- Email: [email protected]
Psychological distress, personality, and adjustment among nursing students
Nurse Education Today (2007) 27, 597–601
Nurse Education Today intl.elsevierhealth.com/journals/nedt
Psychological distress, personality, and adjustment among nursing students L. Warbah a, M. Sathiyaseelan a, C. VijayaKumar a, B. Vasantharaj b, S. Russell c, K.S. Jacob c,* a b c
College of Nursing, Christian Medical College, Vellore, India Department of Biostatistics, Christian Medical College, Vellore, India Department of Psychiatry, Christian Medical College, Vellore, India
Accepted 13 September 2006
KEYWORDS
Summary Psychological distress and poor adjustment among a significant number of nursing students is an important issue facing nursing education. The concerns need to be studied in detail and solutions need to be built into the nursing course in order to help students with such difficulty. This study used a cross-sectional survey design to study psychological distress, personality and adjustment among nursing students attending the College of Nursing, Christian Medical College, Vellore, India. One hundred and forty five nursing students were assessed using the General Health Questionnaire 12, the Eysenck Personality Questionnaire, and the Bell’s Adjustment Inventory to investigate psychological distress, personality profile and adjustment, respectively. Thirty participants (20.7%) of the 145 students assessed reported high scores on the General Health Questionnaire. Psychological distress was significantly associated with having neurotic personality and adjustment difficulties in different areas of functioning. c 2006 Elsevier Ltd. All rights reserved.
Nursing education; Students; Psychological distress; Personality; Adjustment
Introduction Academic problems and adjustment difficulties are common among students and have been a subject of many investigations. Academic performance
* Corresponding author. Tel.: +91 416 2284513; fax: +91 416 2262268. E-mail address: [email protected] (K.S. Jacob).
and adjustment is influenced by many factors including intelligence and emotional quotients, entry qualification, stress, personality, available support and mentors among others. Academic performance and adjustment among nursing students has been examined in literature (Ofori and Charlton, 2002; Tomey, 2000). Many factors including student category (mature students) (Ofori, 2000; White et al., 1999), support seeking (Ofori and Charlton, 2002), entry qualifications, academic
0260-6917/$ - see front matter c 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.nedt.2006.09.002
598 worries, internal control beliefs, self efficacy (Jeffreys, 1998; Andrew, 1998) were found to have an effect on student performance. Ofori and Charlton (2002) obtained data from questionnaires and university records for 315 students undertaking a pre-registration diploma course in nursing at a university in the Northwest of England. They performed a path analysis. Their results suggested that support-seeking was more predictive of student performance than entry qualifications. Support-seeking also mediated the ageperformance relationship: greater willingness to seek support led to the better academic performance of older students. Other features of the accepted model suggested that students who judged their self-efficacy to be higher expected higher grades and that these highly optimistic expectations led to less support-seeking. Academic worries and internal control beliefs were also found to have positive influences on support-seeking. Ofori (2000) examined data from 222 students undertaking ‘the pre-registration diploma in nursing’ programme at a university in England. The study found no significant differences in performance among those students with GCSE ‘O’ level, those with access and those without any type of domain specific qualifications. However, student age significantly predicted performance, with such performances found to be highly consistent across the three modules. The ‘non-mature’ students (aged <20 years) were identified in the study as being at risk in terms of academic performance whilst the ‘very mature’ students (aged > 34 years) were found to predict better overall performance. White et al. (1999) examined problems faced by nursing students. They studied to three groups of students: current Common Foundation Program (CFP) students; students who had completed the CFP; and students who had discontinued training. The questionnaire responses showed that coursebased problems, identified as prime leaving reasons by the current and completed student groups, differ from the actual leaving reasons of discontinued students obtained by exit questionnaire. The attitudes of participating and discontinued students to theory, clinical and pastoral components of the CFP are not dissimilar. Beck (1995) using the Maslach Burnout Inventory has documented that nursing students experience burnout and that their levels of burnout are comparable to working nurses. The study assessed 28 sophomore nursing students and described situations in which they had experienced burnout during their nursing program. The following themes emerged: engulfing demands, time pressure, no outlet, physically debilitating, emotionally over-
L. Warbah et al. whelming situations, lack of concentration, decreased motivation, impeding relationships and coping attempts. Studies among students in general have also reported psychological distress, and personality variables to play a role in academic performance and adjustment. There is a dearth of data from India on the correlates of adjustment among nursing students. This study attempted to examine the correlation between adjustment to different aspects of life and variables such as psychological distress and personality variables among nursing students studying at the College of Nursing, Christian Medical College, Vellore, India. The specific hypothesis tested by this study was that students who record high scores on neuroticism will also record higher adjustment problems and experience greater degree of psychological distress.
Method Sample All students doing the Bachelor of Science degree in Nursing at the College of Nursing, Christian Medical College, Vellore, India, were requested to participate.
Instruments The following employed:
self
rated
instruments
were
(i) The General Health Questionnaire The General Health Questionnaire (GHQ) (Goldberg and Williams, 1988) is a standardized self report questionnaire used to screen for psychological distress and common mental disorders and has been widely used in primary care. Its main focus is psychological components of ill health. The GHQ has been extensively studied with regard to almost every methodological aspect, ranging from reliability and validity to cross-cultural differences. Versions of different length (12, 18, 30) have been validated for use in different languages and cultures and in diverse settings (Goldberg and Williams, 1988). The GHQ-12 has been widely used in primary care research to identify common mental disorders. It has also been translated into many Indian languages. Goldberg et al. (1997) summarized the data from previous validity studies of the GHQ12. Gender, age and educational level did not have a significant effect on the validity of the GHQ. It takes 2–3 min to complete the questionnaire. The recommended scoring procedure was employed for
Psychological distress, personality, and adjustment among nursing students the study. The locally standardized threshold for use in the community 3/4 was used to identify people with significant psychological distress. (ii) The Eysenck Personality Questionnaire Eysenck, based on his theory of personality, developed the Eysenck Personality Inventory (EPI) to assess personality characteristics (Eysenck and Eysenck, 1964; Eysenck, 1970; Eysenck, 1981). The EPI was used to measure neuroticism and extraversion by several workers in preference to other personality questionnaires by virtue of its brevity, reliability and its negligible correlations with variables such as age and sex. The EPI also has a lie scale to assess the possible role of ‘‘desirability response set’’. Eysenck classified personalities into 4 categories: neurotic-extrovert, stable-extrovert, neurotic-introvert, and stable-introvert. He later developed the Eysenck Personality Questionnaire (EPQ) which had an additional dimension of psychoticism. The EPI and the EPQ have been standardized in different languages by the Department of Psychiatry, Christian Medical College, Vellore, India and have been used in different populations (Verghese and Abraham, 1972; Abraham and Verghese, 1990). The department has also used these instruments among medical students in the college (Verghese et al., 1971). The recommended scoring procedure was employed for the study. (iii) Bell’s Adjustment Inventory Bell’s Adjustment Inventory was developed by Bell (1937) to measure a person’s degree of adjustment in various areas of life such as home, health, social, emotional, and occupational. This inventory has been widely used in clinical practice since it helps to identify relevant areas of maladjustment. This instrument has been used in Vellore to study adjustment among medical students (Abraham and Verghese, 1986). They found a significant positive correlation between neuroticism score on the EPI and scores on the Bell’s Adjustment Inventory sub-scales- home adjustment, health adjustment, social and emotional adjustment. Extraversion was related only to emotional adjustment. The recommended scoring procedure was employed for the study. (iv) Socio-demographic details A questionnaire to elicit socio-demographic details was also administered. Such socio-demographic data often confound psychosocial research and consequently need to be examined and included in the analysis.
599
Ethical issues The study protocol and instruments were presented to and cleared by the Institutional Review Board of the College of Nursing, Christian Medical College, Vellore.
Administration The investigator (LW) met the students in groups, during class hours. The details of the study were explained. The voluntary nature of the study was emphasized and informed consent obtained. Detailed instructions on how to complete the self rated questionnaires were given. The fact that all information will be confidential was emphasized during the instructions. The details of the psychological and social supports available for students were also mentioned.
Analysis Mean, standard deviation and range were employed to describe continuous variables, while frequency distributions were obtained for di/polychotomous variables. The chi squared test was used to assess the significance of associations for categorical data. Student’s t-test was be used to test the associations for continuous variables. The significance of the association between continuous variables was tested using the Pearson’s correlation coefficient. Multiple linear regression and logistic regression were employed to adjust for age and years of collegiate education. Odds ratios and their 95% confidence intervals were calculated. The statistical software SPSS for Windows Release 11.0.1 (SPSS Inc, 2001) was employed for the analysis of data.
Results One hundred and forty five participants (96.67%) of the 150 participants enrolled for the BSc Nursing course took part in the study. The average age was 19.5 (s.d. 1.1) years. The majority were single women (100%), first born (58.9%) and hailed from urban areas (74.5%). The mean GHQ score was 2.54 (s.d. 2.76). The mean scores on the extraversion, neuroticism and psychoticism scales were 12.8 (s.d. 3.9), 11.3 (s.d. 5.0) and 4.5 (s.d. 2.8), respectively. The mean scores on the Bells Adjustment Inventory on health, home, social and emotional adjustments were 8.1 (s.d. 4.9), 8.5 (s.d. 5.3), 17.3 (s.d. 5.7) and 14.3 (s.d. 7.5) respectively.
600 Table 1
L. Warbah et al. Univariate and multivariate statistics for factor associated with psychological distress
Factor
Age (in years) EPQ score – Extroversion EPQ score – Neuroticism EPQ score – Psychoticism BAI Adjustment – Health BAI Adjustment – Home BAI Adjustment – Social BAI Adjustment – Emotional
Univariate statistics (Pearson’s correlation coefficient)
Multivariate statistics (adjusted for age and year in college using linear regression)
Correlation
b
0.04 0.17 0.44 0.05 0.30 0.33 0.26 0.40
p-Value 0.61 <0.05 <0.001 0.55 <0.001 <0.001 <0.001 <0.001
0.07 0.17 0.44 0.05 0.31 0.33 0.26 0.40
t-Value
p-Value
0.60 2.00 5.86 0.60 3.86 4.19 3.26 5.18
0.55 <0.05 <0.001 0.55 <0.001 <0.001 <0.001 <0.001
EPQ – Eysenck Personality Questionnaire; BAI – Bell’s Adjustment Inventory.
Table 1 documents the univariate statistics using the Pearson’s correlations coefficient. Participants with high scores on the GHQ, suggesting a higher probability of psychological distress, had statistically significant correlations with scores on the EPQ to suggest introversion and neuroticism. These relationships remained statistically significant after adjusting for age and year in college using multiple linear regression. Students with higher scores on the GHQ also reported significant adjustment difficulties in the areas of health, home, social and emotional domains in both univariate and multivariate statistics. The relationship between scores on the GHQ and psychoticism, birth order, mother tongue, residence and religion was not statistically significant. Thirty participants (20.7%) reported GHQ scores of 4 or more indicating increased levels of current psychological distress which suggest psychiatric morbidity. The unadjusted and adjusted odds ratios and their 95% confidence intervals are shown Table 2. Psychiatric morbidity was associated with introversion, neuroticism, and poor adjustment on all the fours domains on the Bell’s Adjustment Inventory. These factors remained statistically significant after adjusting for age and year of collegiate education. The following factors were not significantly associated with psychological distress: age, years of collegiate education, birth order, urban-rural residence, religion, and mother tongue.
Discussion Literature on the problems facing nursing students has approached it from many diverse perspectives. Previous studies have examined entry qualifications, maturity of students, supports, academic worries, self efficacy, internal control beliefs, etc. The study aimed to examine psychological dis-
tress, personality and adjustment among nursing students. It employed a cross-sectional design and standardized self report instruments. The majority of students seemed to be report low scores on the GHQ (suggesting reasonable mental health), had stable personalities and reasonable adjustment. However, the students who had high stress score on the GHQ-12 also had neurotic personalities and poorer adjustment. However, the cross-sectional design does not permit definite conclusions on cause and effect. The EPQ assesses personality traits while the GHQ and the Bell’s Adjustment Inventory assess recent psychological distress and adjustment respectively. The statistically significant correlations between the scores GHQ scores and the personality traits suggest that people with scores to suggest neuroticism and introversion may be prone to greater psychological distress which qualifies usual standards for psychiatric morbidity. However, it is not possible to speculate on the direction of the relationship between psychiatric morbidity and current adjustment in cross-sectional study designs. Other studies which have examined distress and adjustment among nursing (Beck, 1995) and medical students (Abraham and Verghese, 1973) and have also found that a proportion of students find the course stressful. Beck (1995) identified different themes which contributed to stress and burnout among nursing students. Extreme demands, time pressure, reduced motivation and poor coping were some of the causes for stress. Psychological distress, poor adjustment and coping can result in poor academic performance among students. In a minority of students this can result in significant psychiatric morbidity and even withdrawal from the course. Personality traits like introversion and neuroticism can make students prone to stress. Early recognition of psychological distress and poor coping
Psychological distress, personality, and adjustment among nursing students Table 2
Unadjusted and adjusted odds ratios for factors associated with psychological distressa
Factor Age Year in collegec Introversion Neuroticism Adjustment – Health Adjustment – Home Adjustment – Social Adjustment – Emotional a b c
601
Adjusted odds ratiosb
Unadjusted odds ratios p-Value
OR
95% CI
p-Value
OR
95% CI
0.56 0.94 0.04 0.001 0.01 0.001 0.003 0.001
1.10 0.98 3.27 5.20 1.10 1.14 1.11 1.11
0.80–1.52 0.63–1.54 1.07–10.0 1.93–14.0 1.02–1.19 1.06–1.22 1.04–1.19 1.05–1.18
0.37 0.50 0.04 0.001 0.01 0.001 0.003 0.001
1.23 0.81 3.22 5.12 1.11 1.14 1.11 1.11
0.78–1.92 0.43–1.51 1.05–9.90 1.98–13.95 1.03–1.20 1.06–1.22 1.04–1.20 1.05–1.18
GHQ score P 4. Adjusted for age and year in College of Nursing. Year in BSc course.
and the provision of support are mandatory for all good educational programs. The College of Nursing has appointed class advisors, student counselors and a student welfare cell. These positions are manned by senior members of the faculty (including those from psychiatric nursing) and the students are encouraged to meet them to sort out the various issues related to academic and hostel life which are stressful. Early recognition of students under stress and counseling will go a long way in helping students adjust to the demands of the nursing course and to hostel life.
References Abraham, A., Verghese, A., 1973. The association between EPI scores and academic achievement among medical students. Indian Journal of Psychiatry 15, 354–357. Abraham, A., Verghese, A., 1986. Eysenck Personality Inventory and Bell’s Adjustment Inventory. Indian Journal of Clinical Psychology 13, 125–126. Abraham, A., Verghese, A., 1990. Translation of the Eysenck Personality Questionnaire into three south Indian languages and their standardization. Indian Journal of Clinical Psychology 17, 37–45. Andrew, S., 1998. Self-efficacy as a predictor of academic performance in science. Journal of Advanced Nursing 3, 596– 603. Beck, C.T., 1995. Burnout in undergraduate nursing students. Nurse Education 20, 19–23. Bell, H.N., 1937. Manual of Bell’s Adjustment Inventory. Consulting Psychologist Press, California, Pala Alto.
Eysenck, H.J., 1970. The Structure of Human Personality. Methueen, London. Eysenck, H.J., 1981. A Model of Personality. Springer-Verlag, New York. Eysenck, H.J., Eysenck, S.B.G., 1964. Manual of the Eysenck Personality Inventory. University Press, London. Goldberg, D., Williams, P., 1988. A User’s Guide to the General Health Questionnaire. Nfer-Nelson, Windsor. Goldberg, D.P., Gater, R., Sartorius, N., Ustun, T.B., Piccinelli, M., Gureje, O., Rutter, C., 1997. The validity of two versions of the GHQ in the WHO study of mental illness in general health care. Psychological Medicine 27, 191–197. Jeffreys, M.R., 1998. Predicting nontraditional student retention and academic achievement. Nurse Educator 23, 42–48. Ofori, R., 2000. Age and ‘type’ of domain specific entry qualifications as predictors of student nurses’ performance in biological, social and behavioural sciences in nursing assessments. Nurse Education Today 20, 298–310. Ofori, R., Charlton, J.P., 2002. A path model of factors influencing the academic performance of nursing students. Journal of Advanced Nursing 38, 507–515. SPSS Inc., 2001. Chicago, Illinois. Tomey, A.M., 2000. Performance assessment. Nurse Educator 25, 59–60. Verghese, A., Abraham, A., 1972. The Eysenck Personality Inventory scores in a group of psychiatric patients. British Journal of Psychiatry 120, 681–682. Verghese, A., Rao, P.S.S., Abraham, A., 1971. The EPI scores in a group of candidates for admission into a medical college. Indian Journal of Psychiatry 13, 107–112. White, J., Williams, W.R., Green, B.F., 1999. Discontinuation, leaving reasons and course evaluation comments of students on the common foundation programme. Nurse Education Today 19, 142–150.
Nurse Education Today intl.elsevierhealth.com/journals/nedt
Psychological distress, personality, and adjustment among nursing students L. Warbah a, M. Sathiyaseelan a, C. VijayaKumar a, B. Vasantharaj b, S. Russell c, K.S. Jacob c,* a b c
College of Nursing, Christian Medical College, Vellore, India Department of Biostatistics, Christian Medical College, Vellore, India Department of Psychiatry, Christian Medical College, Vellore, India
Accepted 13 September 2006
KEYWORDS
Summary Psychological distress and poor adjustment among a significant number of nursing students is an important issue facing nursing education. The concerns need to be studied in detail and solutions need to be built into the nursing course in order to help students with such difficulty. This study used a cross-sectional survey design to study psychological distress, personality and adjustment among nursing students attending the College of Nursing, Christian Medical College, Vellore, India. One hundred and forty five nursing students were assessed using the General Health Questionnaire 12, the Eysenck Personality Questionnaire, and the Bell’s Adjustment Inventory to investigate psychological distress, personality profile and adjustment, respectively. Thirty participants (20.7%) of the 145 students assessed reported high scores on the General Health Questionnaire. Psychological distress was significantly associated with having neurotic personality and adjustment difficulties in different areas of functioning. c 2006 Elsevier Ltd. All rights reserved.
Nursing education; Students; Psychological distress; Personality; Adjustment
Introduction Academic problems and adjustment difficulties are common among students and have been a subject of many investigations. Academic performance
* Corresponding author. Tel.: +91 416 2284513; fax: +91 416 2262268. E-mail address: [email protected] (K.S. Jacob).
and adjustment is influenced by many factors including intelligence and emotional quotients, entry qualification, stress, personality, available support and mentors among others. Academic performance and adjustment among nursing students has been examined in literature (Ofori and Charlton, 2002; Tomey, 2000). Many factors including student category (mature students) (Ofori, 2000; White et al., 1999), support seeking (Ofori and Charlton, 2002), entry qualifications, academic
0260-6917/$ - see front matter c 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.nedt.2006.09.002
598 worries, internal control beliefs, self efficacy (Jeffreys, 1998; Andrew, 1998) were found to have an effect on student performance. Ofori and Charlton (2002) obtained data from questionnaires and university records for 315 students undertaking a pre-registration diploma course in nursing at a university in the Northwest of England. They performed a path analysis. Their results suggested that support-seeking was more predictive of student performance than entry qualifications. Support-seeking also mediated the ageperformance relationship: greater willingness to seek support led to the better academic performance of older students. Other features of the accepted model suggested that students who judged their self-efficacy to be higher expected higher grades and that these highly optimistic expectations led to less support-seeking. Academic worries and internal control beliefs were also found to have positive influences on support-seeking. Ofori (2000) examined data from 222 students undertaking ‘the pre-registration diploma in nursing’ programme at a university in England. The study found no significant differences in performance among those students with GCSE ‘O’ level, those with access and those without any type of domain specific qualifications. However, student age significantly predicted performance, with such performances found to be highly consistent across the three modules. The ‘non-mature’ students (aged <20 years) were identified in the study as being at risk in terms of academic performance whilst the ‘very mature’ students (aged > 34 years) were found to predict better overall performance. White et al. (1999) examined problems faced by nursing students. They studied to three groups of students: current Common Foundation Program (CFP) students; students who had completed the CFP; and students who had discontinued training. The questionnaire responses showed that coursebased problems, identified as prime leaving reasons by the current and completed student groups, differ from the actual leaving reasons of discontinued students obtained by exit questionnaire. The attitudes of participating and discontinued students to theory, clinical and pastoral components of the CFP are not dissimilar. Beck (1995) using the Maslach Burnout Inventory has documented that nursing students experience burnout and that their levels of burnout are comparable to working nurses. The study assessed 28 sophomore nursing students and described situations in which they had experienced burnout during their nursing program. The following themes emerged: engulfing demands, time pressure, no outlet, physically debilitating, emotionally over-
L. Warbah et al. whelming situations, lack of concentration, decreased motivation, impeding relationships and coping attempts. Studies among students in general have also reported psychological distress, and personality variables to play a role in academic performance and adjustment. There is a dearth of data from India on the correlates of adjustment among nursing students. This study attempted to examine the correlation between adjustment to different aspects of life and variables such as psychological distress and personality variables among nursing students studying at the College of Nursing, Christian Medical College, Vellore, India. The specific hypothesis tested by this study was that students who record high scores on neuroticism will also record higher adjustment problems and experience greater degree of psychological distress.
Method Sample All students doing the Bachelor of Science degree in Nursing at the College of Nursing, Christian Medical College, Vellore, India, were requested to participate.
Instruments The following employed:
self
rated
instruments
were
(i) The General Health Questionnaire The General Health Questionnaire (GHQ) (Goldberg and Williams, 1988) is a standardized self report questionnaire used to screen for psychological distress and common mental disorders and has been widely used in primary care. Its main focus is psychological components of ill health. The GHQ has been extensively studied with regard to almost every methodological aspect, ranging from reliability and validity to cross-cultural differences. Versions of different length (12, 18, 30) have been validated for use in different languages and cultures and in diverse settings (Goldberg and Williams, 1988). The GHQ-12 has been widely used in primary care research to identify common mental disorders. It has also been translated into many Indian languages. Goldberg et al. (1997) summarized the data from previous validity studies of the GHQ12. Gender, age and educational level did not have a significant effect on the validity of the GHQ. It takes 2–3 min to complete the questionnaire. The recommended scoring procedure was employed for
Psychological distress, personality, and adjustment among nursing students the study. The locally standardized threshold for use in the community 3/4 was used to identify people with significant psychological distress. (ii) The Eysenck Personality Questionnaire Eysenck, based on his theory of personality, developed the Eysenck Personality Inventory (EPI) to assess personality characteristics (Eysenck and Eysenck, 1964; Eysenck, 1970; Eysenck, 1981). The EPI was used to measure neuroticism and extraversion by several workers in preference to other personality questionnaires by virtue of its brevity, reliability and its negligible correlations with variables such as age and sex. The EPI also has a lie scale to assess the possible role of ‘‘desirability response set’’. Eysenck classified personalities into 4 categories: neurotic-extrovert, stable-extrovert, neurotic-introvert, and stable-introvert. He later developed the Eysenck Personality Questionnaire (EPQ) which had an additional dimension of psychoticism. The EPI and the EPQ have been standardized in different languages by the Department of Psychiatry, Christian Medical College, Vellore, India and have been used in different populations (Verghese and Abraham, 1972; Abraham and Verghese, 1990). The department has also used these instruments among medical students in the college (Verghese et al., 1971). The recommended scoring procedure was employed for the study. (iii) Bell’s Adjustment Inventory Bell’s Adjustment Inventory was developed by Bell (1937) to measure a person’s degree of adjustment in various areas of life such as home, health, social, emotional, and occupational. This inventory has been widely used in clinical practice since it helps to identify relevant areas of maladjustment. This instrument has been used in Vellore to study adjustment among medical students (Abraham and Verghese, 1986). They found a significant positive correlation between neuroticism score on the EPI and scores on the Bell’s Adjustment Inventory sub-scales- home adjustment, health adjustment, social and emotional adjustment. Extraversion was related only to emotional adjustment. The recommended scoring procedure was employed for the study. (iv) Socio-demographic details A questionnaire to elicit socio-demographic details was also administered. Such socio-demographic data often confound psychosocial research and consequently need to be examined and included in the analysis.
599
Ethical issues The study protocol and instruments were presented to and cleared by the Institutional Review Board of the College of Nursing, Christian Medical College, Vellore.
Administration The investigator (LW) met the students in groups, during class hours. The details of the study were explained. The voluntary nature of the study was emphasized and informed consent obtained. Detailed instructions on how to complete the self rated questionnaires were given. The fact that all information will be confidential was emphasized during the instructions. The details of the psychological and social supports available for students were also mentioned.
Analysis Mean, standard deviation and range were employed to describe continuous variables, while frequency distributions were obtained for di/polychotomous variables. The chi squared test was used to assess the significance of associations for categorical data. Student’s t-test was be used to test the associations for continuous variables. The significance of the association between continuous variables was tested using the Pearson’s correlation coefficient. Multiple linear regression and logistic regression were employed to adjust for age and years of collegiate education. Odds ratios and their 95% confidence intervals were calculated. The statistical software SPSS for Windows Release 11.0.1 (SPSS Inc, 2001) was employed for the analysis of data.
Results One hundred and forty five participants (96.67%) of the 150 participants enrolled for the BSc Nursing course took part in the study. The average age was 19.5 (s.d. 1.1) years. The majority were single women (100%), first born (58.9%) and hailed from urban areas (74.5%). The mean GHQ score was 2.54 (s.d. 2.76). The mean scores on the extraversion, neuroticism and psychoticism scales were 12.8 (s.d. 3.9), 11.3 (s.d. 5.0) and 4.5 (s.d. 2.8), respectively. The mean scores on the Bells Adjustment Inventory on health, home, social and emotional adjustments were 8.1 (s.d. 4.9), 8.5 (s.d. 5.3), 17.3 (s.d. 5.7) and 14.3 (s.d. 7.5) respectively.
600 Table 1
L. Warbah et al. Univariate and multivariate statistics for factor associated with psychological distress
Factor
Age (in years) EPQ score – Extroversion EPQ score – Neuroticism EPQ score – Psychoticism BAI Adjustment – Health BAI Adjustment – Home BAI Adjustment – Social BAI Adjustment – Emotional
Univariate statistics (Pearson’s correlation coefficient)
Multivariate statistics (adjusted for age and year in college using linear regression)
Correlation
b
0.04 0.17 0.44 0.05 0.30 0.33 0.26 0.40
p-Value 0.61 <0.05 <0.001 0.55 <0.001 <0.001 <0.001 <0.001
0.07 0.17 0.44 0.05 0.31 0.33 0.26 0.40
t-Value
p-Value
0.60 2.00 5.86 0.60 3.86 4.19 3.26 5.18
0.55 <0.05 <0.001 0.55 <0.001 <0.001 <0.001 <0.001
EPQ – Eysenck Personality Questionnaire; BAI – Bell’s Adjustment Inventory.
Table 1 documents the univariate statistics using the Pearson’s correlations coefficient. Participants with high scores on the GHQ, suggesting a higher probability of psychological distress, had statistically significant correlations with scores on the EPQ to suggest introversion and neuroticism. These relationships remained statistically significant after adjusting for age and year in college using multiple linear regression. Students with higher scores on the GHQ also reported significant adjustment difficulties in the areas of health, home, social and emotional domains in both univariate and multivariate statistics. The relationship between scores on the GHQ and psychoticism, birth order, mother tongue, residence and religion was not statistically significant. Thirty participants (20.7%) reported GHQ scores of 4 or more indicating increased levels of current psychological distress which suggest psychiatric morbidity. The unadjusted and adjusted odds ratios and their 95% confidence intervals are shown Table 2. Psychiatric morbidity was associated with introversion, neuroticism, and poor adjustment on all the fours domains on the Bell’s Adjustment Inventory. These factors remained statistically significant after adjusting for age and year of collegiate education. The following factors were not significantly associated with psychological distress: age, years of collegiate education, birth order, urban-rural residence, religion, and mother tongue.
Discussion Literature on the problems facing nursing students has approached it from many diverse perspectives. Previous studies have examined entry qualifications, maturity of students, supports, academic worries, self efficacy, internal control beliefs, etc. The study aimed to examine psychological dis-
tress, personality and adjustment among nursing students. It employed a cross-sectional design and standardized self report instruments. The majority of students seemed to be report low scores on the GHQ (suggesting reasonable mental health), had stable personalities and reasonable adjustment. However, the students who had high stress score on the GHQ-12 also had neurotic personalities and poorer adjustment. However, the cross-sectional design does not permit definite conclusions on cause and effect. The EPQ assesses personality traits while the GHQ and the Bell’s Adjustment Inventory assess recent psychological distress and adjustment respectively. The statistically significant correlations between the scores GHQ scores and the personality traits suggest that people with scores to suggest neuroticism and introversion may be prone to greater psychological distress which qualifies usual standards for psychiatric morbidity. However, it is not possible to speculate on the direction of the relationship between psychiatric morbidity and current adjustment in cross-sectional study designs. Other studies which have examined distress and adjustment among nursing (Beck, 1995) and medical students (Abraham and Verghese, 1973) and have also found that a proportion of students find the course stressful. Beck (1995) identified different themes which contributed to stress and burnout among nursing students. Extreme demands, time pressure, reduced motivation and poor coping were some of the causes for stress. Psychological distress, poor adjustment and coping can result in poor academic performance among students. In a minority of students this can result in significant psychiatric morbidity and even withdrawal from the course. Personality traits like introversion and neuroticism can make students prone to stress. Early recognition of psychological distress and poor coping
Psychological distress, personality, and adjustment among nursing students Table 2
Unadjusted and adjusted odds ratios for factors associated with psychological distressa
Factor Age Year in collegec Introversion Neuroticism Adjustment – Health Adjustment – Home Adjustment – Social Adjustment – Emotional a b c
601
Adjusted odds ratiosb
Unadjusted odds ratios p-Value
OR
95% CI
p-Value
OR
95% CI
0.56 0.94 0.04 0.001 0.01 0.001 0.003 0.001
1.10 0.98 3.27 5.20 1.10 1.14 1.11 1.11
0.80–1.52 0.63–1.54 1.07–10.0 1.93–14.0 1.02–1.19 1.06–1.22 1.04–1.19 1.05–1.18
0.37 0.50 0.04 0.001 0.01 0.001 0.003 0.001
1.23 0.81 3.22 5.12 1.11 1.14 1.11 1.11
0.78–1.92 0.43–1.51 1.05–9.90 1.98–13.95 1.03–1.20 1.06–1.22 1.04–1.20 1.05–1.18
GHQ score P 4. Adjusted for age and year in College of Nursing. Year in BSc course.
and the provision of support are mandatory for all good educational programs. The College of Nursing has appointed class advisors, student counselors and a student welfare cell. These positions are manned by senior members of the faculty (including those from psychiatric nursing) and the students are encouraged to meet them to sort out the various issues related to academic and hostel life which are stressful. Early recognition of students under stress and counseling will go a long way in helping students adjust to the demands of the nursing course and to hostel life.
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