key: cord-0737551-x521czzd authors: Kuru Alici, Nilgun; Ozturk Copur, Ebru title: Anxiety and fear of COVID‐19 among nursing students during the COVID‐19 pandemic: A descriptive correlation study date: 2021-05-20 journal: Perspect Psychiatr Care DOI: 10.1111/ppc.12851 sha: 0e659630c89f88afa6db3aea129848c5db2727f5 doc_id: 737551 cord_uid: x521czzd PURPOSE: The aim of this study was to assess current situations regarding anxiety and fear of coronavirus disease 2019 (COVID‐19) level among nursing students. DESIGN AND METHODS: A descriptive correlation design was adopted. The sample consisted of 234 nursing students. Data were collected using sociodemographic form, Beck Anxiety Inventory (BAI), and Fear of COVID‐19 scale. FINDINGS: The mean BAI score of the students was 26.56 ± 8.86 and Fear of COVID‐19 total score was 18.95 ± 7.00. A positive correlation between total scores of the BAI and Fear of COVID‐19. The results of this study reveal that anxiety and fear of COVID‐19 levels were high among nursing students. PRACTICE IMPLICATIONS: These findings have underlined there is an urgent need for interventions to reduce anxiety and fear of COVID‐19 among nursing students. Severe acute respiratory syndrome (SARS) coronavirus 2 disease is an infectious disease caused by the newly discovered coronavirus 2019 . Cases of the COVID-19 have been reported in a growing number of countries, and World Health Organization (WHO) declared a global pandemic. 1 According to WHO, there are 7,145,539 confirmed cases with 408,025 deaths in the world, and 2,321,147 confirmed cases and 185,537 confirmed deaths in Europe as of June 10, 2020. The first case of COVID-19 was recorded on March 11, 2020 in Turkey. As of June 10, 2020, the total number of reported cases in Turkey is 172,114 with 4729 deaths. 2 Restriction measures have been introduced as a result of the increased number of the confirmed cases, such as immediate closure of the hotels and restaurants. All conferences, events, gatherings, and concerts have been postponed or canceled. Disadvantaged groups (those with immune problems, cancer, chronic respiratory diseases, obesity and diabetes, cardiovascular diseases and organ transplant patients, and overall chronic diseases patients) have been granted administrative leaves as of March 16, 2020 . 3 Turkish Council of Higher Education decided to close the onsite education for the spring term and shifted to remote teaching due to coronavirus as of March 23, 2020. Remote teaching is still ongoing. 4 Turkey is the second largest country of the European Higher Education Area; 7.5 million students are currently receiving education at 207 universities. Turkish Council of Higher Education seeks to manage the remote teaching process successfully. It announced that Turkish higher education institutions should approach these challenges carefully and pay maximum attention to the values that keep students motivated socially, emotionally, and mentally. 4 Previous studies have shown that the psychological impact of the pandemic affects the young population more adversely. [5] [6] [7] A longitudinal study on the mental health of the general population has shown that; the respondents especially among the ages of 12-21 demonstrate a higher psychological impact of COVID-19 in China. 6 A phenomenological study has shown that college students have developed negative emotions, confusion and pessimism, sleep problems, fear, concerns about family health, economic, and social concerns because of COVID-19. 5, 8 It is suggested that the mental health of college students should be monitored during epidemics. 9,10 However, there is limited study on the psychological effects of COVID-19 on undergraduate students, especially nursing students. 10 Nursing students already have high levels of anxiety due to nursing education. [11] [12] [13] Academic stressors, difficult learning materials, long hours of study, physical, and emotional demands of the nursing programs are some of the stressors indicated by nursing students. [14] [15] [16] During the COVID-19 pandemic, most of nursing students have experienced more anxiety. The studies conducted so far have revealed the relationship between anxiety and gender, parental status, income, concerns about future careers, family support, helplessness, and doubt among nursing students, that is, statistically significant. In addition, anxiety may be triggered by the fear of being infected by COVID-19. 17, 18 Fear of COVID-19 is directly associated with COVID-19 morbidity and mortality rate. 19 Pandemic and epidemics can induce fear among people, and it is important to measure the level of fear and anxiety among nursing students so that they can cope with these emotions successfully. 10, 20, 21 The predictors of anxiety and fear of COVID-19 may change among different population groups in a pandemic situation. However, to our knowledge, anxiety, and fear of COVID-19 among nursing students have not been investigated yet in the Turkish population. The aim of this study was to assess the current situation regarding anxiety and fear of COVID-19 among nursing students and to determine whether anxiety was associated with nursing students' fear of COVID-19 during the pandemic. This was a descriptive correlational study. The study was conducted during the first semester of the academic year 2020-2021, at a public university in Turkey between June and July 2020. The population of the present study comprises 304 nursing students. Power analysis was conducted to determine the level of statistical power and estimate the minimum sample size needed. The required sample size was determined as 170 with 0.05 level of error with a 95% confidence interval and 90% power according to the post hoc statistical power analysis. Inclusion criteria were as follows: willingness to take part in the study, being enrolled in the 2020-2021 academic year, and completing the questionnaires. Finally, data of 234 nursing students were analyzed (response rate: 78%). Data were collected using an online questionnaire survey. This questionnaire consisted of sociodemographic information form, Beck Anxiety Inventory (BAI) and Fear of COVID-19 scale. Sociodemographic information form was used to collect nursing students' sociodemographic characteristics such as age, gender, education level, their experience of COVID-19, and remote education. Anxiety symptoms were measured using BAI, with 21 item screening instruments. Each item was measured via a 4-point Likert scale that ranges from "strongly disagree (0)" to "strongly agree (3)." Scores may range from 0 to 63, with higher scores indicating higher severity of anxiety. 22 Validity and reliability tests of the Turkish version were performed by Ulusoy. 23 Alpha reliability coefficients for state anxiety have been reported as 0.93. In the present study, the Cronbach's α score was 0.85. Fear of COVID-19 was assessed via the fear of COVID-19 scale. The scale was developed by Ahorsu et al. 19 to provide a self-report measure of fear levels of COVID-19. This is a unidimensional 7-item, 5-point Likert scale, ranging from 1 (strongly disagree) to 5 (strongly agree). Total scores may range from 7 to 35, with higher scores indicating higher levels of fear for COVID-19. 19 Fear of COVID-19 scale was adapted to Turkish by Satici et al. 24 The Turkish version of the fear of COVID-19 has also shown acceptable psychometric properties as 0.84. In the present study, Cronbach's α was 0.91. The study was approved by the Ethical Commission of a Public University (2020/20). Permission was obtained from the Ministry of Health to conduct the study. All participants received an information sheet outlining the purpose of the study and a statement that the responses would remain anonymous. Written informed consent was obtained from each participant. Contact details of the researchers were also given to allow participants to gain further details about the study. The data were analyzed using SPSS for Windows 25.0: SPSS Inc. Descriptive statistics (frequencies and percentages) were used to analyze nursing students' sociodemographic data. The independent t-test and analysis of variance (ANOVA) were used to examine the presence of statistically significant differences in the mean BAI and Fear of COVID-19 scores between the categorical variables. Pearson's and Spearman's correlation coefficients were used to examine the correlations among the study variables. The significance level of 0.05 was employed. Table 2 . As shown in Table 3 , there is a positive correlation between total scores of the BAI and Fear of COVID-19 (r = 0.172, p = 0.000). The mean BAI and Fear of COVID-19 scores were compared between participants' demographic variables (Table 4 ). There was statistically significant difference between the BAI scores and gender, year in nursing school, place of residence, family or relatives with COVID-19, home-quarantine, and satisfaction with the remote learning. The BAI was found to be higher in female students than males (t = 2.043, p = 0.042). First-year students suffer more severe anxiety than the other students (f = 3.141, p = 0.026). Students living in urban areas scored higher for anxiety than those living in rural cities (t = 3.203, p = 0.002). Students who had experienced home-quarantine during the pandemic had more anxiety than those who did not (t = 2.121, p = 0.017). Students whose family or relatives had COVID-19, had higher levels of anxiety than those with family or relatives without COVID-19 (t = 2.320, p = 0.012). Students who were not satisfied with the remote learning had more anxiety than those who were (t = 2.142, p = 0.021). The results of this study reveal that anxiety and fear of COVID-19 levels were extremely high among nursing students during COVID-19 pandemic. In this study, anxiety score and fear of COVID-19 score were high among nursing students and 51.5% of the students suffered from severe anxiety. This finding is in line with the previous literature that is rather limited. 10, 18, [25] [26] [27] [28] Similarly, Huang et al. 17 found that young people reported a significantly higher prevalence of generalized anxiety and depressive symptoms than older people. 29 A study reported that high-level anxiety among nursing students besides social isolation, economic instability, uncertainty about future, challenges of remote learning, and fear of getting infected affect anxiety levels of nursing students adversely during the ongoing COVID-19 pandemic in Israel. 18 A study found that health professional students experienced significant distress during the COVID-19. 30 In addition, the important shortage of masks and disinfectants, dramatic headlines, and inaccurate news reported increase anxiety and fear. 27 Besides, students' anxiety levels may increase due to ever-growing distances among people, because of quarantine conditions. It is known that anxiety disorder can occur and worsen due to a lack of interpersonal communication. 31 Nursing students have already high levels of anxiety due to nursing education. [11] [12] [13] Because of the pandemic, nursing students had to face new problems such as online education, and uncertain future. 17, 32, 33 Furthermore, additional factors may cause nursing students feel more stressful such as, the uncertainty about the future and the idea of playing an active role in the fight against epidemic if needed. Anxiety level among female students was usually higher than males before the pandemic. 11, 15 During the COVID-19 pandemic, it was found that anxiety level among female students was higher than males also in Israel 18 and this study results agree with findings reported by Savitsky et al. 18 Similarly, female students were found to have higher levels of anxiety than male students in the study of Zhi et al. 34 in which nursing students examined the relationship between psychological stress and professional identity during the COVID-19 outbreak. Although there are studies in the literature showing that female students have higher anxiety levels, 35, 36 there is also one study indicating that male students experience more anxiety. 37 In a study, it was determined that students studying in health sciences (nursing, medicine, etc.) got higher scores on the COVID-19 fear scale compared to other student groups. 38 47 the group with the highest perceived stress score was determined as fourth-year nursing students. 47 It may be thought that the senior students experience anxiety due to the idea of the possibility of being infected or infecting others because they will play an active role in the epidemic when they begin working after graduation. In a study of Li et al., 30 the psychological stress among healthcare professional students during the COVID-19 outbreak is examined, and approximately one-fifth of the students stated that the outbreak could affect their future career plans. Results indicate that nursing students' anxiety levels were significantly related to place of residence and living in towns due to a higher prevalence of anxiety during the pandemic. In a similar study, nursing students who live in urban areas have been determined to have more anxiety than those who live in rural areas. 34, 48 A study reveals that living in rural areas was a protective factor for college students against experiencing anxiety during the COVID-19 outbreak. 10 Moreover, students who experienced quarantine had high levels of anxiety. In a study that investigated the psychological impact of quarantine during the SARS outbreak indicated depression prevalence was 31.2%. 49 The result of the nursing students from Turkey revealed in this study may have been affected by the strict implementation of lockdowns during weekends in the urban cities, besides the long durations of staying at home. There is a significant relation between having anxiety and having COVID-19 positive family members or relatives among the nursing students according to the results of the study. Previous studies found that anxiety was common among patients with COVID-19. 17, 32, 35, 50 Having a relative or a family member who is infected with COVID-19 is a risk factor for anxiety. 17 The results showed that people suffered serious psychological trauma due to observing other people's death and fear of death. 51 In the study, 84.2% of nursing students were not satisfied with remote teaching and this situation adversely affected their anxiety level during the pandemic. Previous studies have shown that the distance education system caused anxiety in nursing students. 52, 53 Nursing education comprising of both theoretical and practical studies was moved to the alternative of remote teaching with E-exams reported anxiety about academic performance and 89% had difficulty in concentration. 33 All these factors can increase anxiety levels of nursing students in the learning process. 56 This study had a few limitations. First, the data were collected from only one nursing school department in Kilis, Turkey; therefore, the results may not be generalized to all nursing students in Turkey. Second, the data were investigated in June and July 2020 and were collected using convenience sampling. Third, all factors were not investigated that may affect anxiety and fear of COVID-19 among nursing students. should learn coping skills such as meditation and stress management techniques for reducing anxiety and fear. In addition, the nurse educator and academic advisors who actively engage with students also need to be aware of the potential harms associated with the COVID-19 pandemic. Nurse educator should use stress management procedures by providing a student-centered remote learning atmosphere and academic advisors must implement strategies to improve the mental health of students. Authors would like to express their gratitude to everyone for supporting the entire process of this study. The authors desire to thank all the participants in the study. This study did not receive grants from funding agencies in public, commercial, or not-for-profit sectors. The authors declare that there are no conflict of interests. Conception and design of the study: Nilgun Kuru Alici. Collection of data: Ebru Ozturk Copur. Analysis of data: Nilgun Kuru Alici. Drafting the article: Nilgun Kuru Alici and Ebru Ozturk Copur. Final approval: Nilgun Kuru Alici and Ebru Ozturk Copur. The ethical approval was obtained from Ethical Commission of Kilis 7 Aralık University (2020/20). Permission was obtained from the Ministry of Health to be able to conduct the study. All participants received an information sheet outlining the purpose of the study and a statement that responses were anonymous. Written informed consent was obtained from each participant. Contact details of the researchers were also given to allow participants to gain further details about the study. The data that support the findings of this study are available from the corresponding author upon reasonable request. Nilgun Kuru Alici https://orcid.org/0000-0002-5200-6821 Ebru Ozturk Copur https://orcid.org/0000-0003-1843-3499 WHO Virtual Press Conference on COVID-19 Situation Report COVID-19 outbreak control, example of ministry of health of Turkey CoHE Takes Decision to Discontinue Face-to-Face Exams The outbreak of COVID-19 coronavirus and its impact on global mental health A longitudinal study on the mental health of general population during the COVID-19 epidemic in China The psychological impact of quarantine and how to reduce it: rapid review of the evidence Living in home quarantine: analyzing psychological experiences of college students during COVID-19 pandemic Mental health care for international Chinese students affected by the COVID-19 outbreak The psychological impact of the COVID-19 epidemic on college students in China Stress, depression, and anxiety among undergraduate nursing students Anxiety and spiritual well-being in nursing students: a crosssectional study Undergraduate student nurses' lived experiences of anxiety during their first clinical practicum: a phenomenological study Perceived stress and social support in undergraduate nursing students' educational experiences Stress and anxiety among junior nursing students during the initial clinical training: a descriptive study at College of Health Sciences, University of Bahrain Physical and mental determinants of dropout and retention among nursing students: protocol of the SPRiNG cohort study Emotional responses and coping strategies in nurses and nursing students during COVID-19 outbreak: a comparative study Anxiety and coping strategies among nursing students during the COVID-19 pandemic The fear of COVID-19 scale: development and initial validation Multidisciplinary research priorities for the COVID-19 pandemic: a call for action for mental health science. The Lancet Psychiatry COVID-19 and mental health: a review of the existing literature An inventory for measuring clinical anxiety: psychometric properties The Beck Anxiety Inventory: psychometric properties Adaptation of the fear of COVID-19 Scale: its association with psychological distress and life satisfaction in Turkey Determination of anxiety levels and perspectives on the nursing profession among candidate nurses with relation to the COVID-19 pandemic Impacts of coping mechanisms on nursing students mental health during COVID-19 lockdown: a cross-sectional survey Economic impacts of Wuhan 2019-nCoV on China and the world Stress, anxiety, and depression levels in the initial stage of the COVID-19 outbreak in a population sample in the northern Spain. Cadernos de Saúde Pública Generalized anxiety disorder, depressive symptoms and sleep quality during COVID-19 outbreak in China: a webbased cross-sectional survey Psychological distress among health professional students during the COVID-19 outbreak Rules on isolation rooms for suspected covid-19 cases in GP surgeries to be relaxed Studying during the COVID-19 pandemic: a qualitative inductive content analysis of nursing students' perceptions and experiences Effects of COVID-19 on college students mental health in the United States: interview survey study Investigation and analysis of psychological stress and professional identity of nursing students during COVID-19 pandemic Increased levels of anxiety among medical and non-medical university students during the COVID-19 pandemic in the United Arab Emirates Conspiracy beliefs are associated with lower knowledge and higher anxiety levels regarding COVID-19 among students at the University of Jordan Disease prevention knowledge, anxiety, and professional identity during COVID-19 pandemic in nursing students in Zhengzhou The fear of COVID-19 scale: validation in Spanish university students Gender and fear of COVID-19 in a Cuban population sample Clinical characteristics of coronavirus disease 2019 in China Prevalence of depression, anxiety, and insomnia among healthcare workers during the COVID-19 pandemic: a systematic review and meta-analysis Middle East respiratory syndrome coronavirus (MERS-CoV) outbreak perceptions of risk and stress evaluation in nurses Sex differences in anxiety and depression clinical perspectives Neural responses to masked fear faces: sex differences and trauma exposure in posttraumatic stress disorder Turkish nursing students' views of their clinical learning environment: a focus group study Mental health effects of school closures during COVID-19 A study to assess the perceived stress and coping strategies among b. sc. nursing students of selected colleges in Pune during COVID-19 pandemic lockdown Emotional responses and coping strategies in nurses and nursing students during COVID-19out-break: a comparative study SARS control and psychological effects of quarantine Management of corona virus disease-19 (COVID-19): the Zhejiang experience Psychosocial effects of an Ebola outbreak at individual, community and international levels The problems nursing students experience in distance education during the COVID-19 pandemic Determination of nursing students' attitudes and views towards distance learning during the COVID-19 pandemic process Stress and behavioral changes with remote E-exams during the Covid-19 pandemic: a cross-sectional study among undergraduates of medical sciences Technological barriers and challenges in the use of ICT during the COVID-19 emergency remote learning The impact of COVID-19 on medical education Anxiety and fear of COVID-19 among nursing students during the COVID-19 pandemic: A descriptive correlation study