|Year : 2020 | Volume
| Issue : 1 | Page : 59-63
Effect of perceived social support on stress, anxiety and depression among Nepalese nursing students
Associate Professor, School of Nursing and Midwifery, Patan Academy of Health Sciences, Lalitpur, Nepal
|Date of Submission||08-Mar-2020|
|Date of Decision||05-Jun-2020|
|Date of Acceptance||22-Jun-2020|
|Date of Web Publication||14-Sep-2020|
Dr. Priscilla Samson
School of Nursing and Midwifery, Patan Academy of Health Sciences, Lalitpur
Source of Support: None, Conflict of Interest: None
High levels of stress, anxiety and depression can adversely influence physical health, psychological well-being, academic and clinical performance of the nursing students. Social support serves as a buffer against life stressors and improves individuals' psychological well-being. The aim of this quantitative cross-sectional study was to examine the effect of perceived social support on stress, anxiety and depression among Nepalese nursing students. A descriptive cross-sectional study was done among 680 female nursing students enrolled for Bachelor of Science in Nursing program in nine colleges in Kathmandu valley. Depression Anxiety Stress Scale-21 was used to assess the levels of depression, anxiety and stress, whereas perceived social support was measured using Multidimensional Scale for Perceived Social Support. About half the proportion of students reported moderate to extremely severe levels of stress (47%). Majority reported moderate to extreme anxiety (72.9%) and depression (51.7%). Most students perceived high-level social support (68.9%) from family, friends and significant others. A one-way multivariate analysis of variance revealed that perceived social support had a significant effect on stress, anxiety and depression among Nepalese nursing students (Wilks' ƛ = 0.97, F (3, 676) = 8.1, P 0. 000). A discriminant analysis indicated that depression demonstrated the strongest relationship (0.95) with perceived social support contributing to the significant overall effect. The study revealed a strong relationship of perceived social support with stress, anxiety and depression among nursing students. Although most students reported high level of perceived social support, they experienced high levels of stress, anxiety and depression. Hence, the college administration should take the initiative to introduce and implement periodic mental health screening, counselling and referral services.
Keywords: Anxiety, depression, Nepalese nursing students, social support, stress
|How to cite this article:|
Samson P. Effect of perceived social support on stress, anxiety and depression among Nepalese nursing students. Indian J Cont Nsg Edn 2020;21:59-63
|How to cite this URL:|
Samson P. Effect of perceived social support on stress, anxiety and depression among Nepalese nursing students. Indian J Cont Nsg Edn [serial online] 2020 [cited 2020 Oct 1];21:59-63. Available from: http://www.ijcne.org/text.asp?2020/21/1/59/295051
| Introduction|| |
Stress, anxiety and depression have been identified as significant conditions related to psychological distress during nursing education. The literature indicates a high prevalence of psychological distress among nursing students., Furthermore, nursing students are often exposed to high levels of stress when compared with students from other programs., Excessive and prolonged stress can be harmful to students' academic performance and their physical and psychological well-being., The literature identifies social support as one of the key factors that may help in minimising the prevalence of anxiety, stress and depression., In a more recent literature, Heerde and Hemphill  defines social support as assistance that the individuals in a social network render to each other for the management of stress.
Social support protects the person under stress and works as an external factor that may influence the levels of anxiety and depression. The most common sources of social support include family, friends and significant others. This study was based on Lazarus and Folkman's theory of stress, coping and adaptation. The assumption of this theory indicates that individuals experiencing stressful situations may become vulnerable to anxiety and depression. The theorists emphasised that social support plays a significant role in coping with stressful situations. Limited literature is available on the relationship of social support with stress, anxiety and depression among nursing students. In Nepal, few studies related to stress, anxiety and depression have been done among Nepalese nursing students., However, there is no study done to find out what effect the levels of social support has on stress, anxiety and depression among Nepalese nursing students. Therefore, the objective of this study was to find out the effect of perceived social support on stress, anxiety and depression among nursing students in Nepal. The hypothesis for this study was that there will be a significant main effect for levels of social support.
| Materials and Methods|| |
A cross-sectional, descriptive, correlational research design was used to examine the effect of levels of social support (independent variable) on stress, anxiety and depression (dependent variables). The population included all undergraduate students enrolled for the Bachelor of Science in Nursing (B. Sc.) program, which is a 4-year degree program in a university in Nepal. The minimum sample size as determined by G*Power was 180, using multivariate analysis of variance (MANOVA) for global effect, 95% power, with the alpha level of 0.05 and with a medium effect size of 0.0625. Correlational studies require a large sample to obtain a true reflection of variables being measured. Therefore, 744 nursing students were approached from nine colleges and 682 agreed to participate. The selection bias that may have occurred using convenience sampling in this study was reduced by excluding the participants known to the researcher personally and the nursing students from the college where the researcher was employed.
Ethical approval for this study was obtained from the Nepal Health Research Council. All participants signed informed consent.
The participants' general information included age, current living conditions, arrangement for paying college fees and enrolment of academic year. The Depression, Anxiety, Stress Scale (DASS-21) by Lovibond and Lovibond  was used to assess stress, anxiety and depression. DASS-21 comprises three subscales, i.e., DASS-S for Stress, DASS-A for Anxiety and DASS-D for Depression, that measure the symptoms related to stress, anxiety and depression experienced by the participants over the past week. The instrument is a 4-point Likert scale (0 = did not apply to me, 1 = applied to me some of the time, 2 = applied to me to a good part of time and 3 = applied to me most of the time) with seven items each for subscales. Each subscale has a total score of 21, ranging from 0 to 21. The scores are interpreted as normal, mild, moderate, severe and extremely severe and ranges differently for stress, anxiety and depression. DASS-S is interpreted as normal (0–7), mild (8–9), moderate (10–12), severe (13–16) and extremely severe (17+). The scoring criteria for DASS-A are categorised as normal (0–3), mild (4–5), moderate (6–7), severe (8–9) and extremely severe (10+). Similarly, DASS-D is interpreted as normal (0–4), mild (5–6), moderate (7–10), severe (11–13) and extremely severe (14+). In the original validation study, DASS-21 indicated good internal consistency in which the Cronbach's alpha was 0.88, 0.82, 0.90 and 0.93 for depression, anxiety, stress and overall scale, respectively. In this study, the Cronbach's alpha was 0.78, 0.74, 0.76 and 0.89 for depression, anxiety, stress and overall scale, respectively.
The concept of perceived social support was measured using the Multidimensional Scale for Perceived Social Support (MSPSS) by Zimet et al. This scale has three subscales: family, friends and significant other, which is a 12-item scale on a 7-point Likert scale. MSPSS scores ranged from 12 to 84. Higher scores indicated higher perception of social support and lower scores indicated lower perception of social support. In this study, the scoring was based on the mean scale scores, which were calculated by adding up the score in each subscale and dividing by four. The total mean scale score was obtained by summing across all 12 items and dividing by 12. The mean scale scores denote level of support as follows: low support (1–2.9), moderate support (3–5) and high support (5.1–7). The tool reliability value of MSPSS with Cronbach's alpha in this study was 0.89, which was slightly lower than the initial value of 0.93.
The data were collected from participants after scheduling the date and time with the program coordinators and class advisors of the nine nursing colleges within the same university system in Nepal. The time students required to complete the survey questionnaire did not exceed 30 min.
The data were entered into IBM SPSS 23.0 (IBM Corp. Released 2015. IBM SPSS Statistics for Windows, Version 23.0. Armonk, NY: IBM Corp.) for Mac for storage and analysis. Participants' general characteristics, levels of stress, anxiety, depression and level of perceived social support were analysed using descriptive statistics. Whereas, correlations of perceived social support with stress, anxiety and depression were examined using one-way MANOVA. Furthermore, discriminant analysis was conducted as the F-tests for MANOVA in this study were highly significant (P < 0.001) and to further describe the dimension on which groups in this study actually differed. Social support was categorised in two levels: low and high for the purpose of analysing the data. For analysis purposes, the individual mean scores up to 4 was considered as low social support, and the mean scores >4 was categorised into high social support for MSPSS scores.
| Results|| |
The total number of students who consented for participating in the study was 682, of which two students did not complete the survey forms and were excluded from the study leaving 680 complete surveys [Table 1]. The mean age of the participants was 20.29 (range: 18–27) years. All participants were female. The majority of participants (69.1%) reported living with family. Most students' (88.8%) fee was paid by their parents or relatives. A majority of the participants (79.4%) reported that there were no counselling services available in their college.
Most students reported moderate to extremely severe level of anxiety (72%), followed by depression (51%) and stress (47%). The mean score for perceived social support was 68.96 ± 11.27, ranging from 17 to 84. Low perceived social support was found among 31.8% of participants, whereas 68.2% had high perceived social support [Figure 1].
Correlations between variables
[Table 2] shows the result of a one-way MANOVA that determined the effect of two levels of perceived social support (low and high) on the three outcome variables, stress, anxiety and depression. Statistically significant differences were found among the levels of perceived social support on the outcome variables, Wilks' ƛ = 0.97, F (3,676) = 8.1, P < 0.001.
|Table 2: Mean and standard deviation for independent and dependent variables|
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Discriminant analysis was conducted as a follow-up procedure as the F-test for MANOVA in this study was highly significant (P < 0.001) and to further describe the dimension on which the groups in this study actually differs. The variables in discriminant analysis were the reversed form of MANOVA test. The continuous predictor variables included stress, anxiety and depression, whereas the outcome variable used was two levels of perceived social support: low and high.
The overall Wilks' lambda was significant, ƛ = 0.96 (3, n = 680) = 23.93, P < 0.001, indicating that overall, the predictors variables, stress, anxiety and depression differentiated across the two levels of perceived social support [Table 3]. [Table 4] shows the coefficients for the discriminant function that was named by determining the strongest related variable. The discriminant function showed a positive relationship with anxiety and depression and a negative relationship with stress. Based on the within-group relationship between the predictors, stress, anxiety, depression and the discriminant functions in structure matrix, depression demonstrated the strongest relationship (0.95) with the discriminant function [Table 5].
|Table 4: Tests of significance and strengths-of-relationship statistics for perceived social support|
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|Table 5: Coefficients for discriminations and the pooled-with-in-groups correlations for perceived social support|
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Overall, 69.6% of the 680 samples used in the analysis were correctly classified in their original groups based on the discriminant functions. The findings suggested that 70.1% (n = 448) of the 639 participants with high social support were correctly classified and 61% (n = 25) of the participants with low social support were correctly classified.
| Discussion|| |
The purpose of this study was to determine the relationship of perceived social support with levels of stress, anxiety and depression among Nepalese nursing students. Most participants in this study perceived high level of social support from family, friends and significant others, which is consistent with the findings reported by Wolf et al. and Ekbäck et al. found slightly different scores on MSPSS, which were lower than the findings in the present study. The MSPSS tool measures support from family, friends and significant others. The reason for perceiving relatively a high level of social support could be the collectivistic familial culture in Nepal  related to the obligations they may feel to reciprocate with the same gesture of helping those who have supported them, which in turn may increase their stress level.
The results indicated statistically significant differences across the levels of perceived social support on stress, anxiety and depression. This finding supports findings from previous research, in which Wolf et al. reported a significant correlation between social support, stress and depression. Roohafza et al. found that students who had low levels of social support reported higher levels of anxiety and depression. Similarly, Bukhari and Afzal  and Kugbey et al. reported that perceived social support had a negative relationship with stress, anxiety and depression. Brandy et al. revealed that a low level of social support is related to higher levels of depression among nursing students.
The results of the discriminant analysis revealed that 69.6% of original grouped cases were predicted correctly. Within the group, correlations demonstrated depression to have the strongest relationship with the discriminant factor. Furthermore, discriminant function showed a positive relationship with anxiety and depression, while stress showed a negative relationship. There are no recent studies that would suggest the discriminant functions of the variables. Dumont and Provost  reported that social support did not significantly differentiate the groups of stress and depression. Lazarus and Folkman  theory of Stress, Coping, and Adaptation was the theoretical basis for this study. This study found a significant relationship of social support with stress, anxiety and depression, thus meeting the assumption of the theory.
Although students from nine colleges participated, they all were affiliated with one university which limits the generalisability of the findings. The post hoc test to compare each group to all other groups could not be done as it requires a predictor variable with more than two groups, whereas, in this study, predictor variables had only two groups. This limitation was addressed by conducting discriminant analyses on significant MANOVA.
The majority of the students reported unavailability of counselling services in their college. Hence, it may be beneficial to introduce and implement services such as periodic mental health screening and counselling facilities in the colleges that will help students decrease stress and anxiety. Communicating the findings of this study to the nursing faculty, administrators and clinical instructors may indicate that strategies need to be planned to address the stress and anxiety of nursing students. Enabling or strengthening available social support is another vital factor that needs to be considered for nursing students. Counselling services can play a significant supportive role in creating awareness among the students about potential academic, clinical and personal stressors and equipping them to adopt effective coping strategies.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]