Relationship Issues Among College Nursing Students: Associations With Stress, Coping, Sleep, and Mental Disorders

Teaching and Learning in Nursing xxx (2017) xxx–xxx

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Relationship Issues Among College Nursing Students: Associations With Stress, Coping, Sleep, and Mental Disorders1,2,3 Yuan Zhang, PhD, RN ⁎, Michelle Chernaik, Kaylin Hallet Susan and Alan Solomont School of Nursing, 113 Wilder Street, University of Massachusetts Lowell, Lowell, MA 01854, USA

a r t i c l e

i n f o

Available online xxxx Keywords: Interpersonal relationship Problem disengagement coping Emotion disengagement coping Daytime sleepiness Anxiety Depression

a b s t r a c t Maintaining or dissolving a relationship issue among nursing students can add significantly to their overall stress, resulting in a variety of negative consequences, especially when they are unable to cope effectively. The purposes of this study are to examine the associations of relationship issues with stress, coping, sleep, and mental disorders of nursing students. Coping strategies commonly adopted by nursing students to deal with relationship issues are discussed as well. © 2017 Published by Elsevier Inc. on behalf of Organization for Associate Degree Nursing.

Introduction Mental disorders, such as anxiety and depression, have been identified as the leading cause of disability worldwide (Gore et al., 2011). About one quarter of college students in the United States have reported a mental disorder (Byrd et al., 2014; Concepcion et al., 2014). According to a national survey with the university and college counseling center directors, anxiety is the top concern among college students followed by depression (Mistler, Reetz, Krylowicz, & Barr, 2015). In addition to mental disorders, poor sleep quality and daytime sleepiness are common among college students. One study reported that 70% of college students had insufficient sleep, and 50% had daytime sleepiness (Hershner & Chervin, 2014). Stress is a major factor affecting college students, often at a higher level than the general public (Pedersen, 2012). College students encounter a variety of stressors such as academics, financial issues, relationships, and work–study–family imbalance. Accumulation of stress from multiple sources makes college students more vulnerable to poor sleep and mental health (Pedersen, 2012), especially when they are unable to cope

1 IRB protocol number: This study was approved by the Institutional Review Board at the University of Massachusetts Lowell (No. 15-034). 2 Funding: This study was funded by the 2015 Sigma Theta Tau International, Eta Omega Chapter Research Award to Yuan Zhang. This work is solely the responsibility of the authors. The funding organization had no involvement in the study design; data collection, analysis, and interpretation; report writing; and manuscript submission. 3 Disclosure of Interest: The authors report no conflict of interest. ⁎ Corresponding author. Tel.: +1 978 934 4421; fax: +1 978 934 2015. E-mail address: [email protected].

effectively. Besides, stress could be associated with other aspects of the academic and health outcomes of college students, such as poor academic performance (Shankar & Park, 2016), suicide ideation (Zhang, Wang, Xia, Liu, & Jung, 2012), substance abuse including binge drinking, and alcohol-related problems (Gonzalez & Hewell, 2012). Stress among college students is in part from relationship issues (Lewandowski, Mattingly, & Pedreiro, 2014), ranging from romantic to family, professor, and peer relationships. A major cause of relationship issues in college students is lack of autonomy support (Ratelle, Simard, & Guay, 2013). Autonomy support describes the level in which students feel that they are in control of their actions as opposed to their environment coercing them to make decisions (Ratelle et al., 2013). Lack of autonomy support primarily causes family and peer relationship issues but may also stretch across a variety of other relationship issues (Ratelle et al., 2013). Coping, defined as “the cognitive and behavioral efforts to manage specific external and/or internal demands,” may vary by individual student (Rappaport & Seidman, 2000). Broadly, coping strategies may include engaged coping (direct attempts to influence either the stressor or response to the stressor) and disengaged coping (efforts to distance oneself emotionally, cognitively, and physically from the stressor) or emotional coping (reducing the negative emotional responses associated with stress) and problem coping (reducing the stress by tackling the problem or stressful situation that causes stress; Rappaport & Seidman, 2000). Generally speaking, college students do not acquire appropriate coping skills needed to deal with stress (Brougham, Zail, Mendoza, & Miller, 2009; Mahmoud, Staten, Hall, & Lennie, 2012; Wichianson, Bughi, Unger, Spruijt-Metz, & Nguyen-Rodriguez, 2009). Without effective coping strategies, these students are at a higher risk for the negative effect of stress (Zhang et al., 2012).

http://dx.doi.org/10.1016/j.teln.2017.06.005 1557-3087/© 2017 Published by Elsevier Inc. on behalf of Organization for Associate Degree Nursing.

Please cite this article as: Zhang, Y., et al., Relationship Issues Among College Nursing Students: Associations With Stress, Coping, Sleep, and Mental Disorders, Teaching and Learning in Nursing (2017), http://dx.doi.org/10.1016/j.teln.2017.06.005

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Nursing students should receive special attention for stressrelated issues. In addition to similar stressors faced by general college students, nursing students, as primary female student population, face some unique stressors and health behaviors and outcomes. Evidence has supported that female students have a higher overall level of stress (Brougham et al., 2009) and a higher prevalence of mental disorders (Byrd et al., 2014) and poor sleep quality (Tsai & Li, 2004) than male students. Brougham et al. (2009) reported that college women had a greater use of emotion-focused coping strategies than college men. Mental disorders in nursing students from different countries have been associated with multiple stressors, including academic stress, inadequate coping, lack of emotional support and self-esteem, and poor balancing of school, work, and personal life (Cha & Sok, 2014; Chatterjee et al., 2014; Chernomas & Shapiro, 2013; Ross et al., 2005; Xu et al., 2014). Many previous studies have been conducted in regard to stress and its negative consequences in college students; however, few have been done specifically on stress caused by relationship issues. As a part of young college students, nursing students are still developing emotionally, and maintaining or dissolving a relationship issue can add significantly to their overall stress, resulting in a variety of negative consequences. There are limited resources in the literature about the prevalence of various kinds of relationship issues faced by nursing students and potential problems that may arise from these relationship issues (Lewandowski et al., 2014). In addition, what coping strategies are adopted by nursing students to deal with relationship issues have not been studied previously, which warrants further examination. Therefore, the objectives of this study are (a) to describe the prevalence of various kinds of relationship issues among nursing students; (b) to examine the associations of relationship issues with stress, coping, sleep, and mental disorders of nursing students; and (c) to identify coping strategies adopted by nursing students to deal with relationship issues. Methods Setting and Subjects This study used the cross-sectional data collected from a sample of 242 undergraduate nursing students at a public university in the northeast United States. A nonprobability convenience sampling method was used to recruit study participants. All nursing students over 18 years old and enrolled in the baccalaureate nursing program at the public university in fall 2015 were eligible to participate.

cognitive restructuring, express emotions, social contact, problem avoidance, wishful thinking, self-criticism, and social withdrawal. The primary subscales are aggregated to four secondary subscales including problem-focused engagement, emotion-focused engagement, problem-focused disengagement, and emotion-focused disengagement, with a range in score from 8 to 40 for each secondary subscale (Tobin et al., 1989). The reliability (Cronbach's alpha) of the secondary subscales in the study sample averages .76. Sleep Quality. Sleep quality was assessed with the 19-item Pittsburg Sleep Quality Index. The instrument assesses seven components of sleep quality during the past month, including subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleeping medication, and daytime dysfunction (Buysse, Reynolds, Monk, Berman, & Kupfer, 1989). Each component is assessed on a 4-point Likert scale with a range in global score from 0 to 21, and a higher score indicates poorer sleep quality. A global score N 5 yields a diagnostic sensitivity of 89.6% and specificity of 86.5% in distinguishing good and poor sleepers (Buysse et al., 1989). The reliability of this scale (Cronbach's alpha) in the study sample is .68, which is consistent with previous studies with nurses (Ruggiero, 2003). Daytime Sleepiness Daytime sleepiness was assessed with the Epworth Sleepiness Scale, an 8-item scale that assesses daytime sleepiness (Johns, 1992). All items are assessed on a 4-point Likert scale (0 = would never doze; 1 = slight chance of dozing; 2 = moderate chance of dozing; and 3 = high chance of dozing) with a range in total score from 0 to 24, and a higher score indicates more daytime sleepiness. A total score of 10 or more is considered excessive sleepiness (Johns, 1992). This scale demonstrates good reliability in the study sample (Cronbach's alpha = .82). Anxiety. Anxiety was assessed with the Patient-Reported Outcomes Measurement Information System (PROMIS) Emotional Distress Anxiety Short Form, a 7-item scale that assesses the pure domain of anxiety in individuals age 18 and older during the past week (Lanting, Saffer, Koehle, & Iverson, 2013). Each item is rated on a 5-point Likert scale (1 = never; 2 = rarely; 3 = sometimes; 4 = often; and 5 = always) with a range in total raw score from 7 to 35, and a higher score indicates greater severity of anxiety. A T-score is calculated from the total raw score with a range from 36.3 to 82.7 based on the instrument scoring manual. A T-score of 60 or more is considered as moderate to severe anxiety. This scale demonstrates good reliability in the study sample (Cronbach's alpha = .93).

Measurement of Variables Dependent Variables Perceived Stress. Perceived stress was assessed with the Perceived Stress Scale, the 10-item version. This scale is used to assess the degree to which individuals perceive their lives as stressful during the past month (Cohen, Kamarck, & Mermelstein, 1983). Each item is rated on a 5-point Likert scale (0 = never; 1 = almost never; 2 = sometimes; 3 = fairly often; 4 = very often) with a range in total score from 0 to 40, and a higher score indicates more perceived stress. This scale demonstrates good reliability in the study sample (Cronbach's alpha = .88).

Depression. Depression was assessed with the Center for Epidemiologic Studies Depression Scale, the 10-item version (Radloff, 1991). This scale is used to identify current depression symptomatology in individuals age 18 and older during the past week. Each item is rated on a 4-point Likert scale (0 = rarely or none of the time; 1 = some or a little of the time; 2 = occasionally or a moderate amount of the time; and 3 = most or all of the time) with a range in total score from 0 to 30, and a higher score indicates greater severity of depression symptomatology. A total score of 10 or more is considered depression (Andresen, Malmgren, Carter, & Patrick, 1994). This scale demonstrates good reliability in the study sample (Cronbach's alpha = .88). Independent Variables

Coping Styles. Coping styles were assessed with the Coping Strategies Inventory Short Form, the 32-item version (Tobin, Holroyd, Reynolds, & Wigal, 1989). This scale assesses how individual deals with an event or situation that have been very stressful during the past month. Each item is rated on a 5-point Likert scale (1 = not at all; 2 = a little; 3 = somewhat; 4 = much; and 5 = very much). The instrument has eight primary subscales including problem solving,

Relationship Issues. Relationship issues were assessed with questions to evaluate how often the students have run into issues with the following relationships during the past year, including roommates, friends, romantic relationships, professors, and parents. Each question is rated on a 5-point Likert scale (0 = not during the past year; 1 = less than once a month; 2 = once or twice a month; and 3 = three or more times a month).

Please cite this article as: Zhang, Y., et al., Relationship Issues Among College Nursing Students: Associations With Stress, Coping, Sleep, and Mental Disorders, Teaching and Learning in Nursing (2017), http://dx.doi.org/10.1016/j.teln.2017.06.005

Y. Zhang et al. / Teaching and Learning in Nursing xxx (2017) xxx–xxx

Covariates Sociodemographics. The survey collected information on nursing students' sociodemographics, including age, gender, race, and class year. Body Mass Index (BMI) and Sedentary Behavior. Nursing students' height, weight, and frequency of exercise were also collected. BMI was calculated from self-reported weight and height, expressed as weight/ height2 and was categorized as normal (b25.0 kg/m2), overweight (25– 29.9 kg/m2), and obesity (≥30 kg/m2). Sedentary behavior was defined as exercise less than three times per week (for at least 20-min per session to work up a sweat). BMI and sedentary behavior were selected as covariates because they have been previously associated with stress, sleep quality, and mental health of college students (Eidsdottir, Kristjansson, Sigfusdottir, Garber, & Allegrante, 2014; Pelletier, Lytle, & Laska, 2016; Vargas, Flores, & Robles, 2014; Wu, Tao, Zhang, Zhang, & Tao, 2015). Open-Ended Question The survey included an open-ended question that asked students to describe strategies and resources they normally use to heal their relationship issues. Data Collection The survey was administered and collected online through Survey Monkey. In-class announcement and recruitment was made to undergraduate nursing students before distributing the survey. Students received presurvey emails with the recruitment flyer, then an invitation email with the survey link, three follow-up emails, a final reminder, and a thank-you email over the course of 4 weeks from October to November 2015. The link to the survey started with an explanation of the study, which required students' reading and agreement before going to the survey questions. The survey took about 15 min to complete, and each participant received $10 cash incentive for completing the survey. The study was approved by the institutional review board at the University XXX (blinded for review; No. 15–034). Data Analysis

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Table 1 Sociodemographics, relationship issues, stress, coping, sleep, and anxiety and depression among nursing students (N = 242) Variables

Mean ± SD or percentage

Age Gender Female Male Race White Black Others Class year Freshman Sophomore Junior Senior BMI Normal Overweight Obese Sedentary behavior (yes) Relationship issues ≥ once a month Roommates Friends Romantic relations Professors Parents Perceived stress Coping styles Problem engagement Emotion engagement Problem disengagement Emotion disengagement Poor sleep quality (PSQIN 5) Daytime sleepiness Normal or average Excessive sleepiness Depression (CES-D ≥ 10) Anxiety None or mild Moderate or severe

19.8 ± 1.7 91.3% 8.7% 80.9% 5.0% 14.1% 24.0% 24.4% 24.8% 26.9% 24.1 ± 4.1 71.1% 20.2% 8.7% 56.8% 29.7% 21.3% 34.5% 17.3% 31.6% 20.9 ± 7.2 26.0 ± 6.5 26.4 ± 7.8 22.2 ± 6.6 21.0 ± 7.5 66.2% (7.3 ± 3.4) 8.6 ± 4.4 62.8% 37.2% 54.5% (10.9 ± 6.5) 60.7 ± 9.7 43.4% 56.6%

BMI = body mass index, PSQI = Pittsburg Sleep Quality Index, CES-D = Center for Epidemiologic Studies Depression Scale.

Results

reported poor sleep quality (Pittsburg Sleep Quality IndexN 5); over one third reported excessive daytime sleepiness; over half reported moderate or severe anxiety (Emotional Distress Anxiety Short Form T score ≥ 60); and over half reported depression (Center for Epidemiologic Studies Depression Scale ≥ 10; Table 1). More than 70% of the students reported at least one kind of relationship issues happening at least once a month; and 38% of the students reported at least two kinds of relationship issues happening at least once a month (Fig. 1). The number of relationship issues (≥once a month) was categorized as none (0), one (1), and two or more (≥2) for the subsequent analyses. The number of relationship issues reported by nursing students were significantly associated with perceived stress (F = 17.4, p b .01), problem disengagement coping (F = 5.84, p b .01), emotion disengagement coping (F = 8.25, p b .01), poor sleep quality (F = 11.8, p b .01), daytime sleepiness (F = 10.4, p b .01), and anxiety (F = 16.1, p b .01) and depression (F = 10.4, p b .01; Fig. 2). The number of relationship issues were not associated with age, gender, race, class year, BMI, sedentary behavior, problem engagement coping, and emotion engagement coping (p N .05).

Descriptive and Bivariate Analyses

Multivariate Analyses

A total of 242 nursing students completed the survey, primarily female (91.3%) and White (80.9%) students (Table 1). Nearly 30% of the participants were overweight or obese, and over half reported sedentary behavior (Table 1). Nearly two thirds of the students

Multivariate linear regression models for the associations between the number of relationship issues and outcomes were adjusted for covariates, including age, gender, race, school year, BMI, and sedentary behavior (Table 2). Two or more relationship issues at least once a month were

All analyses were conducted using Statistical Package for the Social Sciences (SPSS) software 24.0. Correlations of the number of relationship issues with perceived stress, coping styles, sleep quality, daytime sleepiness, and anxiety and depression were examined using analysis of variance (comparing the means of three or more independent groups; Field, 2009). Multivariate linear regression models were used to examine the associations of the number of relationship issues with perceived stress, coping styles, sleep quality, daytime sleepiness, and anxiety and depression through calculating coefficients and 95% confident intervals, after adjustment for covariates (Field, 2009). Answers to the open-ended question were reviewed separately by two research assistants and compiled to generate common themes related to students' strategies and resources on healing the relationship issues (Polit & Beck, 2014). The themes and quotes were then discussed by the research team. No glaring discrepancies were found. Small discrepancies were resolved through interpretive discussions and consensus building (Polit & Beck, 2014).

Please cite this article as: Zhang, Y., et al., Relationship Issues Among College Nursing Students: Associations With Stress, Coping, Sleep, and Mental Disorders, Teaching and Learning in Nursing (2017), http://dx.doi.org/10.1016/j.teln.2017.06.005

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Fig. 1. Number of relationship issues (≥ once a month) among nursing students.

significantly associated with perceived stress (Model 1), problem disengagement coping (Model 2), emotion disengagement coping (Model 3), poor sleep quality (Model 4), daytime sleepiness (Model 5), and anxiety (Model 6) and depression (Model 7) among nursing students. One relationship issue at least once a month was significantly associated with perceived stress (Model 1), problem disengagement coping (Model 2), and poor sleep quality (Model 4) among nursing students.

Some students provided one strategy/resource, and others provided several strategies/resources. Review and analyses of answers to this question suggested that nursing students were primarily using problem engagement coping strategies, although a small portion of students reported use of emotion engagement coping, problem disengagement coping, and emotion disengagement coping strategies. Themes and selected quotes from the qualitative analyses were described in Table 3.

Qualitative Analyses

Discussion

A total of 217 nursing students (90%) answered the open-ended question about strategies and resources used to heal relationship issues.

In this study, nursing students reported various kinds of relationship issues, in an order from romantic relations (34.5%) to parents

Fig. 2. Associations between the number of relationship issues and outcomes. Note. Students with different number of relationship issues reported significant differences (**p b 0.01) in the scores of perceived stress, problem disengagement coping, emotion disengagement coping, poor sleep quality, daytime sleepiness, and anxiety and depression.

Please cite this article as: Zhang, Y., et al., Relationship Issues Among College Nursing Students: Associations With Stress, Coping, Sleep, and Mental Disorders, Teaching and Learning in Nursing (2017), http://dx.doi.org/10.1016/j.teln.2017.06.005

Y. Zhang et al. / Teaching and Learning in Nursing xxx (2017) xxx–xxx

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Table 2 Multivariate linear regression models for the associations between relationship issues and outcomes among nursing students Models

Dependent variable

Independent variable Relationship issues

β

CI

p

R2

Model 1

Perceived stress Problem disengagement coping

Model 3

Emotion disengagement coping

Model 4

Poor sleep quality

3.55⁎⁎⁎ 5.74⁎⁎⁎ 2.29⁎⁎ 2.81⁎⁎⁎ 2.23⁎ 4.36⁎⁎⁎ 1.25⁎⁎ 2.39⁎⁎⁎

Model 5

Daytime sleepiness

Model 6

Anxiety

Model 7

Depression

1.46–5.64 3.67–7.82 0.22–4.37 0.79–4.82 −0.04 – 4.69 2.06–6.67 0.17–2.32 1.33–3.44 −0.51 – 2.26 1.18–3.89 −0.47 – 5.13 2.55–8.01 −0.39 – 3.51 3.22–7.04

b0.01 b0.01 b0.05 b0.01 b0.1 b0.01 b0.05 b0.01 NS b0.01 NS b0.01 NS b0.01

0.21

Model 2

1 ≥2 1 ≥2 1 ≥2 1 ≥2 1 ≥2 1 ≥2 1 ≥2

0.88 2.53⁎⁎⁎ 2.33 5.28⁎⁎⁎ 1.56 5.13⁎⁎⁎

0.12 0.12 0.18 0.10 0.23 0.18

Note. All regression models were adjusted for age, gender, race, school year, body mass index, and sedentary behavior. ⁎ pb 0.1. ⁎⁎ p b .05. ⁎⁎⁎ p b .01.

(31.6%), roommates (29.7%), friends (21.3%), and professors (17.3%). A high prevalence (70.3%) of nursing students reported at least one kind of relationship issues happening at least once a month. According to the national survey (American College Health Association, 2007), “concern for troubled friend or family member” and “relationship difficulty” ranked among the top 10 reported health impediments to academic performance by college students. As a significant source of stress in nursing students, relationship issues deserve particular attention from the universities and colleges. On the other hand, from the 242 nursing students in this study, 56.6% reported moderate or severe anxiety, and 54.5% reported depression, which are higher rates than these mental disorders reported by general college students in the United States (American College Health Association, 2007). Two thirds of the nursing students reported poor sleep quality, which is also a higher rate than that reported by general college students in the United States (Vargas et al., 2014). Similar to a cross-sectional survey with nursing students (Kaur, Ghai, Grover, & Singh, 2015), nearly 40% of our study participants suffered excessive daytime sleepiness. The high prevalence of sleep and

mental disorders should be addressed as priorities because they are possibly associated with students' academic performance (Hamaideh & Hamdan-Mansour, 2014; Lemma, Berhane, Worku, Gelaye, & Williams, 2014), retention and graduation (Nordstrom, Goguen, & Hiester, 2014), and occupational career as professional nurses. Knowledge about sleep and mental health promotion is increasingly important for health care professionals. Nurses are in a critical position to evaluate and intervene to promote sleep and mental health in patient populations. Furthermore, sleep and mental disorders in nurses lead to substantial safety and health implications for both nurses and patients. It is important for nursing students to acquire appropriate sleep and mental health management strategies before entering the workforce. In this study, relationship issues were found to be positively associated with perceived stress, poor sleep quality, daytime sleepiness, and anxiety and depression among nursing students. Even though romantic relations and intimate violence have been extensively researched in college students (Kaukinen, 2014; Sylaska & Walters, 2014), other relationship issues and the potential problems that

Table 3 Coping strategies with relationship issues among nursing students Primary themes

Secondary themes (number of codes)

Quotes

Problem engagement

Problem solving (209)

“I usually approach the problem head on and tell the person how I am feeling so we can go ahead and fix the issue.” “Talk about the problems and come up with a plan together on how to fix what the problem is.” “I communicate with the person (people) openly as soon as possible and listen to their concerns, apologize for any mistakes I may have made, and am sure that my point of view is at least expressed.” “I find that I'm fairly could at taking a step back, letting the situation sink in, evaluating what has happened, communicating my feelings and taking in account how the other person may be feeling as well.” “I try to be alone and collect my thoughts, then try to calm down and talk to them rationally.” “I step back and examine the situation from an outsider's point of view.” “I talk about my feelings, and listen to my friends/families. Use communication to sort out and fix issues.” “Talk to other friends and my counselor when I do go.” “Exercise, listening to music, walking.” “Talking to people, listening to music, playing sports.” “I have good intentions to talk about issues, but I am afraid to do so. I don't like upsetting people. Sometimes I'll talk out my issues with friends to help figure out what to do. Other times I bottle it up and ignore it.” “Praying.” “I fought with my friend but didn't think it was my fault. So I was waiting for her to act normal again.” “Avoidance.”

Cognitive restructuring (35)

Emotion engagement

Social contact (23)

Relaxation techniques (8) Problem disengagement

Problem avoidance (2)

Emotion disengagement

Wishful thinking (3) Social withdrawal (4)

Please cite this article as: Zhang, Y., et al., Relationship Issues Among College Nursing Students: Associations With Stress, Coping, Sleep, and Mental Disorders, Teaching and Learning in Nursing (2017), http://dx.doi.org/10.1016/j.teln.2017.06.005

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may arise from these issues have not been well studied. Dating and intimate violence are increasingly prevalent on college campuses and have been associated with risky health and behavioral outcomes among college students (Kaukinen, 2014). Negative interpersonal relationships in college students have previously been reported to be significantly associated with symptoms of adverse physical health (Edwards, Hershberger, Russell, & Markert, 2001). Parent–Child conflict has been associated with suicide rumination, depressive symptoms, and anxiety sensitivity among college students (Lamis & Jahn, 2013). Another study indicated that a higher level of concern for a troubled friend or family member and greater perceived conflict with a faculty or staff member significantly increased college students' perceived stress (Dusselier, Dunn, Wang, Shelley, & Whalen, 2005). There were associations reported between sleep problems and friendship quality (Tavernier & Willoughby, 2014), social ties (Tavernier & Willoughby, 2015), and interpersonal conflict (Gorden & Chen, 2014) among college students. These associations were partially mediated by emotional regulation (Tavernier & Willoughby, 2015). Therefore, without effective emotional regulation or coping strategies, students are at a higher risk for the negative consequences of relationship issues. It is new in this study to identify the associations between relationship issues and problem and emotion disengagement coping. It is especially harmful to nursing students when they are facing various relationship issues and, at the meantime, taking disengagement coping strategies with these issues, for example, distancing themselves emotionally, cognitively, and physically from the relationship problems. It is possible that when not coping effectively, nursing students were at a higher risk of developing negative consequences such as poor sleep quality, daytime sleepiness, and anxiety and depression. Future studies with a larger sample size are needed to examine whether disengagement coping strategies may mediate or moderate the associations between relationship issues and these consequences. Themes from the qualitative comments were identified. Different from quantitative findings, the majority of nursing students reported using problem engagement coping strategies, especially problem solving (e.g., “approaching the problem head on”), when dealing with relationship issues. A few students reported using problem and emotion disengagement coping strategies, such as problem avoidance (e.g., “bottle it up and ignore it”), wishful thinking (e.g., “praying”), and social withdrawal (e.g., “waiting for her to act normal”), to deal with relationship issues. Direct quotes added depth to the quantitative findings regarding specific strategies that nursing students are using. The discrepancy in the qualitative findings may attribute to the open-ended question itself, which asked students in a positive way regarding strategies and resources that they are using to heal relationship issues. Strengths and Limitations This study has several limitations. Although the study avoids some possible confounders at the institution level because all nursing students were from a single public university, the generalizability of the findings is limited as a result. Even though the response rate of 60% for an online survey is moderately high, this may still cause selection bias of the nursing student population. A follow-up study using a more nationally representative random sample would improve the generalizability of the findings. Definitive conclusions about causal relationships cannot be drawn with a cross-sectional design. Future analyses of longitudinal data would be desirable to verify the study findings. In addition, although taking directly from the standard instruments, the time frame (in the past year, month, or week) used for the relationship issues and various outcomes are different, which may threaten the internal validity of the study. Future collection and analyses of data with consistent intervals are needed to

verify the study findings. In the end, future interviews or focus groups with neutral questions about nursing students' experience of facing relationship issues are needed to clarify the quantitative findings. The strengths of the study include the moderately high response rate and the use of qualitative data to triangulate the quantitative findings. Conclusions This cross-sectional study found that relationship issues were prevalent among college nursing students and were positively associated with perceived stress, problem and emotion disengagement coping, poor sleep quality, daytime sleepiness, and anxiety and depression. Relationship issues are significant sources of stress among nursing students. The problem itself and its associated negative consequences deserve particular attention from the university, professors, researchers, and the public because they are essential to ensure nursing students' health and academic success. Qualitative comments found that nursing students primarily used problem engagement coping strategies, whereas a few students used problem and emotion disengagement coping strategies to deal with relationship issues. Effective interventions to facilitate the development of appropriate coping strategies are needed to enhance nursing students' overall health and well-being. Practice Implications The development and maintenance of healthy interpersonal relationships should be an integral part of the college life. Positive, functional interpersonal relationships have been found to enhance students' academic motivation, engagement, and achievement (Martin & Dowson, 2009). Practical strategies to enhance positive and healthy interpersonal relationships among college students may include increasing their availability and accessibility of useful information on healthy relationships and effective communication skills, strengthening the institutional culture to better foster positive interpersonal relationship development and interactions, providing resources that empower students to resolve conflicts or unhealthy relationships, and empowering students to access resources for peers in need of support (New York University, 2017). Many universities and colleges have provided counseling services to college students; however, the majority of students do not use counseling services for a variety of reasons, including fear of being judged or openly seeking help. Therefore, ensuring that information is available and accessible in many different formats and through multiple venues is important for engaging the student population. In addition, creating an environment by staff and faculty members to support and encourage peer interaction is critical to build healthy relationships among students. Previous studies have reported that a successful way to cope with intimate relationship issues is to have a close-knit support group, such as peers or family members (Firmin, Firmin, & Lorenzen, 2014). Successful engagement with a social group can positively affect students' academic performance and satisfaction and overall health and well-being. References American College Health Association (2007). American College Health Association-National College Health Assessment (ACHA-NCHA) web summary. Retrieved from http://www.acha-ncha.org/data/PHYSMENTALF06.html. Andresen, E. M., Malmgren, J. A., Carter, W. B., & Patrick, D. L. (1994). Screening for depression in well older adults: Evaluation of a short form of the CES-D (Center for Epidemiologic Studies Depression Scale). American Journal of Preventive Medicine, 10(2), 77–84. Brougham, R. R., Zail, C. M., Mendoza, C. M., & Miller, J. R. (2009). Stress, sex differences, and coping strategies among college students. Current Psychology, 28(2), 85–97. http://dx.doi.org/10.1007/s12144-009-9047-0.

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Please cite this article as: Zhang, Y., et al., Relationship Issues Among College Nursing Students: Associations With Stress, Coping, Sleep, and Mental Disorders, Teaching and Learning in Nursing (2017), http://dx.doi.org/10.1016/j.teln.2017.06.005