key: cord-0820570-xkc80f9x
authors: Black Thomas, Lisa M.
title: Stress and depression in undergraduate students during the COVID-19 pandemic: Nursing students compared to undergraduate students in non-nursing majors
date: 2021-12-06
journal: J Prof Nurs
DOI: 10.1016/j.profnurs.2021.11.013
sha: 7739ac70375e96a8629194f288f8a2fa5c1d3b29
doc_id: 820570
cord_uid: xkc80f9x

BACKGROUND: The COVID-19 pandemic exacerbated an already alarming mental health crisis on college campuses. Nursing students were uniquely impacted through the loss of clinical practicum experiences. PURPOSE: The purpose of this study was to explore relationships between student perceptions of life-stress and depressive symptoms during the COVID-19 pandemic in nursing students compared to students in other academic disciplines. A secondary purpose of this study was to understand nursing student perceptions of how the COVID-19 pandemic impacted their educational experience. METHODS: School-related life stress and depression measures were studied in a cross-section of 2326 undergraduate students using an anonymous online survey. Follow-up qualitative data were collected (N = 12) to further explore relationships between school-related life stress and depression in nursing students. RESULTS: Nursing students had higher levels of student-life stress but fewer depressive symptoms than students in any other academic major. Students related that social support and belongingness were critical to their academic perseverance. CONCLUSIONS: Differences between nursing and non-nursing students are likely due to a multifactorial combination of social support, resilience, and posttraumatic growth.

Specific Psychological Distress Scale, which is consistent with significant impairment in life activities due to severe mental illness (American College Health Association, 2020). Moreover, amid the COVID-19 pandemic, the Centers for Disease Control and Prevention found that 25% of college-age respondents seriously contemplated suicide during the preceding 30 days (Czeisler et al., 2020) .

Numerous international authors have described the pandemic's devastating impact on nursing education and nursing students in developing and developed countries. While international experiences are informative, nurses are educated and regulated quite differently based on the geographic region where the education takes place (National Council for State Boards of Nursing (NCSBN), 2020). Thus, this literature review will specifically report the impact of the COVID-19 pandemic on nursing students in the United States.

As a practice profession, nursing students must participate in direct hands-on patient care activities to become licensed. At the same time that schools of nursing shifted from brick and mortar to remote instruction, hospitals across the United States canceled in-person clinical experiences. Both quantitative and qualitative studies have described U.S. nursing student experiences during this abrupt transition as traumatic, stressful, and filled with fear, uncertainty, loneliness, and missed opportunity (Diaz et al., 2021; Fitzgerald & Konrad, 2021; Goddard et al., 

To address the second research question, semi-structured interviews were conducted with a purposive sample of 12 nursing students in the final month of their nursing program. The qualitative sample was recruited from a cohort of 64 baccalaureate nursing students from the same University where the quantitative data were collected.

Demographic variables were collected from all participants, including age, sex, ethnicity,

year in school, academic major, and cumulative GPA. Student life stress was measured using Gadzella's (2012) revised Student-life Stress Inventory (SSI-R). Depressive symptoms were measured using the nine-item depression module of the Patient Health Questionnaire (Kroenke et al., 2001 ). Gadzella's (2012) revised Student-life Stress Inventory (SSI-R) is a 53-item Likert-scaled measure that examines stressors related to life as a college student and how students react to those stressors. Internal consistency of the total SSI-R inventory is excellent (a = 0.93).

Concurrent validity of the SSI-R was established through correlations with the Text Anxiety (Spielberger et al., 1978) , State-Trait Anxiety (Spielberger et al., 1983) , and Beck Depression because the SSI-R measures the impact of stressors related to academic life outside of the classroom. Permission to use the scale was obtained from the corresponding author of Gadzella et al. (2012) .

The PHQ-9 was psychometrically validated by Kroenke et al. (2001) as an instrument with a high level of sensitivity (88%), specificity (88%), and internal consistency (a = 0.89) in diagnosing both the presence and severity of major depression in patients over the age of 18. Use is in the public domain at no cost. The PHQ-9 operationalizes the DSM-IV diagnostic criteria for major depressive disorder using nine Likert scaled items that assess a person's mood over the preceding two weeks. PHQ-9 scores can range from zero to 27, with each item scored based on the number of days the patient experienced the feeling noted in each item. While the PHQ-9 was initially developed to guide primary care clinicians in diagnosing and monitoring patients with depressive symptoms, recent authors have validated the PHQ-9 for use in college students (Keum et al., 2018; Kim & Lee, 2019) .

The general question asked of participants was: What helped you get through the past year as you completed your nursing degree? Data were collected using a story path approach (Liehr & Smith, 2018 where all participants were first queried about their entrance into nursing school (past), their current experience amid the pandemic (present), and their expectations for becoming a professional nurse (future). Table 4 outlines the specific questions file with admissions and records for all students enrolled full-time in undergraduate coursework.

Responses were collected between February 1 and February 15, 2021, using the Qualtrics XM survey platform. To incentivize response, students who completed the entire survey were given the opportunity to enter a drawing for one of ten Amazon gift cards. Students were provided with a link to an additional Qualtrics XM survey to ensure survey responses could not be associated with entry into the incentive drawing. This second survey allowed students the choice to submit their first name and preferred email address to the pool from which the incentive awards were drawn.

In the qualitative phase, the researcher introduced the study during the first 10 minutes of a final-semester didactic nursing course from which the purposive sample was obtained. Data were collected from a student cohort with whom the researcher did not otherwise have contact to avoid the perception of coercion. Interested students were invited to contact the researcher by email if they wished to participate in a 45 -60-minute semi-structured interview about their experience as a nursing student during the COVID-19 pandemic. Interviews took place during April 2021 to capture participant perceptions of their nursing school experience upon completing their academic journey. All interviews took place via Zoom videoconference to accommodate rapidly evolving COVID-19 protocols. Interviews were audio-recorded and transcribed verbatim.

Recordings were discarded once the accuracy of each interview transcription was confirmed. student responses on the SSI-R and PHQ-9 survey items. Levene's test for homogeneity of variance was calculated due to the sharply different sample sizes between the nursing (n = 267) and non-nursing (n = 1,939) populations. The Levene's test was non-significant (F 1,1975 = 1.41; p = 0.23) so one-tailed t-test was used to measure differences between continuous variables. Chisquare analysis was used to identify relationships between nursing students and students in nonnursing majors. A multiple linear regression model was fitted to the data to create an explanatory model for students whose PHQ-9 scores indicated high levels of depressive symptoms.

Qualitative data were analyzed using conventional content analysis (Hsieh & Shannon, 2005) , a primarily inductive analysis approach. First, the transcripts were read and re-read to gain a sense of the whole meaning. Then, particular transcript segments that were descriptive of the general question of "getting through the pandemic" were highlighted. Highlighted segments with like meanings were grouped for naming. Grouped segments were read and synthesized as interview themes. Trustworthiness was addressed through peer debriefing (with an experienced qualitative researcher who had no connection to data collection) to assure credibility and confirmability (Lincoln & Guba, 1985) .

This study received institutional review board approval from the University of Nevada, Reno. Careful attention was given to ensure that students did not feel coerced or unduly influenced to participate. Quantitative data were collected anonymously using a survey design that did not collect identifiers or the I.P. address of the device used to complete the survey.

Students who participated in qualitative interviews signed a research consent informing students that (a) interviews would be audio-recorded; (b) a pseudonym would be immediately assigned J o u r n a l P r e -p r o o f after the recording was complete; (c) interviews would be transcribed verbatim; and (d) audiofiles would be discarded after transcription was confirmed. These procedures were followed precisely by the researcher during all phases of data collection and analysis.

The mean age of respondents was 21.3 years (SD 4.6), and 68.9% were female (N = 1,520). Respondents were predominately white (60%; n = 1,324) with a mean GPA of 3.42. Just over one-third of the study sample were first-generation college students (36.9%; n = 811). Data were stratified by the college in which the students' academic majors were housed and by the respondents' year in school ( Table 1) .

The average nursing student in this sample was 21.9 years of age (SD 5.2), white (68%), female (88.7%), and was enrolled in school full time with a mean cumulative GPA of 3.74 (n = 266). Nursing students in this sample were statistically older than non-nursing students (t 2165 = 2.32; p < 0.05). Like their non-nursing counterparts, 33.8% (n = 90) of nursing students were first-generation college students.

Nursing students reported statistically significant higher rates of life stress over the preceding week than non-nursing students (χ 2 3 = 19.4; p < 0.01). Specifically, 57.3% of nursing students (n = 153) and 49.1% of non-nursing students (n = 918) rated their overall stress during the past week as "severe" (χ 2 1 = 8.3; p < 0.01). Significant differences were also found in student perceptions of the degree to which the COVID-19 pandemic impacted their academic experience. Fifty eight percent (n = 156) of nursing students compared to 44.7% (n = 855) of non-nursing students rated the impact of the COVID-19 pandemic on their overall student-life J o u r n a l P r e -p r o o f Journal Pre-proof stress experience as "extreme" (χ 2 4 = 30.1; p < 0.01).

Statistically significant differences were identified in nursing student perceptions of their life stress compared to students pursuing non-nursing academic majors. Nursing students perceived their life stress levels to be significantly higher than non-nursing students for total SSI-R scores and on each SSI-R 'stressors' and 'reactions to stressors' subscale (Table 2) . Notably, nursing students were also significantly more likely to report knowledge of (χ 2 1 = 4.5; p < 0.05) and use of (χ 2 1 = 4.1; p < 0.05) effective stress-management strategies than non-nursing students..

Even though nursing students reported higher levels of life stress and expressed the most significant educational impact from the COVID-19 pandemic, nursing students reported statistically significantly lower total PHQ-9 scores than students in any other academic major (Table 3) . Nursing students significantly differed from their non-nursing peers in that nursing students were less likely to report feeling "down, depressed, or hopeless" (χ 2 3 9.7, p < 0.01), "like a failure" (χ 2 3 11.3; p < 0.01), or "like [they] would be better off dead" (χ 2 3 9.3; p < 0.05) than students in non-nursing majors.

Participant age was a statistically significant predictor of elevated PHQ-9 scores in both nursing (t 230 = -20.7, p < 0.01) and non-nursing students (t 1713 = -47.5; p < 0.01). Ethnicity (χ 2 2 = 6.35; p < 0.05) and gender (χ 2 1 = 22.5; p < 0.01) also were statistically significant predictors of increased PHQ-9 score for non-nursing majors. However, the nursing student sample was underpowered to detect statistically significant gender and ethnicity differences given an alpha error of < 0.05 (1 -β = 0.79).

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A multiple linear regression model using PHQ-9 as the dependent variable was fitted to the data ( 

Semi-structured interviews provided contextual data to understand the inverse relationship between student life stress and depression measures in nursing students. While complete presentation of the qualitative findings is beyond the scope of this article, the overarching theme in the qualitative data revolved around the central concepts of belongingness and social support. All 12 of the students interviewed mentioned some combination of family, significant others, and their classmates as the primary influences that helped them persevere. Ten of the 12 (83.3%) students interviewed indicated that the support received from their nursing cohort was integral to their success. One student stated: 

College is a time of transition and stress for young adults regardless of academic major.

For many emerging adults, entrance into higher education marks the first exposure to independent decision-making without parental oversight. How a student navigates this transition is intrinsically linked to the student's academic experience, mental health, and other social factors (Robbins et al., 2018) . The findings of this study demonstrate a previously undescribed inverse relationship between being a nursing student and depressive symptoms compared to students in non-nursing majors. This relationship occurred despite higher student life stress reported by nursing students compared with other undergraduate cohorts. The reasons for these differences are likely a multifactorial combination that includes a sense of belongingness, social support, and posttraumatic growth.

Baumeister and Leary (1995) assert that "human beings are fundamentally and pervasively motivated by a need to belong" (p. 522). Previous authors have found that the need to belong is highest during the transition to adulthood (Marler et al., 2021, in press; von Soest et al., 2020) .

Nursing students typically matriculate through nursing curricula in a cohort model. This pandemic. It is possible that the cohorted nature of nursing education mitigated the mental health impact of student life stress and promoted academic persistence in nursing students.

Every nursing student who participated in a semi-structured interview with the researcher indicated that the student's social support system had the greatest impact on their perseverance through the COVID-19 pandemic. Previous research documents a powerful connection between social support and depressive symptoms in college students. Rankin et al. (2018) found social support a more powerful predictor of depressive symptoms in college students than personality traits, attachment traits, social network size, or perceived stress.

Nursing students were among the first to return to any form of in-person learning (Redden, 2020) . While the academic experience of nursing students during the pandemic remained stressful, the ability to directly interact with peers may have moderated the relationship between stress and depressive symptoms in this study. Conversely, elevated depressive symptoms in non-nursing majors support the findings of other authors that isolating college students from social networks contributes to higher levels of anxiety, depression, and suicidality in emerging adults (Arslan et al., 2021; Marler et al., 2021, in press; Moeller et al., 2020) .

Several nursing students interviewed for this study expressed confidence that the adversity they faced during nursing school would help them successfully transition into the rigors of entry-level nursing practice. This sentiment is consistent with the growing body of November 2020 and February 2021. During these months, nursing students witnessed the worst of the COVID-19 pandemic first-hand. They were at the bedsides of patients dying from COVID-19, and they worked side by side with nurses who had been working under crisis conditions for months.

While connections between academic stress and depression in college students are well documented, this study is the first to directly measure relationships between depression and life stressors of college students independent of academic performance. While this study provides important data that can support further exploration of causal relationships, these data represent the cross-sectional experience of undergraduate students from one institution, limiting generalizability. In addition, Gadzella's SSI-R inventory includes an introductory question asking respondents to rate their level of student life stress during the preceding week. While the SSI-R does not explicitly measure academic stress related to exams and grades, one can assume that academic stress is a component of student life stress and stress related to exams and grades.

For example, academic life stress may be perceived differently if a student performed poorly (or very well) on an exam or assignment during the preceding week.

As colleges and universities across the United States return to the classroom, academic institutions must not view a return to in-person teaching as a return to the academic landscape we left in March 2020. Pandemic-related mental health impacts on college students will linger for the foreseeable future, and students will need support through this transition. Academic institutions must actively reach out to students as they return to campus to provide the support and social connection required for successful reintegration into campus life.

Based on these data, attention to community-building is an essential component of the post-COVID academic environment. University counseling centers quickly pivoted to virtual and distance support models as campuses closed across the country. Despite the pandemic's J o u r n a l P r e -p r o o f Journal Pre-proof devastating mental health impact on college students, counseling centers experienced dramatic decreases in the number of students seeking support (Madrigal & Blevins, 2021, in press 

Trauma-informed nursing education must be a critical component of mental health support efforts through the lingering effects of the COVID-19 pandemic. Nursing students have J o u r n a l P r e -p r o o f Journal Pre-proof experienced trauma, complicated grief, and secondary stress (Goddard et al., 2021) . Traumainformed nursing education supports student-faculty connection and the development of nurturing relationships that mitigate burnout, reduce compassion fatigue, and secondary trauma.

To truly support students, educators must move away from "sage on the stage" teaching modalities to lessen the power imbalance between educators and students. Goddard et al. (2021) identified "teaching with" students as a critical component of the student-faculty dyad. Rather than "teaching down" to students, "engaging with" them incorporates the caring and compassionate nature of nursing practice from a trauma-informed perspective. Through collaboration and mutuality, students and faculty can be strong allies to collectively resolve challenges and achieve common goals (Carello, 2020). Importantly, a trauma-informed pedagogy should not equate to a relaxation of teaching integrity. Clear expectations of continued professionalism and academic integrity provide important boundaries as students prepare to enter the nursing workforce (Goddard et al., 2021) .

The dampened mental health impact of the pandemic on nursing students in this study suggests that social support may moderate the effect of stress on mental health differently depending on the social dynamics of the student's academic major. Exploration of moderating and mediating factors may identify additional ways colleges can support students as we create a new version of 'normal' in our post-pandemic academic landscape. J o u r n a l P r e -p r o o f Journal Pre-proof 

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