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"Depression, Anxiety & Stress (DAS) among Nursing Students: A Cross-

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 International Journal of Research Publication and Reviews, Vol 4, no 5, pp 4078-4086, May 2023

International Journal of Research Publication and Reviews

Journal homepage: www.ijrpr.com ISSN 2582-7421

“Depression, Anxiety & Stress (DAS) among Nursing Students: A Cross-

sectional Design”.

S Manikandan 1, Beema H 2, Laya Vijayan 3

1
Assistant Professor, BGSB University, Rajouri, J&K.
2
Associate Professor, Azeezia College of Nursing, Kollam, Kerala.
3
Nursing Instructor, BGSB University, Rajouri, J&K.

ABSTRACT:

Background: A Cross-sectional study was conducted to assess the level of Depression, Anxiety and Stress experienced among Nursing students in selected Nursing
College(s), Kollam district, Kerala. The objectives of the study were to assess the level of Depression, Anxiety and Stress a mong Nursing students and to compare
the level of Depression, Anxiety and Stress among first year, second year, third year and final year B.Sc. Nursing students. The final objective was to find out the
association between level of Depression, Anxiety and Stress among Nursing students with selected Socio-demographic variables. Materials and Methods: The
study adopted a Descriptive-Cross-sectional design. 320 B.Sc. Nursing students from selected Nursing Colleges were enrolled using Proportionate Stratified -
Random Sampling, technique. The conceptual framework of the study was based on Rosenstock and Becker’s Heath Belief Model, 1974. Tools used for data
collection were Socio-Demographic Questionnaire and Modified Depression, Anxiety and Stress scale. [DASS-21]. Results: Findings of the study revealed that the
Mean Depression score among final year B.Sc. Nursing students was higher [5.73±2.60] as compared to the first year, second year and third-year B.Sc. Nursing
students. ANOVA [F test value 14.77**, (df=03, 316)] calculated was significant at 0.01 level. Also, the Mean Anxiety score [6.18±1.99] as well as the stress score
[11.36±3.04] was found to be higher among the final year students, statistically significant at 0.01level. The first year BSc. Nursing students presented with the
lowest Mean Depression [2.95±2.90], Anxiety [4.40±2.26] and Stress scores [8.21±3.67] on comparison with other student groups. Significant association was
observed between the level of Depression and demographic variables such as Gender, Type of family and Area of residence. (p<0.01). Significant association was
observed between level of Anxiety and Gender, Type of family, Type of stay and Education loan (p<0.01). Also, association was observed between level of Stress
and Gender(p<0.05), Type of family(P<0.01). Conclusion: The findings of the study confirmed that the level of Depression, Anxiety and Stress scores were
significantly higher among the Final year B.Sc. Nursing students than others.
Key Words: Cross-Sectional Study, Depression, Anxiety, Stress, DASS-21, Nursing Students.

INTRODUCTION

“Stress, Anxiety & Depression are caused when we are living to please others” -Paulo Coelho.
Stress is an inevitable part of modern life. Having the blues, feeling a little anxious or getting stressed from time to time are a part of life. Chronic stress
can lead to anxiety and depression.1,2 Nursing is a profession requiring nursing students to have comprehensive knowledge and practical skill for
application in a variety of clinical settings. All of the changes experienced in college can be very stressful. When these things start to interfere with daily
life and the ability to function normally, it could be more serious. 3 The mental and physical challenges of nursing, even under normal conditions, are
exceptional. Nurses work long hours doing physically demanding work, all while maintaining constant vigilance in making decisions and performing
duties with potentially life-or-death consequences. Surrounded by sickness and death, nurses care not only for patients but also for patients’ families,
providing comfort to people who are often experiencing fear, anger, or grief. 4 Clinical placements are an important part of nursing education, but nursing
students are often under greater stress during clinical placements due to their dynamic and challenging nature. Studies have shown that, negative clinical
experiences can reduce nursing students’ self-confidence, professional satisfaction, and sense of professional benefit. 3 Modern man is living in anxious
anticipation of destruction. Such anxiety can easily result in self -destruction.4 It is not uncommon for someone with an anxiety disorder to also suffer
from depression or vice versa. Nearly one-half of those diagnosed with depression are also diagnosed with an anxiety disorder. 5 Depression is the oldest
and most common psychiatric disorder. Depression is a mental state of low mood and aversion to activity. It affects more than 280 million people of all
ages (about 3.5% of the global population). Depression affects a person's thoughts, behaviour, feelings, and sense of well-being.6 Nursing students are
valuable human resources, but there is a paucity of comprehensive research in the area of nursing student’s psychological distress and depressive
symptoms. Detection of these symptoms is crucial since anxiety and depression can lead to low productivity, minimized quality of life and suicidal
thoughts. In a systematic umbrella review of global evidence, it was found that in the group of health care workers, the incidence of anxiety among nurses
ranged from 22.8% to 27% while the incidence of depression among nurses was 28%.7 A study conducted in Kerala reports prevalence of moderate level
of depression (53.6%), anxiety in (37.9%), and stress (46.4%) among Nursing students.8 Nursing students experience psychosocial stress, anxiety and
 International Journal of Research Publication and Reviews, Vol 4, no 5, pp 4078-4086, May 2023 4079

depression in their clinical settings but the available statistics are at variance/scarce 3 and hence, this study was conducted with the need to know the
prevalence levels of Stress, Anxiety and Depression experienced among Nursing students.

OBJECTIVES OF THE STUDY

1. To assess the level of Depression, Anxiety and Stress among Nursing students.
2. To Compare the level of Depression, Anxiety and Stress among First year, Second year, Third year and Final year Nursing students.
3. To find out the association between the level of Depression, Anxiety and Stress among Nursing students and selected Socio-Demographic
variables.

HYPOTHESES

 H1-There is significant difference in the mean Depression, Anxiety and Stress scores among First year, Second year, Third year a nd Final year
Nursing students.
 H2- There is significant association between the level of Depression, Anxiety and Stress among Nursing students with selected Socio-
Demographic variables.

METHODOLOGY

Research Approach: Quantitative research approach.

Research Design: Descriptive-Cross-sectional research design.
Population: BSc. Nursing students; Kollam District.
Settings: Selected Nursing College(s), Kollam district, Kerala.
Sample Size: 320 Nursing students [80 First, 80 Second, 80Third and 80 Final year BSc. Nursing students] from selected Nursing Colleges, Kollam,
Kerala.
Sampling Technique: Proportionate Stratified Random Sampling method.

TOOLS AND TECHNIQUE

Tool-A: Socio-Demographic Questionnaire was used to assess the variables such Age, Gender, Religion, Type of family, Family Income/Month, Dietary
pattern, Area of residence, Type of Stay, Education Loan and Hobbies.
Tool-B: Modified Depression, Anxiety, Stress scale [Dass-21] with an excellent reliability of 0.94 was used to assess the level of Depression, Anxiety
and Stress among Nursing students.
Method of Data collection: Data was collected for a period of one month [10/05/2015 to 10/06/2015] from 02 Selected Nursing College(s) in Kollam
district, Kerala using a Stratified random sampling method. After acquiring formal permission from the concerned authorities, the investigator(s) then
obtained informed consent from the samples. Both Socio-Demographic Questionnaire and Modified DASS-21 were used to collect data from Nursing
students.
Inclusion criteria: All year B.Sc. Nursing students who were willing to participate in the study and available during the period of data collection.
Students who can understand English/Malayalam.
Exclusion criteria: Students who were not willing to participate in the study and unavailable during the period of data collection.
Students undergoing treatment/taking Psychiatric medications for Depression/Anxiety/Stress.
General Nursing & Midwifery and other Auxiliary Nursing students were excluded from this study.
Statistical analysis: Both Descriptive and Inferential statistics were used to analyse the data [using SPSS version 20 (SPSS Inc., Chicago, IL)].
Descriptive statistics such as Frequency distribution and Percentage were used to describe Demographic data and Inferential statistics such as ‘F
test’[ANOVA] was used to compare the mean Depression, Anxiety and Stress scores among Nursing students. Chi Square was performed to find out the
association between level of Depression, Anxiety and Stress with selected Socio-Demographic variables. The level P < 0.05 was ascertained as the
minimum acceptable level of significance.
 International Journal of Research Publication and Reviews, Vol 4, no 5, pp 4078-4086, May 2023 4080

Figure 1: Conceptual framework based on Rosenstock and Becker’s Heath Belief Model

RESULTS

Section-I: Description of Sample characteristics of Nursing Students.

Table 1: Frequency distribution and Percentage of Nursing Students. [N=320]

SL NO. DEMOGRAPHIC VARIABLES

01 Age (In years) f %
Up to 19 yrs. 82 25.63%
20-21 yrs. 212 66.25%
-
Above 21 yrs. 26 08.12%
02 Gender f %
Male 67 20.94%
Female 253 79.06%
03 Religion f %
Hindu 164 51.25%
Muslim 102 31.88%
Christian 54 16.87%
04 Type of family f %
Nuclear 215 67.19%
Joint/Extended 105 32.81%
05 Family Income/Month (f) (%)
 International Journal of Research Publication and Reviews, Vol 4, no 5, pp 4078-4086, May 2023 4081

Up to 10000 ₹ 24 7.5%
10001-20000 ₹ 74 23.13%
20001-30000 ₹ 131 40.94%
More than 30000 ₹ 91 28.43%
06 Dietary Pattern (f) (%)
Vegetarian 32 10%
Non-Vegetarian 288 90%
07 Area of Residence (f) (%)
Rural 75 76.56%
Urban 245 23.44%
08 Type of Stay (f) (%)
Hosteler 167 52.19%
Day Scholar 153 47.81%
09 Education Loan (f) (%)
Taken 172 53.75%
Not Taken 148 46.25%
10 Hobbies (f) (%)

Internet/social media 122 38.13%

TV/Radio/Newspaper 74 23.12%
Books/Magazines 76 23.75%
Outdoor Games 48 15%

Section-II: Level of Depression among Nursing Students

Table 2: Frequency distribution and Percentage of level of Depression among Nursing students. (N=320)
I YEAR II YEAR III YEAR FINAL YEAR
SL. LEVEL OF
NO: DEPRESSION [n=80] [n=80] [n=80] [n=80]
f % f % f % f %
01 Normal Level 61 76.25% 54 67.50% 48 60.00% 22 27.50%
02 Mild Level 09 11.25% 17 21.25% 20 25.00% 36 45.00%
03 Moderate Level 08 10.00% 05 06.25% 12 15.00% 18 22.50%
04 Severe Level 02 02.50% 04 05.00% 00 00.00% 04 05.00%
05 Extreme Level 00 00.00% 00 00.00% 00 00.00% 00 00.00%
control

Section-III: Level of Anxiety among Nursing Students

Table 3: Frequency distribution and Percentage of level of Anxiety among Nursing students. (N=320)

SL. I YEAR II YEAR III YEAR FINAL YEAR

NO: LEVEL OF
ANXIETY [n=80] [n=80] [n=80] [n=80]
f % f % f % f %
01 Normal Level 24 30.00% 18 22.50% 12 15.00% 08 10.00%
02 Mild Level 36 45.00% 24 30.00% 19 23.75% 18 22.50%
03 Moderate Level 12 15.00% 28 35.00% 32 40.00% 32 40.00%
04 Severe Level 08 10.00% 10 12.50% 17 21.25% 22 27.50%
05 Extreme Level 00 00.00% 00 00.00% 00 00.00% 00 00.00%
control
 International Journal of Research Publication and Reviews, Vol 4, no 5, pp 4078-4086, May 2023 4082

Section-IV: Level of Stress among Nursing Students

Table 4: Frequency distribution and Percentage of level of Stress among Nursing students.
(N=320)
SL. I YEAR II YEAR III YEAR FINAL YEAR
NO: LEVEL OF
STRESS [n=80] [n=80] [n=80] [n=80]
f % f % f % f %
01 Normal Level 32 40.00% 08 10.00% 12 15.00% 06 07.50%
02 Mild Level 16 20.00% 42 52.50% 34 42.50% 13 16.25%
03 Moderate Level 28 35.00% 18 22.50% 26 32.50% 34 42.50%
04 Severe Level 04 05.00% 12 15.00% 08 10.00% 27 33.75%
05 Extreme Level 00 00.00% 00 00.00% 00 00.00% 00 00.00%
control

Section-V: Comparison of Level of Depression, Anxiety & Stress among Nursing Students.

Table 5: ANOVA table showing the Mean, Standard deviation and ‘F’ test value of level of Depression among Nursing students.
(N=320)
Parameter Group n Mean ± SD df F value P
I YEAR 80 2.95±2.90
II YEAR 80 3.88±2.81
(03, 316) 14.77** 0.000
DEPRESSION III YEAR 80 3.93±2.48
FINAL YEAR 80 5.73±2.60
**Significant at 0.01 level.
Figure 2: Mean Plot showing the Mean level of Depression among I year, II-year, III year & Final year Nursing students

DEPRESSION MEAN PLOT COMPARISON

 International Journal of Research Publication and Reviews, Vol 4, no 5, pp 4078-4086, May 2023 4083

Table 6: ANOVA table showing the Mean, Standard deviation and ‘F’ test value of level of Anxiety among Nursing students.
(N=320)
Parameter Group n Mean ± SD df F value P
I YEAR 80 4.40±2.26
II YEAR 80 5.06±2.14
(03, 316) 10.80** 0.000
ANXIETY III YEAR 80 5.76±2.11
FINAL YEAR 80 6.18±1.99
**Significant at 0.01 level.
Figure-3: Mean Plot showing the Mean level of Anxiety among I year, II-year, III year & Final year Nursing students.

ANXIETY MEAN PLOT COMPARISON

Table 7: ANOVA table showing the Mean, Standard deviation and ‘F’ test value of level of Stress among Nursing students.
(N=320)
Parameter Group n Mean ± SD df F value P
I YEAR 80 8.21±3.67
II YEAR 80 9.60±2.84
(03, 316) 13.43** 0.000
STRESS III YEAR 80 9.40±3.08
FINAL YEAR 80 11.36±3.04
**Significant at 0.01 level.
 International Journal of Research Publication and Reviews, Vol 4, no 5, pp 4078-4086, May 2023 4084

Figure-4: Mean Plot showing the Mean level of Stress among I year, II-year, III year & Final year Nursing students.

STRESS MEAN PLOT COMPARISON

Section-VI: Association between Level of Depression, Anxiety, Stress and selected Socio-Demographic variables.

Table-8: Association between Level of Depression among Nursing students and selected Socio-Demographic variables.
[N=320]

Demographic
Variables Level of Depression
Normal Mild Moderate Severe
Gender (f) (%) (f) (%) (f) (%) (f) (%) df χ2 p
Male 29 43.3% 21 31.3% 12 17.9% 05 7.5%
03 10.54* 0.014
Female 156 61.7% 61 24.1% 31 12.3% 05 1.9%
Type of
Family
Nuclear 124 57.7% 50 23.3% 37 17.2% 04 1.8%
03 11.73** 0.008
Joint 61 58.1% 32 30.5% 06 5.7% 06 5.7%
Area of
Residence
Rural 46 61.3% 14 18.7% 08 10.7% 07 9.3%
03 14.70** 0.002
Urban 139 56.7% 68 27.8% 35 14.3% 03 1.2%
**Significant at 0.01 level.
Table-9: Association between Level of Anxiety among Nursing students and selected Socio-Demographic variables.
[N=320]

Demographic
Variables Level of Anxiety
Normal Mild Moderate Severe
Gender (f) (%) (f) (%) (f) (%) (f) (%) df χ2 p
Male 21 31.4% 23 34.3% 12 17.9% 11 16.4%
03 12.36** 0.006
Female 41 16.2% 74 29.2% 92 36.4 46 18.2%
Type of Family
Nuclear 54 25.1% 61 28.4% 63 29.3% 37 17.2%
 International Journal of Research Publication and Reviews, Vol 4, no 5, pp 4078-4086, May 2023 4085

Joint/Extended 08 7.6% 36 34.4% 41 39% 20 19% 03 14.16** 0.003

Type of Stay
Hosteler 48 21.8% 75 34.1% 54 24.6% 43 19.5%
03 20.38** 0.000
Day Scholar 14 14% 22 22% 50 50% 14 14%

Education Loan

Taken 36 20.9% 58 33.7% 60 34.9% 18 10.5%

03 13.81** 0.003
Not Taken 26 17.6% 39 26.4% 44 29.7% 39 26.3%
**Significant at 0.01 level.
Table-10: Association between Level of Stress among Nursing students and selected Socio-Demographic variables.
[N=320]

Demographic
Variables Level of Stress
Normal Mild Moderate Severe
Gender (f) (%) (f) (%) (f) (%) (f) (%) df χ2 p
Male 20 29.9% 22 32.9% 18 26.8% 07 10.4%
03 09.03* 0.029
Female 38 15% 83 32.8% 88 34.8% 44 17.4%
Type of Family
Nuclear 45 20.9% 68 31.6% 78 36.3% 24 11.2%
03 14.47** 0.002
Joint/Extended 13 12.4% 37 35.2% 28 26.7% 27 25.7%
* Significant at 0.05 level. **Significant at 0.01 level.

DISCUSSION

The current study reveals mild to moderate prevalence of Depression, Anxiety and Stress among B.Sc. Nursing Degree students. The study findings also
revealed that the final year students had significant higher levels of Depression, Anxiety and Stress compared to other groups. The findings are in partial
agreement with a cross sectional study conducted by Verma Et al. in Central India, which reveals the prevalence of moderate to very severe depressive
symptoms (34.1%), moderate to very severe anxiety (61.9%) and stress symptoms (17.7%) respectively. Binomial logistic regression analysis depicts
family relationship to be significantly associated with depression [P = 0.00, odds ratio 0.638] and stress [P = 0.002, OR 0.582], whereas in the present
study, Gender and type of family were significantly associated with Depression, Anxiety and Stress. The Current study also agree partially with another
Cros-sectional survey conducted among Nursing students in Hong Kong, revealing that the overall estimated prevalence of moderate, extreme to

severelevels of depression, anxiety and symptoms of stress among nursing students were in figures of 24.3%, 39.9% and 20.0%, respectively. The
findings are in contradiction in terms of females having more stress and anxiety compared to male students and final year students reporting more levels
of depression, anxiety and stress compared to other groups.9 Additionally, the present study observed significant Association between gender, type of
family, area of residence, type of stay, education loan (P<0.05, P<0.01 levels). There is a need to conduct more mental health surveys as data pertaining
to nursing students remains scarce and more diligent remedial measures to be introduced, such as a stress Management and Resiliency Training
(SMART) program, which teaches participants to reduce the harmful impacts of stress by eliciting the relaxation response, building stress awareness and
developing adaptive coping strategies in order to control the psychosocial Stress, Anxiety and Depression experienced among student nurses.10

CONCLUSION

The study was conducted to assess the level of Depression, Anxiety and Stress among Nursing students and to compare between first year, second year,
third year and final year B.Sc. Nursing students. The results confirm that the Mean Depression, Anxiety and Stress scores among final year students are
significantly higher than other groups [p<0.01 level]. Therefore, it is concluded that the Final year Nursing students have significantly higher levels of
depression, anxiety and stress compared to other Nursing students.

LIMITATIONS

 This study was limited to B.Sc. Nursing students enrolled in selected Colleges of Nursing.
 The effect of Confounding variables could not be ascertained.

RECOMMENDATIONS

 An interventional study can be conducted to reduce the levels of Depression, Anxiety & Stress among Nursing students.
 A similar study can be replicated among other settings/college students
 International Journal of Research Publication and Reviews, Vol 4, no 5, pp 4078-4086, May 2023 4086

 A comparative study can be performed among GNM and B.Sc. Nursing students.

ETHICAL CONSIDERATIONS

After obtaining the Ethical clearance from the Institutional Committee, the researchers also obtained formal permissions from the concerned authorities.
An informed consent was obtained from the samples after explaining the purpose of the study. Confidentiality was ensured throughout the conduct of the
research.

BUDGET

Self-Funding

CONFLICTS OF INTEREST

There are no conflicts of interest related to the study, authorship and/or publication of the article.

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