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Association of stress factors and depressive symptoms with the academic performance of nursing students* * Extracted from the thesis: “Fatores de estresse, sintomas depressivos, suporte social e resiliência associados ao desempenho acadêmico em estudantes de enfermagem”, Escola de Enfermagem, Universidade de São Paulo, 2016.

ABSTRACT

Objective:

To verify the association of stress factors and depressive symptoms with the academic performance of nursing students.

Method:

Cross-sectional, quantitative, observational research conducted at a public university in Manaus. Socio-demographic data, academic performance coefficient and individual semester performance, the Instrument for the Assessment of Stress in Nursing Students and the CES-D Center for Epidemiologic Studies Depression Scale were used to characterize the students. Pearson's correlation coefficient, ANOVA test and multiple linear regression were used for the analysis.

Results:

155 nursing students participated in the study. The stress factors “performance of practical activities”, “professional communication” and “professional education” had a positive correlation with individual semester performance, while the factors “depressive affect”, “interpersonal” and “somatic/attitudes” had a negative correlation.

Conclusion:

The present study identified positive impacts of stress factors on academic performance, however, the presence of depressive symptoms was associated with lower academic performance.

DESCRIPTORS
Students, Nursing; Stress, Psychological; Depression; Academic Performance

RESUMO

Objetivo:

Verificar a associação dos fatores de estresse e da sintomatologia depressiva com o desempenho acadêmico de estudantes de enfermagem.

Método:

Pesquisa observacional, transversal, quantitativa, realizada em uma universidade pública em Manaus. Utilizou-se de dados sociodemográficos para a caracterização dos estudantes, do coeficiente de rendimento escolar e rendimento semestral individual, da Escala de Avaliação de Estresse em Estudantes de Enfermagem e da Escala de rastreamento de sintomatologia depressiva. Para a análise, foi utilizado o Coeficiente de correlação de Pearson, teste de ANOVA e a regressão linear múltipla.

Resultados:

Participaram 155 estudantes de enfermagem. Os fatores de estresse na realização das atividades práticas, comunicação profissional e formação profissional tiveram uma correlação positiva com rendimento semestral individual, enquanto o fator depressão, interpessoal, somática e iniciativa tiveram correlação negativa.

Conclusão:

O presente estudo identificou aspectos positivos dos fatores de estresse para um melhor desempenho acadêmico, todavia, a presença de sintomas depressivos implicou menor desempenho acadêmico.

DESCRITORES
Estudantes de Enfermagem; Estresse Psicológico; Depressão; Desempenho Acadêmico

RESUMEN

Objetivo:

Verificar la asociación de los factores de estrés y la sintomatología depresiva con el desempeño académico de estudiantes de enfermería.

Método:

Investigación observacional, transversal, cuantitativa, realizada en una universidad pública en Manaus. Se utilizaron datos sociodemográficos para la caracterización de los estudiantes, del coeficiente de rendimiento escolar y rendimiento semestral individual, la Escala de Evaluación de Estrés en Estudiantes de Enfermería y la Escala de rastreo de sintomatología depresiva. Para el análisis, se utilizó el Coeficiente de correlación de Pearson, la prueba de ANOVA y la regresión lineal múltiple.

Resultados:

Participaron 155 estudiantes de enfermería. Los factores de estrés en la realización de las actividades prácticas, comunicación profesional y formación profesional tuvieron una correlación positiva con rendimiento semestral individual, mientras que el factor depresión, interpersonal, somático e iniciativa tuvieron correlación negativa.

Conclusión:

El presente estudio identificó aspectos positivos de los factores de estrés para un mejor desempeño académico, sin embargo la presencia de síntomas depresivos implicó menor desempeño académico.

DESCRIPTORES
Estudiantes de Enfermería; Estrés Psicológico; Depresión; Rendimiento Académico

INTRODUCTION

Studies have shown that the difficulties of academic life have a negative impact on the nursing student' experience in undergraduate studies(11. Roso-Bas F, Pades Jiménez A, García-Buades E. Emotional variables, dropout and academic performance in Spanish nursing students. Nurse Educ Today. 2016;37(2):53-8. DOI: https://doi.org/10.1016/j.nedt.2015.11.021
https://doi.org/10.1016/j.nedt.2015.11.0...
22. Tharani A, Husain Y, Warwick I. Learning environment and emotional well-being: A qualitative study of undergraduate nursing students. Nurse Educ Today. 2017;59(12):82-87. DOI: https://doi.org/10.1016/j.nedt.2017.09.008
https://doi.org/10.1016/j.nedt.2017.09.0...
) and on their academic performance(33. Budu HI, Abalo EM, Bam V, Budu FA, Peprah P. A survey of the genesis of stress and its effect on the academic performance of midwifery students in a college in Ghana. Midwifery. 2019;73(6):69-77. DOI: https://doi.org/10.1016/j.midw.2019.02.013
https://doi.org/10.1016/j.midw.2019.02.0...
). Entering the university with low levels of emotional clarity can lead to pessimistic expectations about nursing, low optimism and intention to dropout(11. Roso-Bas F, Pades Jiménez A, García-Buades E. Emotional variables, dropout and academic performance in Spanish nursing students. Nurse Educ Today. 2016;37(2):53-8. DOI: https://doi.org/10.1016/j.nedt.2015.11.021
https://doi.org/10.1016/j.nedt.2015.11.0...
). In addition, the quality of the academic environment may affect nursing students' learning and academic performance(22. Tharani A, Husain Y, Warwick I. Learning environment and emotional well-being: A qualitative study of undergraduate nursing students. Nurse Educ Today. 2017;59(12):82-87. DOI: https://doi.org/10.1016/j.nedt.2017.09.008
https://doi.org/10.1016/j.nedt.2017.09.0...
).

The distress experienced by the student is seen as a consequence of factors such as academic environment, teaching, evaluation, curriculum requirements and lack of resources, which may increase the perception of overload and affect evaluation results(22. Tharani A, Husain Y, Warwick I. Learning environment and emotional well-being: A qualitative study of undergraduate nursing students. Nurse Educ Today. 2017;59(12):82-87. DOI: https://doi.org/10.1016/j.nedt.2017.09.008
https://doi.org/10.1016/j.nedt.2017.09.0...
). A review study found that stress levels during the academic education of nursing students range from moderate to high and are associated with caring of patients, evaluation assignments and workloads, and negative interactions with staff and faculty(44. Labrague LJ, McEnroe-Petitte DM, Gloe D, Thomas L, Papathanasiou IV, Tsaras K. A literature review on stress and coping strategies in nursing students. J Ment Health. 2017;26(5):471-80. DOI: https://doi.org/10.1080/09638237.2016.1244721
https://doi.org/10.1080/09638237.2016.12...
). In addition to stress, depression has also been a highly prevalent problem among nursing students, with a negative impact on students' health and academic performance(55. Tung YJ, Lo KKH, Ho RCM, Tam WSW. Prevalence of depression among nursing students: A systematic review and meta-analysis. Nurse Educ Today. 2018;63(4):119-29. DOI: https://doi.org/10.1016/j.nedt.2018.01.009
https://doi.org/10.1016/j.nedt.2018.01.0...
).

The emotional distress experienced by the students during the training period can lead to more compromising situations, such as burnout, emotional exhaustion or fatigue resulting from academic demands, and impaired learning(66. Reis D, Xanthopoulou D, Tsaousis IC. Measuring job and academic burnout with the Oldenburg Burnout Inventory (OLBI): Factorial invariance across samples and countries. 2015;2(1):8-18. DOI: https://doi.org/10.1016/j.burn.2014.11.001
https://doi.org/10.1016/j.burn.2014.11.0...
).

The interactionist theory should be considered in this context. In this theory, stress is connected to the interaction between individuals and their environment, and their positive or negative interpretation of a given event. The perception of stressors can lead to physiological and emotional manifestations(77. Lazarus RS, Folkman S. Stress, appraisal and coping. New York: Springer; 1984.).

Thus, the presence of stress factors and depressive symptoms in the environment of the nursing student is an evident problem(44. Labrague LJ, McEnroe-Petitte DM, Gloe D, Thomas L, Papathanasiou IV, Tsaras K. A literature review on stress and coping strategies in nursing students. J Ment Health. 2017;26(5):471-80. DOI: https://doi.org/10.1080/09638237.2016.1244721
https://doi.org/10.1080/09638237.2016.12...
55. Tung YJ, Lo KKH, Ho RCM, Tam WSW. Prevalence of depression among nursing students: A systematic review and meta-analysis. Nurse Educ Today. 2018;63(4):119-29. DOI: https://doi.org/10.1016/j.nedt.2018.01.009
https://doi.org/10.1016/j.nedt.2018.01.0...
). Depressive symptomatology is a set of symptoms which include feelings of guilt, worthlessness, helplessness, hopelessness, loss of appetite and sleep disorders. These symptoms are related to the dimensions depression, interpersonal, positive affect and somatic/attitude, which are important to establish the clinical diagnosis of depression(88. Radloff LS. The CES-D Scale: a self-report depression scale for research in the general population. Appl Psychol Meas. 1977;1(3):385-401. DOI: https://doi.org/10.1177%2F014662167700100306
https://doi.org/10.1177%2F01466216770010...
).

The inherent stressors of academic life are performance of practical activities, professional communication, time management, environment, professional education and theoretical activities(99. Costa ALS, Polak C. Construction and validation of an instrument for the assessment of stress among nursing students. Rev Esc Enferm USP. 2009;43(spe):1017-26. DOI: http://dx.doi.org/10.1590/S0080-62342009000500005
http://dx.doi.org/10.1590/S0080-62342009...
). The Instrument for the Assessment of Stress in Nursing Students (ASNS) was constructed to evaluate these factors and presented good psychometric properties(99. Costa ALS, Polak C. Construction and validation of an instrument for the assessment of stress among nursing students. Rev Esc Enferm USP. 2009;43(spe):1017-26. DOI: http://dx.doi.org/10.1590/S0080-62342009000500005
http://dx.doi.org/10.1590/S0080-62342009...
). Considering Brazilian cultural diversity, this instrument must be applied in places with socio-cultural characteristics different from the original setting, in order to find new evidence to establish the cultural equivalence of the concept.

Given this issue, in addition to the particularities of multiple training environments in the national territory, this study provides evidence on the psycho-emotional aspects of students from the Northern region of Brazil. Specifically, the place selected was the state of Amazonas, which has particular characteristics related to the origin of students from the countryside of the state, who experience difficulties in access and must live away from their families. Moreover, evidence on the impact of these factors on the student's academic performance is still limited.

This kind of study is important as it allows recognizing the signs and symptoms that affect the student's life and the future health of the nursing professional, since psychological stress has been proven to negatively affect the performance of students from other health courses(1010. Aboalshamat K, Hou XY, Strodl E. Psychological well-being status among medical and dental students in Makkah, Saudi Arabia: a cross-sectional study. Med Teach. 2015;37 Suppl 1:S75-81. DOI: 10.3109/0142159X.2015.1006612
https://doi.org/10.3109/0142159X.2015.10...
). The originality of the present study lies in the analysis of psycho-emotional aspects of stress factors, depressive symptoms and their relationship with academic performance. Few studies have addressed this aspect as an outcome. Thus, to confirm the hypothesis that stress factors and depressive symptoms, evident in the context of academic studies, also affect the nursing student's academic performance, the objective of this study was to verify the association between academic performance of nursing students and stress factors and depressive symptoms.

METHOD

Type of study

Observational, cross-sectional, quantitative study conducted at a public university in the city of Manaus, Amazonas. The undergraduate nursing course occurs in the mornings and afternoons and has a 5-year duration.

Population

The study population consisted of 212 students regularly enrolled in the nursing course.

Students regularly enrolled in the odd semesters (1st, 3rd, 5th, 7th, 9th) were included, as this Higher Education Institution (HEI) accepts students annually. Students who were not in the institution in the periods scheduled for data collection, pregnant women and students under age 18 were excluded.

The study population consisted of all students, that is, 212 students were invited to participate in the research, of which 62 were in the 1st semester, 47 in the 3rd, 45 in the 5th, 36 in the 7th and 22 in the 9th semester. A total of 155 (73.1%) students agreed to participate. Among the 57 (26.9%) losses, 37 were due to absence from the classroom during data collection (due to participation in external projects or exchange programs, curricular internship in health units or unexcused absences), five were excluded due to incomplete data, one due to pregnancy and 17 did not accept to participate due to lack of time to respond to the instrument.

Data collection

Data was collected from June 25 to July 30, 2015, through a questionnaire with socio-demographic, academic characteristics and academic performance, measured by the academic performance coefficient (In Portuguese: CRE – Coeficiente de rendimento escolar) and individual semester performance (RSI – Rendimento semestral individual). The RSI was developed for this research and consists of the weighted average of academic performance per semester, calculated from the sum of the final grade of each class of the semester, divided by the number of classes taken in the semester, obtained in the school records. The RSI is obtained by the following formula: RSI=∑[Final Grade 1+ Final Grade 2+ FGn(all classes of the semester)]/ Number of classes of the semester.

The Instrument for the Assessment of Stress in Nursing Students (ASNS) and the Center for Epidemiologic Studies Depression Scale (CES-D) were used. The ASNS was constructed and validated to assess stress factors in nursing students(99. Costa ALS, Polak C. Construction and validation of an instrument for the assessment of stress among nursing students. Rev Esc Enferm USP. 2009;43(spe):1017-26. DOI: http://dx.doi.org/10.1590/S0080-62342009000500005
http://dx.doi.org/10.1590/S0080-62342009...
) and is based on the transactional stress model(77. Lazarus RS, Folkman S. Stress, appraisal and coping. New York: Springer; 1984.). It consists of 30 items, divided into six domains: (1) Performance of Practical activities; (2) Professional Communication; (3) Time Management; (4) Environment; (5) Professional Education; (6) Theoretical Activity. The items use a 4-point Likert scale, ranging from zero to three according to the intensity: 0 – I do not experience this situation; 1 – I do not feel stressed with this situation; 2 – I feel a little stressed with this situation; 3 – I feel very stressed with this situation. In the construction and validation study, the instrument presented good reliability, with Cronbach's alpha values between 0.717 and 0.866.

The CES-D screening scale(88. Radloff LS. The CES-D Scale: a self-report depression scale for research in the general population. Appl Psychol Meas. 1977;1(3):385-401. DOI: https://doi.org/10.1177%2F014662167700100306
https://doi.org/10.1177%2F01466216770010...
) is an instrument that assesses depressive symptomatology in the general population and in various age groups. It was validated in Brazil for university students based on a previous Brazilian version of the scale(1111. Hauck Filho N, Teixeira MAP. A estrutura fatorial da Escala CES-D em estudantes universitários brasileiros. Aval Psicol [Internet]. 2011 [citado 2018 fev. 2];10(1):91-7. Disponível em: http://pepsic.bvsalud.org/scielo.php?script=sci_arttext&pid=S1677-04712011000100010&lng=pt
http://pepsic.bvsalud.org/scielo.php?scr...
). It is composed of four associated factors: “Depressive Affect”; “Interpersonal”; “Positive Affect” and “Somatic/Attitudes”. The factor “Depressive Affect” consists of seven items of negative affect, characteristic of the depressive state. The factor “Interpersonal” consist of two items that evaluate negative beliefs that hinder relationships and social functioning. The factor “Positive Affect” consists of four items that assess optimism, hope and life satisfaction. The Factor “Somatic/Attitudes” consists of seven items related to difficulties to engage and perform daily activities. These four items encompass the main affective, cognitive, somatic, and behavioral aspects of depression. The CES-D is composed of 20 questions, with answers based on the frequency of each symptom in the week prior to application of the instrument. A four-point Likert scale is used for the evaluation of each item, with: 0 – Rarely or none of the time; 1 – Some or a little of the time; 2 – Occasionally or a moderate amount of time; 3 – Most or all of the time. The total score ranges from 0 to 60 points. Four items (questions) are related to positive aspects, that is, positive affect factors, with the objective of avoiding tendency to repetitive responses and evaluating the presence or absence of positive affect. These items are scored in reverse, with higher scores representing lower frequency of symptoms. The cut-off score adopted in this study was: scores ≥16 points indicate the occurrence of symptoms of depression; scores below 16 points indicate absence of symptoms of depression(55. Tung YJ, Lo KKH, Ho RCM, Tam WSW. Prevalence of depression among nursing students: A systematic review and meta-analysis. Nurse Educ Today. 2018;63(4):119-29. DOI: https://doi.org/10.1016/j.nedt.2018.01.009
https://doi.org/10.1016/j.nedt.2018.01.0...
). In the instrument validation study for Brazilian university students, the total alpha was 0.89, which indicates good internal consistency. The scale demonstrated acceptable adjusted indices for a four-factor structure, showing reasonable adequacy for use with Brazilian undergraduate students in the original form with four factors.

Data treatment and analysis

To assess the intensity of stress among nursing students according to the ASNS, the mean of the items of each domain was calculated to identify the highest and lowest stressors for the student. The domain with the highest mean was considered the most stressful. Considering the mean obtained in each domain, based on the normality of the scale the students were classified according to stress intensity as: low, medium, high and very high stress intensity, in each of the six domains. The scores considered for the classification of stress intensity in each domain are shown in Table 1.

Table 1
Classification of stress intensity according to quartiles of risk in each domain(99. Costa ALS, Polak C. Construction and validation of an instrument for the assessment of stress among nursing students. Rev Esc Enferm USP. 2009;43(spe):1017-26. DOI: http://dx.doi.org/10.1590/S0080-62342009000500005
http://dx.doi.org/10.1590/S0080-62342009...
).

To evaluate depressive symptoms according to CES-D, the cut-off point considered was: scores ≥16 indicating the presence of depression symptoms, and scores below 16 indicating absence of depression symptoms(55. Tung YJ, Lo KKH, Ho RCM, Tam WSW. Prevalence of depression among nursing students: A systematic review and meta-analysis. Nurse Educ Today. 2018;63(4):119-29. DOI: https://doi.org/10.1016/j.nedt.2018.01.009
https://doi.org/10.1016/j.nedt.2018.01.0...
).

The data showed normal distribution, so the Pearson test was used to analyze correlations. The ANOVA (Analysis of variance) test was applied to compare measurements between groups. Multiple regression analysis was performed to identify predictors of academic performance. The variables were selected by a LASSO (Least Absolute Shrinkage) model, with RSI and CRE as the response variables. The Cronbach's alpha test was used to evaluate instrument reliability. Confidence interval (95% CI), significance level of 5% and p-value <0.05 were used.

Ethical aspects

This research was approved by the Research Ethics Committee of the Nursing School of the Universidade de São Paulo and of the HEI where data were collected, under Protocol No. 1.122.822 and No. 1.233.289 of 2015. The study met all the specifications of Resolution no. 466/12 of the National Health Council, on guidelines and regulatory standards for research involving human subjects.

RESULTS

A total of 155 nursing students (45 in the 1st semester; 25 in the 3rd semester; 38 in the 5th semester; 27 in the 7th semester; and 20 in the 9th semester), enrolled in the undergraduate nursing course of a HEI of the state of Amazonas, Brazil participated in the research.

The reliability analysis revealed Cronbach's alpha of 0.88 in all ASNS items, and of 0.78 in the CES-D items. The factor analysis found alpha values ranging from 0.62 (Interpersonal) to 0.84 (Depression) in the CES-D; and from 0.64 (Theoretical Activity) to 0.79 (Professional Education) in the ASNS.

Regarding the profile of the students, there was a predominance of women (83%), mean age of 22.8 years (SD=6.1), most (88.4%) were single, 87.1% had no children, 53.5% lived with their parents and 84.5% were financially dependent. Regarding academic characteristics, the majority (29%) were in the first semester, 16.1% were in the third semester, 24.5% in the fifth semester, 17.4% in the seventh semester and 12.9% in the ninth semester. The non-failure rate during the course was 54.2%; 72.9% of the students were not having field classes. Complementary activities (research, extension or monitoring) were performed by 58.1% of the students. Most students (74.2%) did not receive a financial scholarship. Nursing was not the first choice of 51.0% of the students when they entered the University and 49% of the students considered, at some point, dropping out of the course. Most participants (96.9%) reported the desire to continue their studies after graduation, and 56.1% came from public schools. The mean course load was 31.9 (SD=11.5) weekly hours. Students in the ninth semester had a greater workload than those in the other semesters, with a mean of 42.6 (SD=10.9) weekly hours. Students in the ninth semester had the highest mean of failures during the course: on average, they failed six classes. Seventh semester students had more approvals, with an average of 37 classes.

The descriptive analysis of stress factors, shown in Table 2, showed that most students had low stress scores in all domains analyzed. However, medium stress intensity was found in the domains “Performance of practical activities” (29.7%), “Environment” (24.5%), “Time management” (21.3%) and “Theoretical activity” (16.8). High intensity stress was found in the domains “Professional communication” and “Professional education” with 20.6% and 18.7%, respectively.

Table 2
Classification of stress intensity of nursing students, according to ASNS domains – Manaus, AM, 2015.

There was variation in stress intensity by ASNS factor according to the semester. There is a significant increase in stress intensity throughout the school semesters in the factors Theoretical Activity, Profession Education, Professional Communication and Performance of Practical Activities. This means that, throughout the course, the stress related to these factors increases significantly among nursing students. A higher occurrence of depression symptoms was found in the 3rd and 7th semesters, and a lower occurrence in the 1st semester of the course. Depressive symptoms were present in 74 (47.7%) nursing students. Figure 1 shows the occurrence of depressive symptoms according to the semester.

Figure 1
Occurrence of depressive symptoms in nursing students according to the semester – Manaus, AM, 2015.

Table 3 shows the association of stress factors and depressive symptoms with academic performance coefficient (CRE) and individual semester performance (RSI) in the population analyzed.

Table 3
Correlation of stress factors and depressive symptoms with the academic performance of nursing students – Manaus, AM, 2015.

The stress domains “Performance of practical activities”, “Professional communication” and “Professional education” positively affected the academic performance of nursing students. The occurrence of depressive symptoms in the factors depressive affect, interpersonal, somatic/attitudes negatively affected academic performance.

Table 4 shows that the factors that negatively affected the RSI of nursing students (shown by the β value) were: living alone and being in the 7th semester. The model presented explained 33.4% (R2= .334 Adjusted R2= .392) of RSI variability in nursing students.

Table 4
Multiple Linear Regression Model of predictors of Individual Semester Performance – RSI – Manaus, AM, 2015.

DISCUSSION

Data analysis shows the impact of stress factors and depressive symptoms on the academic performance of nursing students. In contrast to other studies that found negative impacts on the academic performance of students of nursing(66. Reis D, Xanthopoulou D, Tsaousis IC. Measuring job and academic burnout with the Oldenburg Burnout Inventory (OLBI): Factorial invariance across samples and countries. 2015;2(1):8-18. DOI: https://doi.org/10.1016/j.burn.2014.11.001
https://doi.org/10.1016/j.burn.2014.11.0...
) and other undergraduate courses(1010. Aboalshamat K, Hou XY, Strodl E. Psychological well-being status among medical and dental students in Makkah, Saudi Arabia: a cross-sectional study. Med Teach. 2015;37 Suppl 1:S75-81. DOI: 10.3109/0142159X.2015.1006612
https://doi.org/10.3109/0142159X.2015.10...
), this study found that stress factors positively affected the academic performance of the nursing student.

The higher stress intensity in the factors “Performance of practical activities”, “Professional communication” and “Professional education” is associated with higher individual semester performance (RSI) and better academic performance. These domains are related to professional practice situations associated with the desire for professional status. We understand that professional aspirations, although related to higher stress intensity, can contribute to a higher pursuit of a better curriculum and theoretical knowledge, which explains the better academic performance. Another possible explanation for this fact is the process of emotion regulation, which can influence coping and management of emotions experienced by individuals trying to achieve their professional goals. In this research, stressful events were well managed by nursing students and did not negatively affect their performance(1212. Gloss JJ. Emotion regulation: current status and future prospects. Psychol Inq. 2015;26(1):1-26. https://doi.org/10.1080/1047840X.2014.940781
https://doi.org/10.1080/1047840X.2014.94...
).

The positive aspect of stress is a fact that stands out in this study, suggesting that students in this research have a positive perception of stressors, reiterating the idea of coping with stress according to the interactionist theory(77. Lazarus RS, Folkman S. Stress, appraisal and coping. New York: Springer; 1984.). In the interactionist model, the perception of the event as a stressor depends on the interaction between the individual and the environment. Subjectivity determines the severity of the stressor, that is, if the event is interpreted as exhausting, stress manifestations may appear(77. Lazarus RS, Folkman S. Stress, appraisal and coping. New York: Springer; 1984.).

In the present study, the “Performance of practical activities”, which is related to the students' skills and their feelings related to patient care, was associated with low and medium stress intensity in fifth, seventh and ninth semester students. Practical activities have been considered as stress factors for nursing students in previous research(1313. Souza VS, Costa MAR, Rodrigues AC, Bevilaqua JF, Inoue KC, Oliveira JLC, et al. Stress among nursing undergraduate students of a Brazilian public university. Invest Educ Enferm [Internet]. 2016 [cited 2018 Jun 23];34(3):518-27. Available from: https://aprendeenlinea.udea.edu.co/revistas/index.php/iee/article/view/325707
https://aprendeenlinea.udea.edu.co/revis...
1515. Suen WQ, Lim S, Wang W, Kowitlawakul Y. Stressors and expectations of undergraduate nursing students during clinical practice in Singapore. Int J Nurs Pract. 2016;22(6):574-83. DOI: https://doi.org/10.1111/ijn.12473
https://doi.org/10.1111/ijn.12473...
). This suggests a concern of students with field practice, which may have arisen after the beginning of the fourth semester, when they start their practical activities in health facilities.

“Professional Communication” was associated with medium and high stress intensity in students of the fifth, seventh and ninth semester, which can be explained by conflictual situations and relationships experienced during academic life. Another possible explanation for this result is the clinical practice setting, since practical activities were conducted in public hospitals that were not as prepared for student reception as university teaching hospitals. Another study found that fourth-year students had higher mean scores in this domain, which is explained by the constant presence of these students in situations with greater demand for interaction with the multidisciplinary team, patients and families and the greater need for decision-making in this final phase of the course(1616. Bosso LO, Silva RM, Costa ALS. Biosocial-academic profile ane stress in first-and fourth-year nursing students. Invest Educ enferm. 2017;35(2):131-38. DOI: https://doi.org/10.17533/udea.iee.v35n2a02
https://doi.org/10.17533/udea.iee.v35n2a...
). A study comparing nursing and medicine students found similar challenges and recommended improving the communication of these conflicts with professors and supervisors(1717. WeurlanderM, Lönn A, Seeberger A, Broberger E, Hult H, Wernerson A. How do medical and nursing students experience emotional challenges durilg clinical placements? Int J Med Educ. 2018;27(9):74-82. DOI: https://doi.org/10.5116/ijme.5a88.1f80
https://doi.org/10.5116/ijme.5a88.1f80...
).

“Time management” is related to the difficulties to manage time between academic, leisure, social and work activities. It was the predominant domain in the analysis of standardized score, and, for the third semester students, it presented the highest scores. This might be explained by the high demand for laboratory activities in basic classes, which are prerequisites for the following semesters, and which require more time for study, reducing the time for leisure activities and social life. The pressure of academic responsibilities and the multiple activities required of the nursing student are stressors(1414. Hirsch CD, Barlem ELD, Almeida LK, Tomaschewski-Barlem JG, Lunardi VL, Ramos AM. Stress triggers in the educational environment from the perspective of nursing students. Texto Context Enferm. 2018;27(1):e0370014. DOI: http://dx.doi.org/10.1590/0104-07072018000370014
http://dx.doi.org/10.1590/0104-070720180...
). Lack of time for academic or personal activities and lack of leisure were predictors of stress in a study with 146 nursing students of a public university in the Southern region of Brazil(1818. Hirsch CD, Barlem ED, Tomaschewski-Barlem JG, Lunardi VL, Oliveira ACC. Predictors of stress and coping strategies adopted by nursing students. Acta Paul Enferm. 2015;28(3):224-9. DOI: http://dx.doi.org/10.1590/1982-0194201500038
http://dx.doi.org/10.1590/1982-019420150...
).

In this research, the “Environment” factor, which refers to the difficulties related to means of transportation and access to the university, was associated with medium stress intensity for the students of the third semester. Long distances require longer travel time and can become a stressor. These findings contrast with the low stress intensity in this domain found in a study conducted in the interior of São Paulo(1919. Almeida LY, Carrer MO, Souza J, Pillon SC. Evaluation of social support and stress in nursing students. Rev Esc Enferm USP. 2018;52:e03405. DOI: http://dx.doi.org/10.1590/s1980-220x2017045703405
http://dx.doi.org/10.1590/s1980-220x2017...
), which may indicate that stress in this domain is a regional characteristic.

“Professional education”, related to the concern with education and its impact on the professional future, had increased stress intensity from the fifth semester on and reached a very high intensity among students of the final year. A possible progressive increase in stress intensity as the student progresses in the course is shown, corroborating the literature that points out several stressors related to the insecurity in the transition from student to professional and the competitiveness of the labor market(1919. Almeida LY, Carrer MO, Souza J, Pillon SC. Evaluation of social support and stress in nursing students. Rev Esc Enferm USP. 2018;52:e03405. DOI: http://dx.doi.org/10.1590/s1980-220x2017045703405
http://dx.doi.org/10.1590/s1980-220x2017...
).

The performance of “Theoretical Activities”, a factor related to the difficulty experienced by the students regarding the course content, was associated with medium stress intensity. Responsibility with the theoretical content, the number of classes per semester, tests and assignments were identified as stressors(2020. Bagcivan G, Cinar FI, Tosun N, Korkmaz R. Determination of nursing students' expectations for faculty members and the perceived stressors during their education. Contemp Nurse. 2015;50(1):58-71. DOI: 10.1080/10376178.2015.1010259
https://doi.org/10.1080/10376178.2015.10...
). The data found in this study suggests that when students enter the university, they experience difficulties in assimilating new information and theoretical content, which may reflect on their performance.

As for depressive symptoms, higher scores on the factors “Depressive Affect”, “Interpersonal” and “Somatic/attitudes” were associated with lower RSI. High stress intensity, despite increasing performance, seems to exceed student's coping ability, as pointed out by the interactionist theory(77. Lazarus RS, Folkman S. Stress, appraisal and coping. New York: Springer; 1984.), and can possibly lead to depressive symptoms and contribute to a lower academic performance.

In other studies, depressive symptoms have been associated with higher stress levels among nursing students(55. Tung YJ, Lo KKH, Ho RCM, Tam WSW. Prevalence of depression among nursing students: A systematic review and meta-analysis. Nurse Educ Today. 2018;63(4):119-29. DOI: https://doi.org/10.1016/j.nedt.2018.01.009
https://doi.org/10.1016/j.nedt.2018.01.0...
), which may explain the relationship between lower academic performance and higher intensity of depressive symptoms. It was found that depressive symptoms were present in 47.7% of the population analyzed. A systematic review of 27 studies found a high prevalence of depression among nursing students, but without significant differences when compared with students from other courses(55. Tung YJ, Lo KKH, Ho RCM, Tam WSW. Prevalence of depression among nursing students: A systematic review and meta-analysis. Nurse Educ Today. 2018;63(4):119-29. DOI: https://doi.org/10.1016/j.nedt.2018.01.009
https://doi.org/10.1016/j.nedt.2018.01.0...
). A study with a sample of 270 university students from various courses in Ghana found an overall prevalence of depression in 39.2% of students(2121. Oppong Asante K, Andoh-Arthur J. Prevalence and determinants of depressive symptoms among university students in Ghana. J Affect Disord. 2015;15(171):161-6. DOI: 10.1016/j.jad.2014.09.025
https://doi.org/10.1016/j.jad.2014.09.02...
). The present study found a high percentage of depressive symptoms among nursing students when compared to the other studies presented. The high prevalence of depressive symptoms may be associated with the stress factors perceived by these individuals, since stress is a distressing factor in the academic context of the nursing student(1313. Souza VS, Costa MAR, Rodrigues AC, Bevilaqua JF, Inoue KC, Oliveira JLC, et al. Stress among nursing undergraduate students of a Brazilian public university. Invest Educ Enferm [Internet]. 2016 [cited 2018 Jun 23];34(3):518-27. Available from: https://aprendeenlinea.udea.edu.co/revistas/index.php/iee/article/view/325707
https://aprendeenlinea.udea.edu.co/revis...
).

Living alone was one of the factors with negative impact on the RSI of nursing students (according to β value). Feelings of loneliness and low social support may affect physical and psychological conditions and academic performance(1919. Almeida LY, Carrer MO, Souza J, Pillon SC. Evaluation of social support and stress in nursing students. Rev Esc Enferm USP. 2018;52:e03405. DOI: http://dx.doi.org/10.1590/s1980-220x2017045703405
http://dx.doi.org/10.1590/s1980-220x2017...
,2222. Holt-Lunstad J, Smith TB. Loneliness and social isolation as risk factors for mortality. a meta-analytic review. Perspect Psychol Sci. 2015;10(2):227-37. DOI: https://doi.org/10.1177/1745691614568352
https://doi.org/10.1177/1745691614568352...
). In this study, there was a remarkable occurrence of depressive symptoms in the 3rd semester, which may be related to the adaptation process, the reality of higher education and the beginning of specific disciplines of the nursing course, in which students are already in greater contact with sick and suffering patients, in situations that require knowledge and skills that are still being developed(99. Costa ALS, Polak C. Construction and validation of an instrument for the assessment of stress among nursing students. Rev Esc Enferm USP. 2009;43(spe):1017-26. DOI: http://dx.doi.org/10.1590/S0080-62342009000500005
http://dx.doi.org/10.1590/S0080-62342009...
,1313. Souza VS, Costa MAR, Rodrigues AC, Bevilaqua JF, Inoue KC, Oliveira JLC, et al. Stress among nursing undergraduate students of a Brazilian public university. Invest Educ Enferm [Internet]. 2016 [cited 2018 Jun 23];34(3):518-27. Available from: https://aprendeenlinea.udea.edu.co/revistas/index.php/iee/article/view/325707
https://aprendeenlinea.udea.edu.co/revis...
). Corroborating these findings, another study found that students in the third and fourth semester presented greater chance of developing depressive symptoms(2323. Horgan A, Sweeney J, Behan L, McCarthy G. Depressive symptoms, college adjustment and peer support among undergraduate nursing and midwifery students. J Adv Nurs. 2016;72(12):3081-92. DOI: https://doi.org/10.1111/jan.13074
https://doi.org/10.1111/jan.13074...
). It is suggested that, after the first year, students have already had the time for academic and social adaptation. Those who did not satisfactorily complete this process in the first-year manifest greater emotional distress from the third semester on.

In this study, students in the seventh semester presented higher academic performance, as measured by the RSI. The good academic performance rates found are possibly due to a characteristic of the studied population, which has many students that engage in extracurricular activities throughout the course, such as research groups, extension activities, academic center, internal committees and organization of events, increasing their social support network. Evidence in the literature shows that peer support is correlated with lower occurrences of depressive symptoms at the university(2323. Horgan A, Sweeney J, Behan L, McCarthy G. Depressive symptoms, college adjustment and peer support among undergraduate nursing and midwifery students. J Adv Nurs. 2016;72(12):3081-92. DOI: https://doi.org/10.1111/jan.13074
https://doi.org/10.1111/jan.13074...
).

The occurrence of depressive symptoms among nursing students in this study points out to the need for interventions developed by educational institutions to help these students handle the difficulties of the undergraduate course. A better management of stress and depressive symptoms among nursing students might improve long-term academic performance and can have positive health impacts for new professionals. Further studies should investigate how academic factors may be associated with the prevalence of depressive symptoms and identify protective mechanisms with an impact on academic performance.

One of the limitations of this study was the small number of students, as this aspect requires greater attention from researchers for the generalization of data and for more complex statistical analyzes. Another aspect is that the research showed the reality in a public institution, thus requiring further studies with students from private institutions.

CONCLUSION

The results of this study showed the impact of stress factors and depressive symptoms on the academic performance of university nursing students in the Northern region of Brazil. Regarding depressive symptoms, higher scores on the factors “Depressive Affect”, “Interpersonal” and “Somatic/attitudes” were associated with lower academic performance. In contrast, higher rates of stress on factors related to “performance of practical activities”, “professional communication” and “professional education” were associated with higher individual semester performance, suggesting a positive impact of stress on academic performance. The fact that these domains are related to nursing practice and the identification of a progressive increase in stress throughout the course may suggest a high stress intensity in the transition to the labor market. Therefore, educational strategies should be focused on facing and managing students' concerns with the future, aiming to ensure better outcomes related to the emotional well-being of nursing professionals.

The data analysis indicated possible factors that can guide interventions aimed at improving the academic performance of nursing students, as well as their health care and their quality of life. In addition, exploring coping strategies for stressors inherent to the education process, which will be present in the daily life of nursing professionals, is fundamental, considering the subjective component that determines positive or negative consequences in response to the stressor event.

  • *
    Extracted from the thesis: “Fatores de estresse, sintomas depressivos, suporte social e resiliência associados ao desempenho acadêmico em estudantes de enfermagem”, Escola de Enfermagem, Universidade de São Paulo, 2016.

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Publication Dates

  • Publication in this collection
    2 Dec 2019
  • Date of issue
    2019

History

  • Received
    22 July 2018
  • Accepted
    21 May 2019
Universidade de São Paulo, Escola de Enfermagem Av. Dr. Enéas de Carvalho Aguiar, 419 , 05403-000 São Paulo - SP/ Brasil, Tel./Fax: (55 11) 3061-7553, - São Paulo - SP - Brazil
E-mail: reeusp@usp.br