Stress and depression among students of the last semester in two nursing courses 1

Objective: to identify the presence of stress and depression among final year students of two nursing courses, and the association between these variables. Method: an exploratory-descriptive study, undertaken with final-year students from the Bachelor’s degree and Licenciate’s degree courses at the Ribeirão Preto College of Nursing, of the University of São Paulo. The Perceived Stress Scale (PSS) and Beck Depression Inventory (BDI) were applied. Results: of the total of 88 participants in the study, 69.8% have no depression, 18.2% presented dysphoria, 6.8% moderate depression, and 5.7% severe depression, which is a low rate compared to the general population. Medium stress levels were the most frequent (76.9%). There was no significant statistical difference in the stress score between the two groups of students (Student’s t-test: p=0.295>0.05). The data showed a relation between the stress and the presence of indicative signs of depression, especially severe depression (Pearson: r-0.755 and p<0.01). Discussion: The majority did not show signs of depression. The depressive states found among the students on the two courses accompanied proportionately those who obtained high stress scores, as recorded by other studies on this issue. Conclusion: Students with higher levels of stress are more prone to present depression, deserving educators’ attention.


Introduction
Stress was studied and understood as a biological response in the nineteen-thirties, by the Canadian endocrinologist Hans Selye, who defined it as a complex of adaptive reactions of the body to new limits -that is, it is the response of impotence in the face of a decline of resources necessary for overcoming a specified demand.
He described the biochemical reactions which occur in the organism in the presence of stress. These take place in the pituitary-hypothalamus-adrenal system with the release of hormones that act by altering the metabolism, so that the organism can defend itself against the process of stress. Thus, the individuals respond to stress differently, due to variations in personality, previous experiences, genetic characteristics and specific social factors (1)(2) .
Negative and persistent stress, Burnout, may involve various unwanted physical manifestations, such as increased blood pressure and a greater susceptibility to cerebro-vascular accidents (CVA). Infection due to Moreira DP, Furegato ARF. reduced immunological response is frequent, as are gastrointestinal disorders such as diarrhea and constipation, eating disorders, weight gain or loss and insulin resistance, associated with type 2 diabetes and exacerbation of diabetes; it may also lead to tension-type headaches, insomnia, reduction in sexual desire and temporary impotence in men, and exacerbation of premenstrual tension in women, reduction in concentration, inhibition of learning and reduction in memory, as well as exacerbation of skin lesions. This set of prejudicial alterations comprises affected person's quality of life (1)(2)(3)(4) .
Depression is a severe disturbance of mood, being the fourth leading cause of social incapacitation in the world. One in every twenty people is struck by depression at some point in their lives. Of every fifty cases, one will require hospitalization, and 15% of these will commit suicide. The beginning of depression is most frequent between the ages of 20 to 50, but the average age for its identification is approximately forty, for 50% of the patients. It is considered a public health problem in view of its social costs which involve drops in productivity (in studies or work), mood changes, cognitive, psychomotor and vegetative alterations, loss of initiative, and apathy (5)(6)(7)(8)(9) .
Can stressful events be related to depression? The depressive episode may be associated with a recent stressful event. The risk factors most associated with depression are family history, events in infancy, aspects related to personality, social isolation and unpleasant experiences in daily life. The combination of genetic factors, stress in early age and continuous stress can determine a person's vulnerability to psychiatric disorders such as depression. Stressors linked directly to self-esteem are more likely to advance depression and thus each person judges the stressful agent as serious or not, depending on the idiosyncratic meanings which it is given (9)(10) .
Professions which demand close contact with people and which are charged with affective involvement -such as medicine, psychology, nursing and physiotherapyare more likely to develop stress at work and Burnout syndrome (11)(12)(13)(14) .
Nursing is one of these stressful professions, and from the academic training onwards, the student runs into situations which require the taking of important decisions for patient care; the insecurity and anxiety which result from this process may cause or worsen stress. Characteristics such as a high level of cognitive skills and proactive disposition and attitudes are constantly required, both among nurses working in practice and nursing students. In this way, stress and depression may prejudice the performance both of student nurses and qualified nurses (12)(13)(14)(15)(16)(17) .
Considering this, the recognition of stress in student nurses is important, such that there are preventive measures and strategies aiming to reduce the predisposing factors of stress, minimizing its consequences for nurses' health and the performance of their daily activities.

Objective
To identify the presence of stress and indicative signs of depression in students in the last semester of two undergraduate nursing courses, and to compare them, seeking associations between these variables.
The BDI contains a header with questions referring to date, group, subject code, age, sex, marital status and religion.

Results
A total of 88 undergraduate students took part in the study, of whom 52 were from the Bachelor's degree daytime course (B), and 36 from the Licenciate's degree evening course in nursing.
On the Bachelor's degree course, the lowest age of the students was 21, the highest was 25, and the average age was 22.5 years old. The standard deviation was 1.07. The greatest concentration was between 21 and 23 years of age (78%).
On the Licenciate's degree course, the age varied from 21 to 33 years, with the greatest concentration between 24 and 30 years (64.5%). The average age was 24.8 years, with a standard deviation of 2.6 years.
In the Bachelor's degree course, 28.8% of the subjects did not respond to the item corresponding to age, while on the Licenciate's degree course, 13.8% opted not to reveal their age.
The majority of participants in both nursing courses were female (B=96.2% and L=97.2%). The predominant marital status was single (B=93.9 e L=91,7%). The majority of the students were Catholic (B=64.3% and L=84.6%), followed by Spiritualists (B=19% and L=15.4%); the remaining participants were Protestants; 12 subjects did not fill out this item.
From the 21 questions in the Beck Depression Inventory, the authors were able to identify if the respondents had signs of depression, depending on whether they scored over 15 points (19) .  Figure 1 shows the relationship between stress levels and the presence of signs indicating depression in the two groups of students. Table 2 gives the results of the tests for correlation between these results.

Discussion
The profile found in this study's sample does not present characteristics which deserve highlighting, as has been reported in other studies involving student nurses. Neither were there found data which stood out in the comparison of the two groups' profiles, such that the average ages in the groups were close, as were the frequencies for sex and other indicators (12,(20)(21)(22)(23) . This process is often accompanied by competitiveness among their own colleagues. In addition to this, for the women, the career (professional or academic) is added to by personal, biological, hormonal, sexual and social demands (17,(20)(21)(24)(25) .
A recent study undertaken in Portugal also determined that nurses, at the start of their careers, have high stress levels, generally resulting from difficulties in interpersonal relationships between the workers, as well as problems with the structure and organization of the work setting (13) .
In the present study it was observed that the states of dysphoria, moderate depression and -especiallysevere depression were present among the final year students on the two nursing courses, corresponding to the people who obtained high stress scores. This corroborates other studies on the issue (13,21,23) .
One study which related depression among medical students to the stress caused by demands during the undergraduate course found, among the causes, the high volume of new information, the shortage of time for leisure and social activities, and the onus of contact with situations which require emotional componentssuch as the illness and death of patients (14) .
People with dysphoria or other levels of depression present a persistent instability of mood which may be manifested in states of depression or excitement, causing difficulties in performing their personal or professional tasks. Although dysphoria is not serious enough to meet the diagnostic criteria for a depressive disorder, such individuals must be observed and directed to seek medical assistance, as well as being encouraged to talk about what is afflicting them with professionals able to help them with coping measures (5)(6) .
It is noteworthy that the subjects of this study were informed about the research's results. The cases identified were sought out, listened to and advised by the lecturer responsible, on the subject of the personal and professional importance of seeking help from a specialist.
These results confirm the need for programs which help to minimize stress and identify the presence of depression among students. Programs which use meditation, hypnosis and physical relaxation techniques, and support groups for expressing emotions or discussing everyday problems may increase immunity to symptoms of stress and depression (1,14,22,25) . This personal learning may also support the professional in the future in helping patients who present problems resulting from stress and depression.

Conclusion
The transition from the academic period to the new phase of professional activity, where the young people need to take important decisions, contributes to the presence of stress, as observed in the present study.
This study, undertaken with two groups of student nurses in the final semester of their courses, showed that stress may be related to the presence of symptoms of depression. The scores for stress were proportionate to the scores for depression, that is, the greater the stress the student presented, the more susceptible he or she would be to presenting signs of depression.
Bearing in mind the results found, one should note the need for the attention of educators and the creation of programs with preventive and therapeutic actions, based on which the students may reflect and find healthy solutions for their distress, and use the knowledge acquired in their future performance of their duties.