Original ResearchSelf-compassion may reduce anxiety and depression in nursing students: a pathway through perceived stress
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
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These authors contributed equally to this work.