Elsevier

Public Health

Volume 174, September 2019, Pages 1-10
Public Health

Original Research
Self-compassion may reduce anxiety and depression in nursing students: a pathway through perceived stress

https://doi.org/10.1016/j.puhe.2019.05.015Get rights and content

Highlights

  • Nursing students in China were experiencing high levels of perceived stress, anxiety and depression.

  • Perceived stress was a significant mediator between self-compassion and anxiety and depression.

  • Self-compassion might indirectly influence nursing students' anxiety and depression through perceived stress.

Abstract

Objectives

Nursing students report high levels of anxiety and depression, which requires urgent attention. A growing amount of evidence indicates that self-compassion may indirectly (through perceived stress) and directly influence anxiety and depression, yet the research to date has not fully examined the reasons for this association. The present study examines the effects of self-compassion on anxiety and depression through perceived stress and may thus provide an innovative starting point for developing effective interventions for affected nursing students.

Study design

This is a cross-sectional study.

Methods

Using structural equation modelling (SEM), we estimated the strength of the pathways between self-compassion, perceived stress and anxiety and depression among 1453 nursing students in Ningbo, China. The measurements included demographics, the Self-Compassion Scale–Short Form, the Chinese version of the Perceived Stress Questionnaire and the Goldberg Anxiety and Depression Scale.

Results

Nursing students had an average score of 4.50 ± 2.44 on the Goldberg Anxiety Scale (GAS) and 3.58 ± 2.34 on the Goldberg Depression Scale (GDS), indicating high levels of anxiety and depression. The GAS and GDS scores were significantly different by the academic year, part-time employment and career prospects. The average scores for self-compassion and perceived stress were 38.99 ± 4.55 and 0.40 ± 0.14, respectively. The SEM results suggested that self-compassion was negatively associated with anxiety and depression (−0.44, P < 0.001). Perceived stress was positively associated with anxiety and depression (0.64, P < 0.001). Self-compassion was negatively associated with perceived stress (−0.65, P < 0.001). Self-compassion had no significant correlation with anxiety and depression in the effect of perceived stress (−0.14, P = 0.127). Thus, self-compassion indirectly influences anxiety and depression through perceived stress.

Conclusions

Self-compassion might reduce nursing students' anxiety and depression through perceived stress. Interventionists can consider using self-compassion training to alleviate perceived stress, anxiety and depression in nursing students.

Introduction

Nursing is widely recognized as a challenging occupation; nursing students, who receive rigorous training to prepare themselves for this occupation, report high levels of anxiety and depression.1, 2 For instance, a 2018 meta-analysis reported that worldwide, 34% of nursing students experienced depressive symptoms. Among students aged younger than 25 years, this prevalence ranged from 39.4% to 41.0%. This prevalence was particularly high among nursing students in Asia, especially in China, where 43.0% of the nursing students had depression.3 However, across the globe, there are few effective intervention strategies tackling this mental health challenge among nursing students,4 including in countries with the most serious nurse shortages, such as China.5, 6, 7 Taken together, high levels of adverse mental health outcomes in nursing professionals require urgent attention and effective intervention.

To develop effective intervention among nursing students, research on the key factors that lead to their adverse mental health outcomes is called for. Perceived stress is a critical psychosocial factor that influences mental health outcomes among nursing students. The concept of perceived stress highlights how people feel about stress, not just stress itself. It is an individual's evaluation of a situation and events beyond his or her self-ability, that is, a cognitive evaluation of stressful events and situations. Nursing students have significantly higher levels of stress than students in other fields.8 Work-related stressors, such as intensive working environments, heavy workload, interactions with dying patients, night shifts and conflicts with patients or doctors all contribute to excessive stress and feelings of depression and anxiety among nursing practitioners.9 Perceived stress can influence nursing students' performance at school and general health and happiness;10, 11, 12 it can also increase their levels of anxiety and depression13, 14 and, worse, can lead to mental dysregulation, systemic physiological disorders15 or even suicidal thoughts.16

Compassion is the capacity of health professionals to understand and respond to patients' physical and emotional experiences of illness. While anxiety and depression among nurses might be related to too much and disproportional compassion dedicated to patients (i.e., compassion fatigue), compassion dedicated to oneself, or self-compassion, is found to be able to alleviate the negative emotions experienced by individuals.17

Specifically, self-compassion is a positive self-attitude or emotion regulation strategy and an emotional awakening state. An individual shows self-compassion when he or she does not evade his or her own pain or failure but feels open and tolerant; in light of this unbiased understanding, one considers his or her personal experience as part of the collective experience of all humanity, thereby relieving one's suffering.17 In recent years, self-compassion has been widely used to predict senses of well-being among a wide range of people, including college students.18, 19, 20

Empirical studies have found that high levels of self-compassion can prevent or reduce the onset of anxiety and depression,21, 22, 23 and it is a better predictor of mixed anxiety and depression.21 In addition, a recent study showed that self-compassion could be attributed to lower perceived stress.24 After completing a conscious self-sympathy programme, participants reported reduced perceived stress, which also indicated that high levels of self-compassion in nursing students may also reduce perceived stress.25

Although growing evidence indicates that self-compassion is associated with lower perceived stress and decreased anxiety and depression, the causal pathways that mediate this relationship are not well understood. Based on the current literature, we hypothesize that self-compassion will reduce anxiety and depression, but mainly indirectly through perceived stress. That is, a high level of self-compassion will reduce nursing students' perceived stress, which in turn will reduce their anxiety and depression. To verify this hypothesis, we collected cross-sectional survey data from a group of Chinese nursing students. The ultimate goal of this study was to provide evidence for effective interventions among nursing students in China. As mindfulness is a prerequisite for self-compassion, if our hypothesis is supported, we can try to implement measures such as mindfulness training to reduce nursing students' anxiety and depression.26

Section snippets

Study design and sample

We used a stratified random sampling strategy, stratifying students by their academic years. The detailed sampling procedures were reported elsewhere.27 Briefly, we aimed to randomly sample 50% of the students from each academic year of nursing students to obtain large, representative samples. Specifically, we randomly selected 616 first-year nursing students from a pool of 1232 first-year students. Similarly, we randomly selected 581 second-year nursing students from a pool of 1162 second-year

Sociodemographic characteristics

Characteristics of the respondents are described in Table 1; 1.4% of respondents were male and 98.6% were female. Participants were between 17 and 23 years of age, with an average age of 19.58 ± 1.09. Of the respondents, 13.4% lived in urban areas, 59.8% lived in rural areas and 26.8% lived in suburban areas. A total of 41.5% of the participants surveyed were first-year nursing students, 39.0% were second-year nursing students and 19.5% were third-year (final year) nursing students. Among all

Discussion

Our study showed that nursing students in China experienced high levels of perceived stress, anxiety and depression. Our SEM results indicated that self-compassion could directly influence perceived stress and that perceived stress was a significant mediator between self-compassion and anxiety and depression. Grounded in Judd and Kenny's42 intermediary test theory, it can be inferred that self-compassion might indirectly influence nursing students' anxiety and depression through perceived

Acknowledgements

Special thanks to Dr. Susan Levenstein, Dr. David Goldberg and Dr. Kristin Neff for providing their research instruments. Thanks to Zongman Qiu (Master candidate in applied psychology) from South China Normal University for his guidance regarding SEM. Additionally, the authors are grateful to all respondents who took part in the present study and the teachers of Ningbo College of Health Sciences for their valued assistance in collecting data. All authors appreciated the anonymous reviewers and

References (51)

  • R.F. Leeman et al.

    Impulsivity, sensation-seeking, and part-time job status in relation to substance use and gambling in adolescents

    J Adolesc Health

    (2014)
  • B. Stubbs et al.

    An examination of the anxiolytic effects of exercise for people with anxiety and stress-related disorders: a meta-analysis

    Psychiatr Res

    (2017)
  • G. Papazisis et al.

    Religious and spiritual beliefs, self–esteem, anxiety, and depression among nursing students

    Nurs Health Sci

    (2014)
  • T. Cheung et al.

    Depression, anxiety and symptoms of stress among baccalaureate nursing students in Hong Kong: a cross-sectional study

    Int J Environ Res Public Health

    (2016)
  • Q. Wu et al.

    Shortage of healthcare professionals in China

    BMJ

    (2016)
  • V.A. Lambert et al.

    Workplace and personal factors associated with physical and mental health in hospital nurses in China

    Nurs Health Sci

    (2007)
  • Y.-Q. Gao et al.

    Anxiety symptoms among Chinese nurses and the associated factors: a cross sectional study

    BMC Psychiatry

    (2012)
  • P.A. Tyler et al.

    Sources of stress and psychological well-being in high-dependency nursing

    J Adv Nurs

    (1994)
  • I. Urquijo et al.

    Emotional intelligence, life satisfaction, and psychological well-being in graduates: the mediating effect of perceived stress

    Appl Res Qual Life

    (2016)
  • V. Sribanditmongkol et al.

    Effect of perceived stress on cytokine production in healthy college students

    West J Nurs Res

    (2015)
  • B. Kulsoom et al.

    Stress, anxiety, and depression among medical students in a multiethnic setting

    Neuropsychiatric Dis Treat

    (2015)
  • G.R. Deckro et al.

    The evaluation of a mind/body intervention to reduce psychological distress and perceived stress in college students

    J Am Coll Health

    (2002)
  • K. Neff

    Self-compassion: an alternative conceptualization of a healthy attitude toward oneself

    Self Ident

    (2003)
  • M.E. Neely et al.

    Self-kindness when facing stress: the role of self-compassion, goal regulation, and support in college students' well-being

    Motiv Emot

    (2009)
  • M. Wei et al.

    Attachment, self-compassion, empathy, and subjective well-being among college students and community adults

    J Personal

    (2011)
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    These authors contributed equally to this work.

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