key: cord-0803234-1rowyvc1
authors: Bahçecioğlu Turan, Gülcan; Köse, Semra; Aksoy, Meyreme
title: Analysis of nursing students' obsessive and coping behaviors during the COVID‐19 pandemic
date: 2021-01-23
journal: Perspect Psychiatr Care
DOI: 10.1111/ppc.12728
sha: e9688dc25e9a9aeafe3535a33c98d31a05673439
doc_id: 803234
cord_uid: 1rowyvc1

PURPOSE: This study was conducted to examine the obsessive behaviors and coping behaviors of nursing students during the coronavirus disease 2019 (COVID‐19) pandemic. DESIGN AND METHODS: This descriptive study was conducted between October 4 and October 17, 2020. FINDINGS: In this study, it was found that nursing students had a mean total COVID‐19 Obsessive Compulsive Scale score of 3.88 ± 3.02 and a mean total Ways of Coping Inventory (WCI) score of 47.05 ± 11.68. When the subscales of the WCI were examined, mean scores were found to be 13.64 ± 4.85 for the self‐confident approach, 8.91 ± 3.35 for the optimistic approach, 7.25 ± 2.24 for the seeking social support approach, 10.97 ± 4.43 for the helpless approach, and 6.24 ± 3.20 for the submissive approach. PRACTICE IMPLICATIONS: Nursing students have low levels of obsession with COVID‐19 and moderate levels of coping behaviors. For this reason, it is very important to recognize the psychological symptoms of today's nursing students—the health workforce of the future—and to determine priorities for their solution.

| 1 from outside should be taken. For some individuals, this situation goes too far, and they become stressed and worried, causing the occurrence of various obsessive situations. 13, 15 These obsessive situations include obsession with contamination and being infected, obsession with getting news about the disease, being unable to stop watching TV, obsession with following the news on the internet, obsession with being in control, which causes the individual to show excessive control to protect themselves and those around them from the disease, and compulsive hoarding, which causes the individual to stockpile food or cleaning products in the house. 13 The COVID-19 pandemic has not only affected people's psychological symptoms, but also has caused coping behaviors to be affected. 16 Coping is a dynamic process in which the individual and the environment interact with and affect each other to control the negative effects of a series of stressful cognitive and behavioral events or situations. 17 Stress can be eliminated if the symptoms of stress are dealt with, but when coping mechanisms are ineffective, various negative feelings and psychological symptoms may occur. 18 Healthcare professionals are considered a high-risk group in terms of psychological symptoms during the COVID-19 pandemic. 19, 20 It is very important to understand the psychological effects of the COVID-19 pandemic and to analyze coping behaviors to maintain the psychological well-being of healthcare professionals. 21 Considering that the majority of healthcare professionals consists of nurses, [22] [23] [24] the aim of the present study was to analyze the obsessive behaviors and coping behaviors of nursing students, who are the nurses of the future and who will work on the frontline during the COVID-19 pandemic.

The present study used a cross-sectional study design.

The study was conducted between October 4 and October 17, 2020.

A nonrandom sampling method, the snowball sampling method, was used in the study. Data-collection forms prepared with the Google-Docs program were sent online (email, WhatsApp) to students studying in nursing departments in Turkey, and they were asked to fill in the forms and share them with people around them. Twelve hundred students were reached with this questionnaire. Of those reached, 48% did not agree to participate in the study (52% participation). Six-hundred twenty-eight nursing students who answered the questionnaire were included in the study. In the literature review, the total sample size found using the G*POWER program was calculated as n = 628, with a 0.13150 effect size, 95% power, and a 0.05 error margin, based on the percentage measurement values for the methods to be studied. Power analysis showed that the data collected was sufficient.

The data were collected using a personal information form, the Obsession with COVID-19 Scale (OCS), and the Ways of Coping Inventory (WCI).

This form, which was prepared by the researchers in line with the literature, included information about the nursing students' age, gender, marital status, and information about COVID-19.

This scale has been developed to help effectively identify COVID-19related thought patterns and individuals with impaired functionality.

Each item of the OCS is rated on a 5-point scale from 0 (not at all) to 4 (almost every day) based on their experience over the past 2 weeks. A total OCS score ≥7 indicates dysfunctional thinking associated with COVID-19. High scores on a particular item or a high total scale score (≥7) indicate that an individual's problematic symptoms may require a more advanced assessment and/or treatment. 5 

This scale was developed by Folkman and Lazarus. 25 The scale, which was adapted into Turkish and shortened by Şahin and Durak, 26 consists of 30 items. 26 It includes five subscales: the self-confident approach subscale (seven items), the optimistic approach subscale (five items), the helpless approach subscale (eight items), the submissive approach subscale (six items), and the seeking social support approach subscale (four items). The scale is answered on a 4-point scale, from 0 (not at all suitable) to 3 (very suitable). However, items 1 and 9 are reverse coded. High scores from the subscales mean that individuals use the related approach more. Cronbach's α coefficients of the scale were found to be between 0.62 and 0.80 for the selfconfident approach, between 0.49 and 0.68 for the optimistic approach, between 0.64 and 0.73 for the helpless approach, between 0.47 and 0.72 for the submissive approach, and between 0.45 and 0.47 for the seeking social support approach. 26 In the present study, Cronbach's α coefficients of the scale were found to be 0.91 for the self-confident approach, 0.82 for the optimistic approach, 0.74 for the helpless approach, 0.65 for submissive approach, and 0.48 for the seeking social support approach. The total Cronbach's α coefficient of the scale was found to be 0.85.

In this study, descriptive statistics of the variables were given as number, percentage, arithmetic mean, and standard deviation. An independent samples t test was used to compare two independent groups, while the Mann-Whitney U test was used when the numerical variables were not normally distributed. Analysis of variance (ANOVA) was used to compare more than two independent groups, while the Kruskall-Wallis test was used when the numerical variables were not normally distributed. Spearman's correlation coefficient was used to analyze the correlation between numerical variables. Statistical analyses were conducted with SPSS version 25, and level of significance was taken to be 0.05 (p value).

Approval was obtained from the Ethics Committee (number 2020/ 09) of a university before starting the study. The form as well as necessary explanations about the purpose and application method of the study were sent online to students and their consent was taken.

This study was conducted in accordance with the ethical standards of the Declaration of Helsinki. Participants included in the study were volunteers and their personal information was kept confidential.

The mean age of participants in the study was 20.99 ± 2.14, 76.4% were female, 35.4% were in their first year, 75.3% had a nuclear family, 45.7% were living in the Eastern Anatolia Region, 71.5% had sufficient information about COVID-19, 51.6% thought COVID-19 measures were sufficient, and 77.5% stated that they did not have anyone around them diagnosed with COVID-19 (Table 1) In this study, it was found that the nursing students had a mean total OCS score of 3.88 ± 3.02 and a mean total WCI score of 47.05 ± 11.68. When the subscales of the WCI were analyzed, it was found that the self-confident approach subscale had a mean score of 13.64 ± 4.85, the optimistic approach subscale had a mean score of 8.91 ± 3.35, the social support approach subscale had a mean score of 7.25 ± 2.24, the helpless approach subscale had a mean score of 10.97 ± 4.43, and the submissive approach subscale had a mean score of 6.24 ± 3.20 (Table 2) .

When nursing students' descriptive features and their mean OCS and WCI scale scores were compared, a statistically significant difference was found between the WCI total and the WCI seeking social support and helpless approach subscale scores in terms of gender (p < 0.05). While no significant difference was found between the mean total OCS and mean total WCI scores, a statistically significant difference was found between the mean OCS and the WCI seeking social support approach subscale scores in terms of family type (p < 0.05). A statistically significant difference was found between the mean total WCI score and the WCI self-confidence and optimistic approach scores in terms of the region that nursing students were living in (p < 0.05). A statistically significant difference was found between mean WCI self-confidence, optimistic, and social support approach subscale scores in terms of having sufficient information about COVID-19 (p < 0.05). A statistically significant difference was found between the mean total OCS score and the WCI self-confident, optimistic, helpless, and submissive approach subscale scores in terms of thinking that COVID-19 measures were sufficient (p < 0.05). A statistically significant difference was found between Table 3 ).

In this study, a positive significant correlation was found between nursing students' mean OCS score and the WCI helpless approach and submissive approach subscale scores, while a negative significant correlation was found between their mean OCS score and the WCI self-confident approach score (p < 0.05; Table 4 ).

In this section, the results obtained were discussed in light of the literature.

It was found that the nursing students in the study had moderate coping skills. The coping skill students used the most was the self-confident approach, while the one they used the least was the submissive approach. A study by Ergin et al. 27 analyzed the association between methods of coping and sociodemographic features in university students and found that students had higher level of ways of coping with stress. Similar to the results of our study, they found that the coping mechanism students used the most was the self-confident approach. In a study conducted on medical faculty and health college students by Kaya et al. 28 and in a study conducted on university students by Gürdil 29 it was found that the coping mechanism students used the most was the self-confident approach, while they used the submissive approach the least. The finding that students have similar ways of coping with stress may result from the fact that their educational backgrounds are similar, that they have opportunities to make use of the innovations of the age, and that they find the solutions with the self-confidence they have.

In our study, when the descriptive features of nursing students and their Ways of Coping Inventory (WCI) mean scores were compared, it was found that female students had higher mean WCI total scores, as well as higher social support and submissive approach subscale scores (p < 0.05). When the literature was examined in terms of ways of coping with stress, it was found that gender was a significant factor, and female and male students used different methods in coping with stress. [30] [31] [32] Matud 33 found that women had higher emotionally-focused and avoidance coping style scores. It is has been stated that being a woman triggers the experience of more stress and creates different reactions in terms of ways of coping. 31, 34 In a study conducted on nursing students, Güler and Çınar 30 found that male students had higher submissive approach scores. Ergin et al. 27 found that men had higher self-confident approach and optimistic approach subscale scores. In a study conducted on nursing students, Yılmaz et al. 35 found that female student nurses had higher seeking social support approach scores than male students. This may be due to social and cultural reasons. In other words, the fact that our society is a male-dominated society may cause males to have an optimistic approach in stressful situations, to have self-confidence and to have material and spiritual strength. Similarly, the fact that our society has the potential to attribute stress and responsibility to women, to show women less tolerance about self-confidence or coping and to lead them to receive social support for their efforts to cope may have caused these results. In parallel with the results obtained and information from the literature, it can be inferred that during the pandemic, female students may experience increased stress levels due to factors such as school responsibilities, housework, anxiety about catching the disease, and providing hygienic conditions, and as a result, they will resort more to social support.

In the study, it was found that students with nuclear families had higher mean social support approach scores (p < 0.05). In a study conducted on university students by Kara, 36 With the effect of modernization, Turkish society has become more individually-based with the transition from an extended family structure to a nuclear family structure. It can be inferred that when individuals who are influenced by their culture encounter a problem, they will seek help from their immediate environment to solve it. In terms of the regions nursing students were living in, it was found that the students who lived in the Marmara region had higher mean WCI total scores, while students who lived in the Eastern Anatolia region had higher mean self-confident approach scores, and students who lived in the Mediterranean region had higher mean optimistic approach scores (p < 0.05). In Turkey, the differences be- Marmara region showed such a reaction due to the stress brought by the fast tempo of life and having to stand up on their feet. In terms of the pandemic, it was found in an epidemiological study in which individuals from all age groups in Turkey participated, it was found that the highest anxiety due to COVID-19 was seen in Eastern Anatolia (50%) and Aegean (49%) regions. In the Marmara region, this rate was found to be undeniably high (43%). 39 This can be explained by the fact that high numbers of cases in the Marmara region affect anxiety-stress levels.

It was found that the students who thought they had enough information about COVID-19 had higher mean self-confident, optimistic and social support approach scores (p < 0.05). Information will enable patients to see the risks that might be caused by COVID-19 more correctly and help them to experience anxiety unnecessarily. 40 Being informed about COVID-10 and being satisfied with this information may relieve stress and trauma symptoms. 41 In a study conducted in China by Wang et al., 10 it was found that providing more detailed, up-to-date, and correct health information to individuals (e.g., about treatment and the state of the local epidemic) and taking special precautionary measures (e.g., hand hygiene, wearing mask) reduced psychological effects, stress, depression, and anxiety levels. 10 et al., 19 it was found that individuals who were diagnosed with COVID-19, those who knew or lived in the same house with someone diagnosed with COVID-19, had high anxiety levels. With this finding, which is in parallel with the literature, it may be thought that all kinds of behavioral obsessions may occur in students who knew someone diagnosed with COVID-19; however, due to reasons such as changing roles, responsibilities, and future anxiety, they may show submissive approach in fighting with stress.

In the study, a positive correlation was found between nursing students' OCS and WCI total, helpless approach, and submissive approach subscale mean scores, while a negative correlation was found between their OCS and self-confident subscale mean scores (p < 0.05).

While nursing students are expected to show a desperate and submissive approach in the face of uncontrollable situations that cause stress such as pandemic seen in this century in which technology, manpower, and economic wars are common, it is thought that it is unexpected of them to show a self-confident coping approach.

This study found that nursing students had low levels of obsession related to COVID-19 and moderate levels of ways of coping with stress. It was found that the coping method that students used most was the self-confident approach, while the method they used least was the submissive approach. A positive significant correlation was found between students' total OCS and total WCI scores and their helpless approach and submissive approach subscales mean scores, while a negative significant association was found between their OCS and self-confident approach subscale mean scores.

In line with these results, it is extremely important to determine the psychological symptoms and to determine the priorities for solving these problems in nursing students, who will constitute the health workforce of the future. It is thought that providing psychological counseling services to students will be important for nurses who fight on the frontline during disasters or epidemic diseases such as COVID-19; these services will help them to cope with stress and thus fight psychiatric problems.

The limitations of the study are the fact that snapshot measurements were conducted cross-sectionally within specific dates, 48% of the students did not agree to participate in the study and obsession and coping behaviors of the students were evaluated with only self-report scales

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The authors are grateful to all participants who agreed to participate voluntarily in this study.

The authors declare that there are no conflict of interests.

Gülcan Bahçecioğlu Turan, Semra Köse, and Meyreme Aksoy were involved in the initial conception of the study. Gülcan Bahçecioğlu Turan, Semra Köse, and Meyreme Aksoy conducted the interviews.Gülcan Bahçecioğlu Turan and Semra Köse analyzed the data. All authors interpreted the data. All authors reviewed, revised, and edited the paper. All authors read and approved the final manuscript submitted for publication.

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.