Authors

  1. Hand, Mikel W. EdD, RN, OCN, NE-BC, NEA-BC
  2. Evans, Jennifer DNP, RN
  3. Swenty, Constance DNP, RN, CWON
  4. White, Ann PhD, RN, NE-BC
  5. Chen, Chen DrPH

Abstract

Background: Student resiliency, success, and retention are top priorities for nursing programs.

 

Purpose: The purpose of the cross-sectional descriptive study was to identify factors associated with the resiliency level and physical and mental health of nursing students.

 

Methods: A cross-sectional descriptive study design was used with a convenience sample of 199 nursing students from organizations that comprise the Community Patient Safety Coalition Nursing Research Consortium. Resiliency was measured with the Connor Davidson Resiliency Scale. Physical and mental health was measured with the Patient Reported Outcomes Measurement Information System Global Health Short Form.

 

Results: Most of the nursing students in the sample were female (92%), White (94%), and in BSN programs (74.4%). Students had low resiliency (P < .0001) and low physical and mental health (P < .0001) compared with the general population.

 

Conclusions: Student resilience was positively correlated to self-perception of physical and mental health.

 

Article Content

Most nursing programs are quite rigorous, and strategies that support students through the curriculum and help them to be successful are essential. Evidence suggests that a relationship exists between nursing student success and resiliency.1 Resiliency is defined as "the personal qualities that enable one to thrive in the face of adversity."2(p76) For the purpose of this study, resiliency was defined as the ability to cope with and adapt to stress, a dynamic process that can buffer the effects of stress by adapting to the environment. In addition, persistence is increasingly related to resiliency.1 The correlation between persistence and strong resilience indicates that nursing students' likelihood of achieving academic success while facing the inherent stresses and adversities commonly found within nursing programs may be related to persistence to continue in the nursing program.

 

To determine strategies needed to support students and build resiliency, the level of resiliency among current nursing students as well as their perceived levels of physical and mental health should be considered. Members of a collaborative academic-practice Nursing Research Consortium conducted a study to evaluate the perceived resiliency, physical, and mental health status of student nurses using the Connor-Davidson Resilience Scale (CD-RISC) and the Patient Reported Outcomes Measurement Information System (PROMIS) Global Health Short Form v1.1. The CD-RISC instrument has been used in previous research involving university nursing students.2,3 The PROMIS has been used in young adults within the context of a particular medical condition.4-7

 

Nursing students' resiliency has been the topic of several descriptive research studies and scoping reviews of the literature.8-13 Many factors affect student performance such as outside employment, family and financial obligations, and the course load per semester. Bartlett et al14 reported higher stress levels in nursing students as compared with nonnursing students. Lekan et al10 found that the top contributor of nursing students' stress was extreme financial hardship. He et al11 found that higher stress scores negatively affected psychological well-being, and resiliency and external support positively affected psychological well-being. Before this study, the authors noted that nontraditional students had higher stress levels and speculated that this was due to juggling responsibilities between family, work, and school.

 

Contrary to the traditional belief that resiliency is an innate trait, resiliency is described as dynamic and can be learned, promoted, and enhanced.9 The implication is that developing and implementing strategies to help build resilience among nursing students is possible. To better understand and create an environment promoting student resilience, educators need to have a better understanding of the students' perception of their resiliency.9-11

 

In addition, understanding the factors related to resilience and how they are unique to nursing students supports the creation of successful strategies to increase resiliency among students. Nursing programs are known to be stressful, which may negatively impact students' psychological well-being.10,11 Students with more resilience report higher psychological well-being despite the high-stress environment associated with nursing programs.9 Additional evidence supports resilience as a key factor or predictor of student success as well as a major factor for health and well-being that can be beneficial to health care students as they transition into practice.9

 

Despite the current evidence reporting resiliency as a key factor to student success and well-being, there is much work to be done. A universal definition as well as more information to develop and implement evidence-based strategies promoting resiliency and addressing student psychological well-being are needed.6

 

Purpose and Research Questions

The purpose of the cross-sectional descriptive study was to identify factors associated with the resiliency level and physical and mental health of nursing students. The students' perceived resiliency level along with their perceived physical and mental health were assessed. In addition, relationships among factors were evaluated and correlated with the resiliency and physical and mental health scores.

 

The research questions posed in this study were the following:

  

1. What are the sociodemographic characteristics associated with degree of resiliency, perceived physical health, and perceived mental health among nursing students?

 

2. What is the relationship between degree of resiliency and perceived physical health and mental health status of nursing students?

 

Methods

Design

This was a descriptive cross-sectional study conducted in 4 Midwest nursing programs affiliated with the regional Nursing Research Consortium. The study was approved by the authors' university institutional review board.

 

Sampling

Permission was obtained from the program directors of the 4 nursing programs to sample the students using 2 validated tools. Convenience sampling was used to survey nursing students enrolled in 1 of the 4 nursing programs, 2 associate of science in nursing (ASN) and 2 BSN, by sending a URL through email to the program chair/dean who in turn sent to all students in that program. The results were returned to a separate database, so the chair/dean never saw any student responses. Once students clicked on the URL, they were led to the online survey page with the informed consent that offered the option to participate.

 

Instruments

Instruments used with the students included a demographic survey, the CD-RISC, and the PROMISv1.1.15-17 The CD-RISC psychometric ratings include a Cronbach's a, which resulted in an internal consistency of 0.89. Reliability and validity are well documented in previous studies.2,3 Demographic data were collected including personal and academic-program-related factors. The CD-RISC consists of 25 questions with 5 Likert-type responses ranging from 0 to 4, with 0 indicating not true at all to 4 indicating true nearly all the time. Degree of resilience is calculated by totaling the score of the 25 items, with higher scores reflecting greater resilience.10 An example of a sample item of the CD-RISC is Having to cope with stress makes me stronger: 0 (not true at all) to 4 (true nearly all of the time).15

 

The PROMIS instrument assesses self-perceived health status and is publicly available.16 The 10-item instrument measures physical and mental health components. Higher scores represent a better perceived health status. The scale has internal consistency reliability coefficients of 0.81 and 0.86 for physical and mental health measurements, respectively. Research evidence for validity has also been well documented.13,15-17 An example of a sample item from the PROMIS is In general, would you say your quality of life is 5 (very excellent) to 1 (poor).16

 

Data Collection

The online survey questionnaire was administered using electronic survey software. No identifying data were collected. Nursing students (n= 802) from 4 nursing programs (2 ASN and 2 BSN) were approached to participate in the study. Of the 802 students, 199 agreed to participate with an overall response rate of 24.8%.

 

Statistical Analysis

Data included the resiliency, physical health, and mental health scores. Each student had a resiliency score ranging from 0 to 100 and physical and mental health scores ranging from 4 to 20. Physical and mental health scores were converted to t scores following the procedure in the PROMIS instrument manual. This enabled comparison of sample scores with general population scores. Several demographic factors were used as independent variables including age, gender, race/ethnicity, degree program, and the number of semesters completed in the nursing program.

 

Data were analyzed using Stata/MP 14.0 statistical software (College Station, Texas). Descriptive statistics were presented using frequency tables. Linear regression analysis determined factors associated with resiliency. One-sample t test values were used to compare the means of the students' resiliency score, perceived physical health t score, and perceived mental health t score to the means for the general population. Pearson correlation coefficient was used to determine the relationship between students' resiliency scores, physical health scores, and mental health scores. To explore factors associated with resilience and self-perceived physical and mental health, linear regression analyses were conducted between outcome variables and each independent variable. A P value of less than .05 was considered statistically significant. On the basis of how variables loaded in the regression analysis, dominance analysis was used to determine the relative importance of factors associated with resiliency, physical health, and mental health.

 

Results

Demographic Variables

Most students were in BSN programs (74.4%), the average nursing student age was 23 years (mean [SD], 22.99 [6.03] years), 92% (n = 182) were female, and 94% (n = 188) identified as White. All nursing programs involved in the study awarded semester credit hours. Students were asked about their experience while in their nursing programs, and results indicated that 97 of 199 students (48.74%) sometimes want to give up compared with 88 of 199 students (44.22%) who will never quit. In addition, 119 of 198 students (60.20%) acknowledged that the course load was sometimes too much as compared with 67 of 198 students (33.84%) who thought the course load was always or usually too much (Supplemental Digital Content, Table, http://links.lww.com/NE/B13).

 

Degree of Resilience, and Self-perceived Physical and Mental Health

One-sample t test and univariate analysis revealed that nursing students' resilience scores (mean [SD], 73.82 [11.18]; t = 8.63, P < .0001) were lower than those of the general US population. Scores for the perceived physical health (mean [SD], 47.76 [5.78]; t = 5.46, P < .0001) and perceived mental health (mean [SD], 45.06 [9.16]; t = 7.59, P < .0001) were also lower than those of the general US population (Table 1).

  
Table 1 - Click to enlarge in new windowTable 1. Comparison Between Nursing Students and the General Population

Correlation Between Degree of Resilience and Perceived Physical and Mental Health

The relationships between resilience and perceived physical and mental health were assessed using Pearson correlation coefficients. Perceived physical health (r = 0.48, P < .05) and perceived mental health (r = 0.59, P <.05) are moderately and positively correlated with the degree of resilience in nursing students.

 

Factors Associated With Resiliency, Physical Health, and Mental Health

Nursing students who had completed 3 or more semesters of nursing had lower resiliency than students who had completed 1 semester ([beta] = -4.56, P = .034). Nursing students who usually or always thought of giving up on their nursing program had lower resiliency than those who never thought of giving up ([beta] = -14.87, P < .001). Nursing students who usually or always think that the course load is too much had significantly lower resiliency scores than those who never thought the course load is too high ([beta] = -8.17, P =.019).

 

Factors significantly associated with the perceived physical health in nursing students were examined. Nursing students who completed 3 semesters had worse physical health than students who had completed 1 semester ([beta] = -1.22, P = .002), nursing students who usually or always think of giving up on their nursing program had worse physical health than those who never thought of giving up ([beta] = 1.75, P = .003), and nursing students who usually or always think their course load is too much had worse physical health than those who never think their course load is too much ([beta] = -1.84, P = .003).

 

Factors associated with the perceived mental health of nursing students followed the same trend as those affecting perceived physical health. Nursing students who completed 3 semesters had worse perceived mental health than those students who had completed 1 semester ([beta] = -1.63, P = .015), students who usually or always think of giving up on their nursing program had worse perceived mental health than those who never thought of giving up ([beta] = 3.36, P = .001), and students who usually or always think their course load is too much had worse perceived mental health than those who never think their course load is too much ([beta] = -3.42, P = .002).

 

A dominance analysis was completed of the regression factors affecting perceived resiliency, physical health, and perceived mental health with rankings of predictor variables identified. For resiliency, the dominant factors were (1) thought of giving up on the nursing program (51.13%), (2) how often the student felt the course load was too much (26.39%), (3) and semesters completed (14.33%). For perceived physical health, the dominant factors were ranked as follows: (1) how often the student felt the course load was too much (41.15%), (2) semesters completed (30.10%), and (3) thought about giving up on the nursing program (28.19%). For perceived mental health, the dominant factors were (1) how often the student felt the course load was too much (46.94%), (2) thought of giving up on the nursing program (30.38%), and (3) semesters completed (18.22%) (Table 2).

  
Table 2 - Click to enlarge in new windowTable 2. Dominance Analysis of Factors Associated With Resiliency, Physical Health, and Mental Health in Nursing Students

Discussion

The first objective of the study was to analyze sociodemographic characteristics associated with degree of resiliency, perceived physical health, and perceived mental health among nursing students. Compared with the general US population, nursing students had significantly lower resiliency scores, perceived physical health t scores, and perceived mental health t scores. This study also found that perceived physical health and perceived mental health are positively correlated with the degree of resilience in nursing students. This suggests that nursing students' degree of resilience affects their perceived physical and mental health. The findings are consistent with literature that correlates the degree of stress with nursing students' physical and mental health.9-11

 

Factors were identified that affect students' perceived physical health and mental health: how often the student felt the course load was too much, thoughts about giving up on the nursing program, and number of semesters completed. The results provide valuable information for designing interventions to improve nursing student retention, support their physical and mental health, and increase their resiliency. Examination of the nursing curriculum's third semester is necessary to determine why students score lower in resiliency in that semester. The literature notes a number of interventions that can support persistence and enhance resiliency such as hardiness training, simulated training exercises, and mindfulness programs.11

 

An interesting finding was that students had lower resiliency scores for the third semester. Factors to examine include the content taught in the third semester, the number of clinical hours expected, and the consideration of outside stressors after the student has completed 1 year of the nursing program. Is this the point that students feel the course load is too much and consider giving up on their nursing program? As nursing moves to competency-based curricula, educators should integrate this information into their plans to enhance student success. Published studies endorse classroom curriculum changes and simulated training exercises.12 Educators should listen to students and their concerns. Students can share lived experiences and guide strategies that they feel will enhance their success. Further qualitative studies should gather data on the students' lived experiences to provide a granular assessment of the factors identified in this study. These data would also aid in developing a universal definition of resiliency.

 

It is important to note that the data in this study were collected before the COVID pandemic. A replication of the study post COVID to determine whether similarities exist within the results is currently being conducted. In addition, a qualitative research study is being conducted to further explore the lived experience. Of the nursing students, the prepandemic mental health scores were lower than the national mean. If similar results are obtained post COVID, it is important to identify interventions addressing concerns to improve students' perceived mental health. Significant factors associated with low resiliency, such as why so many students frequently consider leaving nursing, nursing program rigor, and the third semester curriculum, should be examined post COVID because of the significant changes that were made in the delivery of courses during the pandemic.

 

Limitations

A key limitation was the low response rate of 28.4% (199/802) of students approached. The study was limited to 4 schools. This may pose some restrictions in relation to generalization of the study results. This study was also pre-COVID-19.

 

Conclusion

In this study, low resilience level was associated with both low perceived physical health and mental health in nursing students. The findings are consistent with the literature related to student resiliency and their overall well-being. However, nursing students report lower resilience scores and physical and mental health than the general public. The outcomes from this study are concerning because these students will be entering a stressful and chaotic health care environment that requires resilience, physical well-being, and mental stamina. Identifying and understanding the lived experiences of students after their first and second semesters may provide insight into their resiliency state. This information could be used to develop strategies designed to strengthen resiliency and enhance physical and mental wellbeing. Deliberate methods for enhancing resiliency among nursing students not only have the potential to impact academic success but also may have a positive and broader impact through the creation of a more resilient nursing workforce.

 

References

 

1. Meyer G, Shatto B, Kuljeerung O, et al Exploring the relationship between resilience and grit among nursing students: a correlational research study. Nurse Educ Today. 2019;84:104246. doi:https://doi.org/10.1016/j.nedt.2019.104246[Context Link]

 

2. Connor KM, Davidson JR. Development of a new resilience scale: the Connor Davidson Resilience Scale (CD-RISC). Depress Anxiety. 2003;18(2):76-82. doi:10.1002/da.10113 [Context Link]

 

3. Mealer M, Schmiege SJ, Meek P. The Connor-Davidson Resilience Scale in critical care nurses. A psychometric analysis. J Nurs Meas. 2016;24(1):28-39. doi:10.1891/1061-3749.24.1.28 [Context Link]

 

4. Henderson JRII, Kiernan E, McNeer JL, et al Patient-reported health-related quality-of-life assessment at the point-of-care with adolescents and young adults with cancer. J Adolesc Young Adult Oncol. 2018;7(1):97-102. doi:https://doi.org/10.1089/jayao.2017.0046[Context Link]

 

5. Kahan JB, Kassam HF, Nicholson AD, et al Performance of PROMIS Global-10 to legacy instruments in patients with lateral epicondylitis. Arthroscopy. 2019;35(3):770-774. doi:10.1016/j.arthro.2018.09.019 [Context Link]

 

6. Kasturi S, Szymonifka J, Burket JC, et al Feasibility, validity, and reliability of the 10-item Patient Reported Outcomes Measurement Information System Global Health Short Form in outpatients with systemic lupus erythematosus. J Rheumatol. 2018;45(3):397-404. doi:https://doi.org/10.3899/jrheum.170590[Context Link]

 

7. Cella D, Riley W, Stone A, et al PROMIS Cooperative Group. The Patient-Reported Outcomes Measurement Information System (PROMIS) developed and tested its first wave of adult self-reported health outcome item banks: 2005-2008. J Clin Epidemiol. 2010;63(11):1179-1194. doi:10.1016/j.jclinepi.2010.04.011 [Context Link]

 

8. Akeman E, Kirlic N, Clausen AN, et al A pragmatic clinical trial examining the impact of a resilience program on college student mental health. Depress Anxiety. 2020;37(3):202-213. doi:https://doi.org/10.1002/da.229690[Context Link]

 

9. Chow KM, Tang WKF, Chan WHC, et al Resilience and well-being of university nursing students in Hong Kong: a cross-sectional study. BMC Med Educ. 2018;18:13. doi:https://doi.org/10.1186/s12909-018-1119-0[Context Link]

 

10. Lekan DA, Ward TD, Elliott AA. Resilience in baccalaureate nursing students: an exploration. J Psychosoc Nurs Ment Health Serv. 2018;56(7):46-55. doi:10.3928/02793695-20180619-06 [Context Link]

 

11. He FX, Turnbull B, Kirshbaum MN, et al Assessing stress, protective factors and psychological well-being among undergraduate nursing students. Nurse Educ Today. 2018;68:4-12. doi:https://doi.org/10.1016/j.nedt.2018.05.013[Context Link]

 

12. Sanderson B, Brewer M. What do we know about student resilience in health professional education? A scoping review of the literature. Nurse Educ Today. 2017;58:65-71. http://dx.doi.org/10.1016/j.nedt.2017.07.018[Context Link]

 

13. Amerson R, Fisher B, Bible J, et al Nursing education amid a pandemic: mental health in a time of virtual learning. Nurse Educ. 2021;46(4):255-260. doi:10.1097/NNE.0000000000001039 [Context Link]

 

14. Bartlett ML, Taylor H, Nelson JD. Comparison of mental health characteristics and stress between baccalaureate nursing students and non-nursing students. J Nurs Educ. 2016;55(2):87-90. doi:10.3928/01484834-20160114-05 [Context Link]

 

15. Davidson JRT. Connor-Davidson Resilience Scale (CD-RISC) manual. Accessed April 16, 2021. Available at http://www.connordavidson-resiliencescale.com[Context Link]

 

16. Health Measures. PROMIS. 2021. Accessed April 9, 2021. Available at https://www.healthmeasures.net/explore-measurement-systems/promis/obtain-adminis Health Measures (2021). PROMIS. Accessed 4-9-2021. https://www.healthmeasures.net/explore-measurement-systems/promis/obtain-adminis[Context Link]

 

17. Riley WT, Rothrock N, Bruce B, et al Patient-reported outcomes measurement information system (PROMIS) domain names and definitions revisions: further evaluation of content validity in IRT- derived item banks. Qual Life Res. 2010;19(9):1311-1321. doi:10.1007/s11136-010-9694-5 [Context Link]

 

mental health; nursing students; persistence; physical health; resilience