Academic Stress and Biobehavioral Profile of Senior Nursing Students

Purpose:

The rigor of nursing education is continuously increasing to meet more complex and challenging healthcare needs. Accordingly, nursing students are under significant stress to achieve both academic and clinical competencies, and clinical competencies include working with the sick with diverse health conditions at various healthcare settings. Although academic stress has been studied with nursing and other professional students, few studies have included biological assessment. Concurrent assessments of psychobehavioral and biological responses would enhance the understanding of biobehavioral interactions between subjective perceptions and objective biological responses in nursing students.

Nursing education can be delivered in various formats, and the composition of nursing students often is diverse. A baccalaureate nursing curriculum typically consists of four consecutive semesters of education, and, at the current school, nursing curriculum is offered in two different tracks to compare its efficacy, traditional versus pacesetter. Both tracks cover the same materials over time but in a different format. Students in the traditional track take didactic courses and matching clinical practicum in the same semester, whereas students in the pacesetter track take all didactic courses first, followed by all clinical practicums in their last semester. Students were randomly assigned to one of the tracks at the entry into nursing program. In terms of student characteristics, it is common to see a wide range of age and various academic preparations prior to the entry to nursing program. Many students hold a prior baccalaureate or professional degree in other disciplines. At this unique setting, it is unclear how age difference or a prior degree affects the management of educational demands.

Psychological stress, mood disturbance (e.g., anxiety, depression), and loneliness are common concerns expressed by students. Psychological factors may, in turn, alter biological responses, particularly responses of the two major systems, the neuroendocrine and immune systems.  For example, stress can activate the hypothalamic-pituitary-adrenal (HPA) axis and the sympathetic nervous system, releasing hormones such as cortisol and epinephrine. Because saliva can be collected non-invasively, salivary biomarkers have been utilized frequently. Salivary cortisol represents a free fraction of biologically active cortisol, and cortisol levels and diurnal patterns have been widely examined in relation to acute and chronic stress. Salivary alpha-amylase (sAA) has been regarded as a reliable and sensitive surrogate marker of the sympathetic nervous system activity in response to acute stress. Furthermore, sex hormones are thought to modulate biobehavioral responses.

Stress and mood disturbances also elevate inflammatory mediators, such as interleukin (IL)-1. In adolescents, daily interpersonal stress predicted an elevation of CRP levels months later, and chronic childhood stress has been associated with elevated CRP levels in adulthood. Similarly, lonelier medical students showed lower immune function (e.g., natural killer cell activity), and lonelier people showed higher inflammatory responses. 

The major purposes of this study were to: (1) Determine the levels of stress, moods disturbance, and loneliness; (2) examine the associations between psychosocial factors and salivary biomarker responses (C-reactive protein, Interleukin-1β, cortisol, sAA, estradiol, and testosterone); and (3) compare the levels of psychosocial and biological responses between two different baccalaureate curricula tracks (pacesetter vs. traditional), two age groups (younger than 26 vs. equal to or older than 26), and two academic preparation level at the entry to nursing education (a prior professional or college degree vs. no prior degree) in senior graduating nursing students at a 4-year university setting. 

Methods:

Design: A cross-sectional descriptive study was conducted to assess the levels of selective psychosocial and biological responses and associations between psychosocial factors and biological responses. 

Sample: Seventy seven undergraduate senior nursing students participated in the study. Power analysis indicated that the sample size of 82 would provide power of .80 with two-tailed test based on a small effect size of correlation coefficient of 0.3 and alpha level 0.05 using G*Power 3.17 program. Inclusion criteria were: (1) current college students enrolled in nursing program; (2) no known psychiatric or physical illness that required active treatment; (3) not taking corticosteroid, antibiotics, or anti-depressants; (4) no current infection; (5) aged 18 -45. Exclusion criteria were: (1) currently receiving structured psychotherapy; (2) inability to produce saliva; (3) current or recent substance abuse within 3 months.

Data Collection and Analysis:  Data were collected between 8:00 and 12:00 am around class hours. Students rinsed the mouth with water, started to fill out the questionnaires while collecting saliva samples, and completed questionnaires.  Restrooms were readily available for rinsing the mouth as needed, and personal space was available in and around the classrooms as desired. All data were collected in the fall semester, 2013, using reliable and valid standardized questionnaires: College Readjustment Rating Scale for stress; Profile of Mood State short form for mood disturbance; Revised UCLA Loneliness Scale for loneliness. Biological measures were assessed from saliva using enzyme immunoassay kits for each specific biomarker. The study protocol was approved by the Institutional Review Committee of the university. Data were analyzed for descriptive statistics and to test the specific aims of the study using the SPSS statistical package. All biological data were transformed using logarithm or square root before testing correlations with Pearson’s r and student’s t-tests for group comparison.

Results:

The mean age of the participants was 26.6 ± 5.8 years old with body mass index within normal range. Although there were more female students, the sample included 24% of male nursing students.  Stress levels measured with CRRS were relatively low with the mean of 123.6, although the score ranged up to 581, which was very high. Mood disturbance total score was not high with the mean 34.7. However, three individual dimensions of the POMS, lack of vitality, anxiety, and fatigue, showed the mean level higher than 5.0. Loneliness score was modest with the mean of 34.3. Biological responses indicated that the range of the values for each biomarker was wide, indicating substantial inter-individual variability in biological responses. The mean values, however, seem to be within the expected range for markers when reference values were available from the manufacturer (cortisol, estradiol, and testosterone).

For correlations, the CRRS stress score was significantly and positively correlated with fatigue and confusion dimensions of the POMS, r = .27 to .32, p = .05 to .01, but not with anxiety, depression, or anger. As expected, total mood disturbance score was significantly and positively correlated with each dimension of the POMS, r = .74 to .83, p < .01, although the lack of vigor dimension showed the lowest correlation, r = .35, p < .01. Loneliness was significantly and positively correlated with depression, anger, and confusion, r = .28 to .39, p = .05 to .01. sAA showed a significant inverse correlation with stress and fatigue dimension, whereas testosterone showed a significant positive correlation with anger and confusion dimension of the POMS.

For subgroup comparisons, there were minimal differences between the two groups of different curricula tracks, age, and prior degree status in both psychosocial and biological responses. Only difference was noted in the total CRRS stress score in that students with a prior degree showed a significantly higher level of stress score than the students without a prior degree, p = .039. The levels of CRP and estradiol showed a tendency for younger group having higher CRP and lower estradiol levels, p = .07, but neither reached statistical significance.

Conclusion:

On average, the levels of stress, mood disturbance, loneliness, as well as the levels of stress hormones and inflammatory biomarkers, were not high in senior graduating nursing students. There were some correlations between psychosocial factors and biological responses and some group differences, but the findings were relatively normal. Despite relatively normal responses on average, the wide range of biobehavioral responses suggests considerable inter-individual differences. For example, about 30% of the students reported significant levels of stress with potentially increased health risks. Therefore, efforts should be focused on identifying those subgroups of high risk students and make the needed resources available.