key: cord-342496-4na1e2de authors: Savitsky, Bella; Findling, Yifat; Ereli, Anat; Hendel, Tova title: Anxiety and coping strategies among nursing students during the covid-19 pandemic date: 2020-06-02 journal: Nurse Educ Pract DOI: 10.1016/j.nepr.2020.102809 sha: doc_id: 342496 cord_uid: 4na1e2de Anxiety is highly prevalent among nursing students even in normal circumstances. In Israel during the covid-19 pandemic and mandatory lockdown, nursing students encountered a new reality of economic uncertainty, fear of infection, challenges of distance education, lack of personal protection equipment (PPE) at work etc. The objective of this study was to assess levels of anxiety and ways of coping among nursing students in the Ashkelon Academic College, Southern District, Israel. A cross-sectional study was conducted among all 244 students in the nursing department during the third week of a national lockdown. Anxiety level was assessed using the Generalized Anxiety Disorder 7-Item Scale with a cut-off point of 10 for moderate and of 15 for severe anxiety. Factor analysis was used to identify coping components. The prevalence of moderate and severe anxiety was 42.8% and 18.1% respectively. Gender, lack of PPE, parental status, and fear of infection were significantly associated with a higher anxiety score. Stronger self-esteem and usage of humor were associated with significantly lower anxiety levels, while mental disengagement with higher anxiety levels. The nursing department's staff may contribute in lowering student anxiety by staying in contact with students and encouraging and supporting them through this challenging period. At the time of writing (April 06,2020), the small state of Israel (population 9,136,000 residents (Central Bureau of Statistics, 2020) is in a state of lockdown with 8,611 verified cases of covid-19, 332 of them moderately or critically ill, and 106 patients on ventilators (Weizman Institute of Science, 2020). Israel is a country used to battles and our medical professionals have always been in the forefront, supporting those on the battlefield. However, this battle is different and the medical professionals have become the commanders and the foot soldiers. In the light of this situation, we decided to examine the anxiety of nursing students in these unusual times. Anxiety is highly prevalent among college students. The top three concerns among students are academic performance, pressure to succeed, and post-graduation plans (Beiter et al., 2015) . Nursing education has been consistently associated with anxiety among students. Heavy course loads, stringent examinations, continued pressure to attain a high grade point average (Chernomas and Shapiro, 2013) , complex interpersonal relationships, challenges of the clinical environment (Chen et al., 2015) , caring for chronic and terminally ill patients (Sancar, Yalcin and Acikgoz, 2018 ) results in greater anxiety among nursing students than among students from any of the other healthcare disciplines. Anxiety has a negative effect on the quality of students' life, their education and clinical practice (Sanad, 2019) . During an epidemic/pandemic, state nursing students are exposed to additional stressful factors. A study conducted among nursing students the during the SARS outbreak (2003) in Hong-Kong showed that nursing students perceived themselves to be at higher risk of infection (Wong et al., 2004) . Similarly, in a study from Saudi-Arabia during the MERS outbreak (2016), healthcare students expressed their reluctance to work in healthcare facilities with inadequate MERS infection control isolation policies (Elrggal et al., 2018) . In Israel during the covid-19 pandemic, a state-wide mandatory closure of all institutions of learning, universities, colleges, schools and kindergartens was imposed from the beginning of March 2020 and an isolation policy was introduced by the government. Only 30% of workers in both public and private sectors were allowed to continue to work (others either continued to work from home, received unpaid leave or were fired). In addition, the government mandated that all citizens had to stay within 100 meters of their home if they went out for sport, dog-walking, etc. which made it problematic to perform the most basic chores and religious activities. All stores were closed except for grocery stores, supermarkets and pharmacies. The staff of all academic institutions faced a new reality had to turn to online teaching with the aim of continuing the academic year and trying to carry out end-of-semester exams as usual. Staff members started to practice and use remote reaching strategies almost immediately with the college lockdown. Meanwhile students working for payment in healthcare facilities (outside of the curriculum framework) continued to work in the new reality of uncertain conditions and controversial information in relation to the new virus and often with lack of sufficient PPE. Due to labor shortage in hospitals and in the community, the Ministry of Health's Office of the Director of Nursing asked all nursing students in the country to voluntarily agree to work in the hospitals and community settings. As a result, more than 1,600 nursing students (100 students of them from our department (41%)) answered the call. The objective of this study was to assess level of anxiety and ways of coping during the period of covid-19 pandemic and identify association of coping strategies with characteristics of the students among nursing students in the Ashkelon Academic College, Southern District, Israel. A cross-sectional study was conducted during the third week of the lockdown among all students in the nursing department (244 students), first to fourth year of study. The questionnaire was conducted using Google Forms and a request to participate in the study was sent to all students. The study received approval from the Ethical Board of our Department of Nursing. The questionnaire was anonymous (demographic questions were asked but did not include identification details). Filling out the questionnaire reflected consent to participate. The total response rate was 88% (215 out of 244 students -93% among the students of the first year, 95% among the second year students, 82% among the third year students and 80% among the students of the fourth, final year of studies ). The questionnaire included demographic information on students including gender, age, year of the study, family status, ethnic group, country of birth, level of religiosity and employment status (among students who worked for a salary). Age was used as a continuous variable and as a dichotomic variable with the median as the cut-off point (25 years). Level of religiosity was used as a categorical variable with categories: Secular; Traditional and Religious. Occupational status was used as a categorical variable with categories: salaried work in healthcare facilities; work in unrelated to the nursing field; does not work. Anxiety level was assessed using The Generalized Anxiety Disorder 7-Item Scale (GAD-7) (Löwe et al., 2008) . GAD-7 was used with a suggested cut-off point of 10 for defining moderate anxiety and with a cut-off point of 15 for defining severe anxiety. This questionnaire has been widely used and is reported to have high internal consistency and good test -retest reliability among adults (Zhong et al., 2015; Rutter and Brown, 2017), adolescents (Spitzer et al., 2006) and college students (Bártolo et al., 2017) . In a previous study at a cut point of 10 or greater, sensitivity and specificity exceeded 0.80, and sensitivity was nearly maximized (Spitzer et al., 2006) . The internal consistency of the questionnaire was validated in this study using the Cronbach's Alpha (CA). CA was found 0.93 for the total sample, pointing to high internal consistency. For defining coping strategies we used Coping Behavior Questionnaire (COPE) (Carver and Scheier, 1989) and choose 10 items after adaptation for the current stressors. The differences in anxiety score were assessed with Mann-Whitney and Kruskal-Wallis nonparametric tests. The differences in frequency of the moderate and severe anxiety disorder by demographic sub-groups was checked with chi-square test. Scores characterizing coping strategies were constructed using factor analysis with varimax rotation and an unrestricted number of factors. The following variables were included in summarizing the information regarding coping strategies of the students: four questions concerning self-esteem and ten items from the Coping Behavior Questionnaire (COPE) (Carver and Scheier, 1989) . Variables with factor loadings ≥0.5 were considered contributing variables to a given factor and five factors were created and together explained approximately 60% of the variability ( Table 1) . The first factor, referred to as "Factor of Self-Esteem," explained 19.2% of the variance. With an increase in self-esteem of the students that they have "strong" personalities and are capable of dealing with challenges, this factor increased. The second factor, referred to as "Factor of Seeking Information and Consultation," explained 13.1% of the variance. This factor increased with escalation of seeking information and using consultations with professionals about the situation by the student. The third factor, referred to as "Factor of Mental Disengagement" explained 9.9% of the variance. With an increase of usage of the coping strategies such as eating, consuming sedative drugs and alcohol, this factor increased. The fourth factor, referred to as "Factor of Spiritual and not Scientific Sources of Support, " explained 9.8% of the variance. With an increase of belief in God and usage of social networks to get information, this factor increased. The last fifth factor, referred to as "Factor of Humor" explained 8.1% of the variance. With an increase of usage of humor to deal with the situation, this factor increased. After designating the factors, we used a t-test or ANOVA test to check the association between each factor and demographic variables and a logistic regression model to investigate the associations of each factor simultaneously and after adjustment for gender with moderate and severe anxiety. Statistical analyses were performed with SPSS statistical software version 25.0. For all analyses performed, a value of p<0.05 was considered statistically significant. The demographic characteristics of the study population are presented in Table 2 . It should be noted that each year of study sees an increase in the number of married students, students with children and students working for a salary. Among students who work with payment in the healthcare facilities, 69% work in a hospital and 31% work in the community setting. Among students who work in healthcare facilities 50% reported that they encountered the lack of PPE at work. The percentage of students with GAD-7 of 10 and above (moderate anxiety) was 42.8% (30.8% among males and 44.7% among the females, p value of X 2 test=0.21). The percentage of students with GAD-7 of 15 and above (severe anxiety) was 18.1% (0% among males and 20.7% among the females, p value of X 2 test=0.006) . Differences in the anxiety score was assessed by students' characteristics and presented in Table 3 . Males had significantly lower anxiety scores (median=7.0, IQR:1.0-11.0) in comparison with females (median=9.0, IQR:5.25-14.0) (p value=0.011). None of the other demographic characteristics were found significantly associated with the anxiety score; academic year of study was not found associated with level of anxiety. Lack of PPE among working students was found associated significantly with a higher anxiety score in comparison with those students who did not experience a lack of PPE at work (median=11.0, IQR:8.0-13.5 and median=6.0, IQR:2.5-10.0 respectively) (p value=0.019). Students who were more concerned with the future continuation of this academic year had a significantly higher anxiety score (median=9, IQR:6.0-14.0) than those who were concerned at a low or moderate level (median=7, IQR:2.0-12.0) (p value of Mann-Whitney non-parametric test=0.024) (data is not presented in the Table) . The anxiety score increased among those students who are the parents of young children with the increase of the burden following the lack of educational frameworks for children (schools and kindergartens); parents who reported that they do not feel such a burden had a lower mean anxiety score than those who experienced an extreme burden (mean anxiety score was 6.5 [median=6] vs. The anxiety score was found to be positively significantly associated with dose-response relationship with fear of becoming infected (Figure 1 ). The anxiety score of students who reported intense fear of infection was found significantly higher. We used logistic regression to identify the association between each of the five factors, representing coping strategies and levels of anxiety (with 10 and 15 cut-of-point respectively) as an outcome. The adjustment for gender was performed in relation to moderate anxiety only as none of males suffered from severe anxiety. Table 4 presents the role of each factor. The factor of Self-Esteem was found significantly and negatively associated with moderate and severe anxiety: among students who perceived themselves as having strong personalities, the odds for moderate and severe anxiety were significantly lower. The factor of Mental Disengagement was found significantly associated with moderate and severe anxiety. The odds for moderate and severe anxiety were higher among students who reported alcohol usage, sedative drugs or excessive eating. The factor of Factor of Humor was found associated only with severe anxiety: the more this strategy was in use, the odds for severe anxiety were lower. Coping strategies and students' characteristics (data is not presented). Seeking information and consultation (Factor II) was significantly associated with the female gender (p value of t-test=0.023) and with occupational status "work as students with payment in the healthcare facilities" (p value of ANOVA test=0.05). Mental disengagement (Factor III) was significantly associated with family status "not married" (p value of t-test=0.024 for Factor III), with parental status "no children" (p value of t-test=0.013), and with level of religiosity "secular" (p value of ANOVA test=0.001). Using the coping strategy of Spiritual and not Scientific Sources of Support (Factor IV) was significantly associated with age≤25 (p value of t-test=0.005), female gender (p value of t-test<0.0001), birth county "Israel" (p value of t-test=0.001), population group "Muslims (Arabs and Bedouins)" (p value of ANOVA test=0.004), religiosity levels 'traditional" and "religious" p value of ANOVA test<0.0001). Using Humor (Factor V) was significantly associated with the population group "Jews" (p value of ANOVA test<0.0001) and with religiosity level "secular" (p value of ANOVA test=0.01). The results of our study reflects anxiety at high levels among nursing students during the continuing covid-19 pandemic. According to previous studies, even in normal circumstances students experience anxiety (among university and college students, prevalence of moderate and severe anxiety was found 12.2% and 5.8% in Hong-Kong (Lun et al., 2018) , 15.6% and 8.3% in Portugal (Bártolo et al., 2017) and 17.5% in Australia (Farrer et al., 2016) . Among medical students prevalence of moderate anxiety was 25% in UK, 20% in North America, 13.7% in New-Zealand and 23% in Lebanon (Quek et al., 2019) . Anxiety level among female students was usually higher than among males in previous studies (Mclean and Hofmann, 2012; Lun et al., 2018; Mirón et al., 2019; Quek et al., 2019; Sanad, 2019) and was also found in our study. Given the fact that females comprise the majority of our study population of nursing students, it can explain in part high the prevalence of anxiety in our study. We believe that the reason for this high prevalence of anxiety is explained by the extremely exceptional living situations and conditions during the continuing covid-19 pandemic. These circumstances include social isolation, economic instability, children who need to be taken care of at home, uncertainty about the future, challenges of remote learning, fear of getting infected and more. We did find that the anxiety score was higher as the fear of getting infected was stronger among those who encountered the lack of PPE at work and grew with the increase of concern regarding the continuation of the current academic year. As to the self-esteem factor, we found that stronger self-esteem was associated with the lowest anxiety levels (moderate and severe). Our findings are consistent with the theory that people with high self-esteem presumably engage in positive, active attempts to cope with stressors (Carver and Scheier, 1989) . Similar results were found among Chinees nursing students who showed that a positive coping style is significantly correlated with a higher level of self-esteem (Ni et al., 2010 (Ni et al., , 2012 . In our study mental disengagement (usage of alcohol, sedative drugs and excessive eating) was associated with a higher state of anxiety. Consistent with what is known about alcohol and drugs to cope with anxiety, this coping strategy is ineffective and may worsen the level of anxiety (Carver and Scheier, 1989) . Maladaptive coping strategies are more likely to lead to eating disorders (Zheng et al., 2020) . We still cannot conclude whether excessive eating in our sample represented the destructive coping strategy or whether this was a result of long home quarantine. Boredom and frustration related to the lockdown may have resulted in excessive eating. Usage of humor was associated in this study with lower levels of anxiety. Freud's psychodynamic viewpoint described humor as one of the strongest defense mechanisms that allow individuals to face problems and avoid negative emotions and researchers believe that humor has a stress-moderating effect (Penson et al., 2007) . Interestingly, searching for information, was not associated with anxiety level in our study. We believe that in the particular case of the covid-19 pandemic, seeking for information might increase anxiety by overflow and multiple sources of information, sometimes broadcasting contradicting information. In our study religiosity was not associated with a lower anxiety level. Numerous empirical studies have found that religion assists in an individual's ability to cope with a variety of personal and collective stressors, such as illness, the loss of a child, terrorist threats and war (Bryan et al., 2016) . We believe that in particular during this period a religious lifestyle was seriously compromised following mandatory prohibitions against praying in a mosque or synagogue and using a Mikveh (Jewish ritual bath), the anxiety of religious people could increase. In addition, a religious lifestyle is associated with a higher birth rate (in our study the percentage of parents was twice as high among religious students in comparison with the secular group). Being isolated with young children could be challenging, as we found higher anxiety level among those students who are parents and reported a heavy burden following closure of schools and kindergartens. Despite the limitations of the present study related to a cross-sectional design with self-reported measures, our findings add new evidence concerning anxiety among nursing students during the 9 pandemic of covid-19. The staff of our nursing department believe that the most important way to help students during this period is to stay in continuous contact with them beyond online teaching. Students face severe anxiety related to economic uncertainty, fear for health of their families, fear of infection, the need to support and care for children, and to deal with the challenges of distance education. The main goal of the department faculty is to keep in touch with students, to encourage and support them through this challenging period, which is still far from being finished as we write these words. We are planning to conduct an additional study in the near future to assess whether there has been a change in the state of anxiety of the students and their use of various coping strategies to meet the challenges of the situation. Age ≤ 25 years 9.6 (5.5) 9.0 (6.0-13.0) 0.511* >26 years 9.1 (5.7) 9.0 (5.0-14.0) Salaried work as a student in healthcare facilities 9.2 (5.3) 9.0 (5.0-13.0) 0.988** Work unrelated to nursing field 9.2 (5.9) 9.0 (5.0-14.0) Does not work 9.4 (5.4) 8.0 (6.0-12.0) PPE a Supplied at work place 6.8 (5.0) 6.0 (2.5-10.0) 0.019 Lack of equipment 11.6 (4.5) 11.0 (8.0-13.5) a only among students working as students with payment in the healthcare facilities * p value of Mann-Whitney non-parametric test ** p value of Kruskal-Wallis non-parametric test 1 • Anxiety is highly prevalent among nursing students even in normal circumstances. • In Israel during the covid-19 pandemic and mandatory lockdown, nursing students encountereda challenging reality. • The prevalence of moderate and severe anxiety was 43% and 18% respectively. • Female gender, lack of protective equipment at work, and being a parent were significantly associated with higher anxiety scores. • Stronger resilience and usage of humor were associated with significantly lower anxiety levels. • Mental disengagement (alcohol, sedative drugs usage and excessive eating) was associated with higher anxiety levels. 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