.2.0 was used for all statistical analyses. Results: 701 respondents participated in this research; the response rate was 73.8%. About 60% of the study sample was female, and the average age was 20.9 years. 80.3% of students have poor sleep quality; the participants’ mean sleeping hours per night was 6.81 ± 1.88 h. About three-quarters of students (72.9%) perceive themselves as stressed. A significant positive correlation was observed between sleep quality and perceived stress (r-value = 0.363), anxiety (r-value = 0.387), and depression (r-value = 0.347). Poor sleep quality was more likely among those with stress than those without stress (AOR = 1.79; 95% CI 1.07, 2.99) and two times more likely among students with cases of anxiety than those without anxiety (AOR = 2.07; 95% CI 1.10, 3.94). Conclusions: Our study highlights the high prevalence of poor sleep quality, anxiety, depression, and stress among healthcare students in Saudi Arabia. Students’ reported stress, anxiety, and residence region were associated with poor sleep quality. These results imply the necessity of regular screening and appropriate intervention for sleep problems, stressors, and anxiety among healthcare students.

1. Introduction

Sleep quality is an individual’s satisfaction with all aspects of the sleep experience [ 1 , 2 ]. This concept includes several aspects, such as sleep efficiency, sleep onset latency, duration, and the number of awakenings after sleep onset [ 1 , 2 ]. Several published studies reported that poor sleep quality is highly prevalent among healthcare students. For example, a systematic review of 57 published studies that included 25,735 medical students has estimated a pooled prevalence of poor sleep quality of 52.7% using the Pittsburgh Sleep Quality Index (PSQI) [ 3 ]. A substantial body of evidence suggests that poor sleep quality is associated with adverse physical and mental problems [ 4 , 5 , 6 ]. Insufficient sleep appeared to be associated with obesity, cardiovascular morbidity, and risk of diabetes [ 4 ]. Also, poor sleep quality was associated with students’ academic performance, life satisfaction, anger, and fatigue [ 7 , 8 , 9 ]. Additionally, adults who do not obtain sufficient sleep also have a higher risk of developing stress, anxiety, and depression [ 5 ].

The relationship between stress, anxiety, depression, and poor sleep quality has been highlighted in several published studies among healthcare students [ 10 , 11 , 12 , 13 , 14 , 15 ]. A study among nursing students reported that poor sleep quality was associated with stress and symptoms of depression and anxiety. Mishra et al., in their study among 284 undergraduate medical students, found that students with stress had twofold odds of poor sleep quality compared to those without stress [ 13 ]. Another study found that higher perceived stress levels were significantly associated with poor sleep quality [ 12 ]. In a survey of 1125 college students between 17 and 24 years old, more than 60% of participants were classified as poor sleepers. According to the students, tension and stress significantly related to sleep disturbance, and they were responsible for 24% of the variance in the sleep quality score [ 14 ].

Although the association between stress and sleep quality seems well established by several studies, the prevalence of poor sleep quality among healthcare students and its relation to stress and mental health has not been sufficiently addressed in Saudi Arabia. Most of the studies in Saudi Arabia focused on medical students only [ 16 , 17 , 18 , 19 ] and not students from other health science programs such as pharmacy and nursing students. Therefore, this study intended to examine the prevalence of poor sleep quality; evaluate the association between perceived stress, anxiety, and depression and sleep quality among healthcare students in Saudi Arabia. We hypothesize that stress, anxiety, and depression are all related to poor sleep quality. Findings from this study are crucial for understanding what contributes to poor sleep quality in this academic population, bringing this issue to the attention of decision-makers, and aiding in developing successful interventions to improve sleep quality among healthcare students and help them cope with the pressures of academic learning.

2.1. Study Design and Sample

A cross-sectional study was carried out among healthcare students in Saudi Arabia using an online survey. The data were collected from 26 September 2022 to 30 October 2022. The study sample was composed of undergraduate healthcare students from different healthcare schools. The inclusion criteria include undergraduate students of all levels of health science bachelor programs (medicine, pharmacy, dentistry, and nursing, applied medical sciences) who consented to participate in this study. Students from non-health science programs were excluded from the study.

2.2. Ethical Considerations and Consent to Participate

The study was approved by the Research Center of the Medical College of King Saud University and its Ethical Committee (Protocol No. E-21-6192). The informed consent was given to the participants to describe the study goal and the participant’s freedom to withdraw at any time. No participant identifiers were used in this study to guarantee the privacy of the participant’s information.

2.3. Questionnaire Development and Validation

An anonymous online survey was written in English language and composed of four sections pertaining to sociodemographic data (age, gender, nationality, and region of residence); type of health science program and year of study; perceived physical health (excellent/very good, good, and fair/poor); and health (sleep quality, perceived stress, depression, and anxiety). A group of researchers (n = 3) reviewed the questionnaire for the content and ease of understanding of the questions to ensure content and face validity; researchers’ comments were taken into account. The questionnaire’s clarity and suitability for the intended sample were pilots tested among 22 participants who completed a self-administered survey. Minor adjustments were made in response to the pilot group’s feedback, and their responses have not been included in the final analysis of the sample.

2.4. Data Collection/Data Source

The questionnaire was hosted on a Google form; the survey link was distributed online via email. First, the informed consent form was displayed in our online survey on the first page before any research questions were asked. The study’s overall goal, the risks and benefits, the methods for protecting participants’ privacy, their rights, and a statement that the participation was entirely voluntary are all explained to participants in the consent form. Next, after the participants’ consent was obtained, students who agreed to participate were asked to complete the questionnaires.

2.5. Outcome Variable (Sleep Quality)

Sleep quality was evaluated using the Pittsburgh Sleep Quality Index (PSQI) [ 12 ]; the PSQI contains 19 self-reported questions. The PSQI is the most widely used assessment tool to evaluate subjective sleep quality during the previous month, which covers a broad range of indicators relevant to sleep quality [ 20 ]. It has seven components: subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleeping medication, and daytime dysfunction. Global PSQI score is the sum of the 7 component scores, ranging from 0–21. A global score of 5 or under indicates “good sleep quality”, and a score greater than 5 indicates “poor sleep quality”.

2.6. Key Variables: Perceived Stress

Perceived stress was evaluated using the Perceived Stress Scale-14 (PSS), a method for assessing psychological stress widely [ 21 , 22 ]. PSS is a self-reported scale that is used to evaluate “the degree to which individuals perceive stressful situations in their life” [ 23 ]. Each item in this scale is rated on a 5-point Likert scale, with 0 indicating “never” and 4 indicating “very often” [ 24 ]. After reversing positive items’ scores (i.e., items 4, 5, 6, 7, 9, 10, and 13) and summing up all scores, the total scores range from 0 to 56. A score above 28 points was considered stressed, and 0–28 points were considered unstressed.

Mental health (anxiety and depression) was evaluated using the hospital anxiety and depression scale (HADS) [ 20 ]. It has been widely used among undergraduate healthcare students. It consists of 14 items, seven items to measure the anxiety subscale and seven items to measure the depression subscale. A total subscale score of 11 and over indicates a probable case of depression or anxiety, a score of 8–10 indicates borderline, and a score of 0–7 is considered normal.

2.7. Other Variables

Independent variables included sociodemographic data, type of health science program, year of study, and perceived physical health. The perceived physical health was evaluated by a single-item self-rated question: “How is your physical health in general?” The categories for the responses were (1) Excellent, (2) Very Good, (3) Good, (4) Fair, and (5) Poor [ 25 ].

2.8. Statistical Analysis

All data were analyzed using PSPP Statistical Analysis Software version 1.2.0 (GNU PSPP, Boston, MA, USA). In order to compare sleep quality groups, univariate and multivariate analyses were performed using Chi-square tests, independent groups t -tests, and regression analysis. Pearson correlation was conducted between the continuous scores of anxiety, depression, perceived stress, and sleep quality. Regression assumptions were evaluated first to ensure that assumptions were met. Then, a binary logistic regression analysis was performed to examine the associations between sleep quality and reported stress, anxiety, and depression after considering various confounders. The findings were presented as adjusted Odds ratios (AORs) with 95% confidence intervals (CIs), and the level of significance was ( p -value < 0.05).

3.1. Characteristics of the Study Sample

From a total of 950 students who received our online survey, 701 students participated in this study; the response rate was 73.8%. The average age of the participants was 20.9 years. The majority of participants were female (60.0%). Most of the students were from the middle region (53.1%). Table 1 displays the characteristics of the participants.

Baseline Characteristics of the Study Sample (n = 701).

3.2. Prevalence of Perceived Stress, Anxiety, Depression, and Sleep Quality

Almost 73.0% of students were stressed ( Table 2 ). Around 52.9% reported having cases of anxiety, and 32.2% of the participants had cases of depression. In 80.3% of healthcare students, poor sleep quality was prevalent. The subjects’ average nightly sleep duration was 6.81 ± 1.88 h. The subjects’ average perceived stress was (30.88 ± 7.09), sleep quality (8.30 ± 2.73), anxiety (10.59 ± 4.21), and depression (8.60 ± 3.90).

Prevalence of stress, anxiety, depression, and sleep quality.

3.3. Correlation between Anxiety, Depression, Perceived Stress, and Sleep Quality

Table 3 displays the correlation between anxiety, depression, perceived stress, and sleep quality. There was a positive correlation between sleep quality and perceived stress (r-value = 0.363, p < 0.05), anxiety (r-value = 0.387, p < 0.05), and depression (r-value = 0.347, p < 0.05).

Correlation between Pittsburgh Sleep Quality Index and other parameters.

3.4. Sleep Quality

An association was found between poor sleep quality and stress ( p < 0.001), anxiety ( p < 0.001), and depression ( p < 0.001) ( Table 4 ). For example, poor sleep quality was significantly higher in healthcare students who reported stress than those without stress (89.6% versus 73.3%, p -value < 0.001) and cases of depression than those without depression (90.3% versus 78.2%, p -value < 0.001).

Relationship between stress, anxiety, depression, and sleep quality (n = 701).

p -value presents differences in stress from chi-square tests.

An association was found between poor sleep quality and region of residence ( p = 0.044) and perceived physical health ( p < 0.001) ( Table 5 ). For example, a higher percentage of poor sleep quality was among healthcare students who perceived their physical health as poor than those with excellent health (87.5% versus 76.6%, p -value < 0.001). However, no association between sleep quality and age, gender, or type of healthcare program was found ( p -value was greater than 0.05). Some reported reasons by students for having difficulty sleeping in our study include; stress, overthinking, studying, coffee consumption, and family-related issues.

Association between sleep quality and other study variables.

p -value presents differences in stress from chi-square tests and t -test.

3.5. Factors Associated with Sleep Quality from Adjusted Regression Analysis

An adjusted regression analysis was used to identify factors associated with sleep quality ( Table 6 ). Participants who had stress were more likely to have poor sleep quality than those without stress (AOR = 1.79; 95% CI 1.07, 2.99). Students with anxiety were twice as likely as those without anxiety to have poor sleep quality (AOR = 2.07; 95% CI 1.10, 3.94). Less frequently did students from the north, east, and south have poor sleep quality than those from the western region.

Statistics from logistic regression of the factors associated with sleep quality.

* asterisk represents significant findings. AOR: adjusted Odds ratio; CI: confidence interval; Ref: Reference Group.

4. Discussion

The current study investigated the relationship between perceived stress, anxiety, depression, and poor sleep quality among healthcare students in Saudi Arabia. Results showed a high prevalence of poor sleep quality among healthcare students. Also, our findings highlighted that perceived stress and anxiety are essential factors that were associated with the odds of poor sleep quality.

Our findings of a prevalence of poor sleep quality in almost 80% of participants are higher than the reported prevalence from previous studies in Saudi Arabia (30–76%) [ 16 , 17 , 18 , 19 , 26 , 27 , 28 ] and the global pooled prevalence (52.7%) using the same assessment scale (i.e., Pittsburgh Sleep Quality Index) [ 3 ]. The variation in the prevalence of poor sleep quality reported in previous studies could be due to the difference in the study population or the different assessment methods used to measure sleep quality. Some reported reasons by students for having difficulty sleeping in our study include; stress, overthinking, studying, coffee consumption, and family-related issues. The availability and use of stimulants (like coffee) are related to changes in sleep patterns, an essential modifiable lifestyle risk factor for students. Caffeine is the most popular psychoactive substance used globally [ 29 , 30 ]. According to a recent systematic review of epidemiologic research and randomized clinical trials, caffeine use has been found to harm both subjective and objective sleep quality [ 29 ]. According to this review, caffeine was associated with perceived sleep quality, decreased total sleep time and efficiency, and prolonged sleep latency.

The results of this study highlighted a high prevalence of stress, anxiety, and depression among healthcare students. Anxiety was reported by half of students, stress affected nearly three-quarters, and depression affected one-third of participants. Our findings, which indicate a higher prevalence of stress, are consistent with previous research among Saudi medical students [ 17 , 31 , 32 ] but greater than what was reported globally (31.0–64.0%) [ 33 , 34 ]. Participants in the study reported high levels of anxiety and depression. The depression rate is consistent with the national and international rates among medical students [ 16 , 35 , 36 ], and the anxiety level was comparable to the documented prevalence in earlier studies among medical students worldwide and in Saudi Arabia [ 16 , 35 , 37 , 38 ].

This research found significant associations between perceived stress and anxiety with poor sleep quality. Perceived stress relation with poor sleep quality result aligns with the earlier studies that have underscored this meaningful relationship [ 16 , 17 , 26 , 35 , 39 ]. Another significant finding in this research was the association between anxiety and poor sleep quality. Those with anxiety cases were twofold to have poor sleep quality. In fact, anxiety has been previously reported to be linked to poor sleep quality in Saudi medical students [ 16 , 17 , 26 ]. Although those findings have been reported in earlier research, this study added to the existing literature the focus on this relationship among students in different healthcare fields, not only medical students. This study’s findings emphasize the need to offer healthcare students stress management interventions and coping techniques. Evidence suggests a connection between adults who stutter and sleep quality, stress, and anxiety [ 40 ]. Stuttering is a condition of the speech motor system. According to research, stuttering is linked to social anxiety, and lack of sleep is linked to increased anxiety levels. As a result, the degree of stuttering is correlated with the severity of sleep disturbances.

Age, gender, residence region, and the type of health science program were all examined in this study as potential influences on the quality of sleep. The residence region was associated with sleep quality, whereas age, gender, and sleep quality were not shown to be associated in our study [ 18 ]. These findings contradict past research, which showed that women experienced much higher levels of poor sleep quality than men [ 41 ]. The gender disparities in the prevalence of sleep quality exist in the univariate analysis but not in the adjusted analysis. Gender disparities were anticipated due to the differences in sociocultural factors such as income and biological factors such as sexual hormones; however, it was not statistically significant in our study. Additionally, the adjusted regression analysis revealed no significant change in sleep quality across several health science programs.

4.1. Study Implications

The current study has several potential applications. First, the increasing prevalence of poor sleep quality and its link to stress and anxiety underscores the need to enhance mental health services, which will ultimately enhance their sleep quality and improve health-related quality of life (HRQoL). Studies have demonstrated a relationship between the aspects of sleep quality and good physical and mental health, and good HRQoL [ 42 , 43 , 44 , 45 , 46 ]. For example, a recent study revealed that all of the distinct correlations between anxiety, depression, stress, and HRQoL were mediated by overall sleep quality. These preliminary results imply that medical students’ well-being is related to the quality of their sleep and that it may be advantageous to address sleep problems in this academic population [ 42 ].

Additionally, considering that improving sleep quality is associated with enhanced physical and mental health [ 47 ], future research should evaluate healthcare students’ sleep knowledge and provide them with sleep education. This training must cover subjects including sleep and circadian science, sleep hygiene, and the clinical evaluation and treatment of sleep disturbances and disorders [ 48 ]. Some evidence of the effectiveness of sleep education programs in enhancing sleep hygiene knowledge, sleep hygiene behavior, and/or sleep quality when compared to traditional techniques has been documented by a comprehensive review of four interventional trials [ 49 ].

4.2. Strength/Limitations

This study evaluated sleep quality and the association between stress, anxiety, and depression and poor sleep quality in different healthcare schools in Saudi Arabia. In contrast, previous studies focused only on medical students. However, it is important to take into account some of this study’s limitations. Due to the study design’s cross-sectional nature, we cannot evaluate the causal relationship. Also, other confounders, such as the use of social media, family support, physical activity, and academic performance, needed to be measured and adjusted. Also, this study did not explore the other reasons that are associated with poor sleep quality, which could be either physiological (e.g., body mass index), environmental (e.g., television/device use), or a combination [ 1 ]; thus, future research should address this. Additionally, we cannot rule out recall bias since the data were self-reported.

5. Conclusions

Our study highlights the high prevalence of poor sleep quality, anxiety, depression, and stress among healthcare students in Saudi Arabia. Students’ reported stress, anxiety, and residence region were associated with poor sleep quality. These results imply the necessity of regular screening and appropriate intervention for sleep problems, stressors, and anxiety among healthcare students to enable prompt assistance and support from social work educators to consider including sleep hygiene education and offer counseling and stress management interventions to help healthcare students obtain better sleep and cope with stressors in academic education.

Funding Statement

The authors extend their appreciation to the Deputyship for Research & Innovation, Ministry of Education in Saudi Arabia, for funding this research (IFKSURC-1-1701).

Author Contributions

M.A. conceptualized and designed the manuscript structure, reviewed the literature, and drafted the initial manuscript and survey. M.A. analyzed the data and wrote the results. N.A.A.A. conducted the literature review and reviewed the manuscript and the survey. M.A. and N.A.A.A. approved the final manuscript. All authors have read and agreed to the published version of the manuscript.

Institutional Review Board Statement

Ethics approval was obtained for this project through the Research Center of the Medical College of King Saud University and its Ethical Committee (Protocol No. E-21-6192).

Informed Consent Statement

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A Robot-assisted real case-handling approach to improving students’ learning performances in vocational training

• Published: 14 May 2024

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• Chun-Chun Chang 1 &
• Gwo-Jen Hwang   ORCID: orcid.org/0000-0001-5155-276X 2 , 3  

In vocational education, cultivating students’ ability to deal with real cases is a crucial training objective. The BSFE (i.e., Brainstorming, Screening, Formation, Examination) model is a commonly adopted training procedure. Each stage is designed for guiding students to analyze and find solutions to handle real cases. However, as one teacher is generally responsible for several dozen students, it becomes challenging for the teacher to adequately address each student’s questions and individual needs. Therefore, this study proposed the robot teaching assistant-supported learning (RTAL) mode following the BSFE model to cope with this problem. This investigation assessed its efficacy through an experiment within an Acute Asthma Attack curriculum. The research involved 103 nursing students in their third year from two distinct classes at a vocational university. Fifty-three students from a class constituted the experimental group that implemented the RTAL approach, whereas the other class, comprising 50 students, was the control group utilizing the standard technology-supported learning (CTL) approach. Findings indicated that the experimental group surpassed the control group in various aspects, including learning outcomes, learning attitudes, problem-solving tedencies, critical thinking awareness, acceptance of technology, and satisfaction with the learning experience. The interview findings also revealed that the RTAL mode could cater to individualized learning needs, facilitate interaction, and serve as an auxiliary instructional tool.

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This study is supported in part by the National Science and Technology Council of Taiwan under contract numbers NSTC 112-2410-H-011-012-MY3 and MOST 111-2410-H-011 -007 -MY3. The study is also supported by the “Empower Vocational Education Research Center” of National Taiwan University of Science and Technology (NTUST) from the Featured Areas Research Center Program within the framework of the Higher Education Sprout Project by the Ministry of Education (MOE) in Taiwan.

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Department of Nursing, Chang Gung University of Science and Technology, Taoyuan City, Taiwan

Chun-Chun Chang

Graduate Institute of Educational Information and Measurement, National Taichung University of Education, Taichung City, Taiwan

Gwo-Jen Hwang

Graduate Institute of Digital Learning and Education, National Taiwan University of Science and Technology, Taipei City, Taiwan

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The authors contributed to the conceptualization and design of the study. Material preparation, data collection, analysis, project management and methodology were performed by Chun-Chun Chang. Methodology and supervision were performed Gwo-Jen Hwang.

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Correspondence to Gwo-Jen Hwang .

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The study has been evaluated and approved by the research ethics committee of Chang Gung with the IRB number 202300304B0C101.

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Chang, CC., Hwang, GJ. A Robot-assisted real case-handling approach to improving students’ learning performances in vocational training. Educ Inf Technol (2024). https://doi.org/10.1007/s10639-024-12778-w

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Received : 13 March 2024

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Published : 14 May 2024

DOI : https://doi.org/10.1007/s10639-024-12778-w

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