Informed Consent Form
Study Title: Assessing the Mental Health Status of Transferee Nursing Students in
Relation to Academic and Clinical Adjustment
Researchers:
● Montero, Maryrose Samantha L.
● Morallon, Stephanie Kyle
● Navarra, Kenneth M.
● Neniel, Eia Shine S.
● Matildo, Syll Jan A.
● Ople, Roland Jr. P.
Institution: Brokenshire College
You are being asked to participate in this research study because you are a transferee
nursing student who meets the eligibility requirements for this study. Please read this
form carefully and feel free to ask the researchers if you have any questions or need
clarification.
1. PURPOSE
The purpose of this research study is to assess the mental health status of transferee
nursing students and examine how it relates to their academic and clinical adjustment.
2. PROCEDURE
If you agree to participate, you will be asked to complete a survey. The survey includes
questions about your stress, anxiety, depression levels, academic adjustment, and
clinical adjustment. The survey will take approximately 10–15 minutes to complete.
3. RISKS/BENEFITS
There are minimal risks associated with participating, no more than what you would
encounter in everyday life. Your responses may help improve understanding of
transferee students’ needs.
4. CONFIDENTIALITY
All information collected in this study is strictly confidential. No personal or identifying
information will be requested, and your responses cannot be traced back to you. The
data will be used only for academic purposes. Your information will not be disclosed in
any form.
5. VOLUNTARY PARTICIPATION
Your participation is completely voluntary. You may refuse to participate or withdraw at
any time.
6. CONSENT
By selecting one of the options below, you indicate whether you agree to participate in
this study.
☐ I AGREE to participate in this research study.
☐ I DO NOT AGREE to participate in this research study.
I have read and understood the information above and have had the opportunity to ask
questions.
Statement of the Problem
The goal of this research is to assess the mental health status of transferee
nursing students and its relationship with their academic and clinical adjustment.
Specifically, the study will examine the following core problems.
1. What is the mental health status of transferee nursing students in terms of:
1.1. Stress
1.2. Anxiety
1.3. Depression
2. What is the level of academic adjustment of transferee nursing students in
terms of:
2.1. Study Habits
2.2. Workload Management
2.3. Motivation
3. What is the level of clinical adjustment of transferee nursing students in
terms of:
3.1. Clinical Performance
3.2. Patient Interaction
3.3. Time management
4. Is there a significant relationship between the mental health status of
transferee nursing students and their academic adjustment?
5. Is there a significant relationship between the mental health status of
transferee nursing students and their clinical adjustment?
Title: ASSESSING THE MENTAL HEALTH STATUS OF TRANSFEREE NURSING
STUDENT IN RELATION TO ACADEMIC AND CLINICAL ADJUSTMENT
Direction: Please indicate your level of agreement with the following statements:
Scale:
4.20 – 5.00 → Strongly Agree
3.40 – 4.19 → Agree
2.60 – 3.39 → Barely Agree
1.80 – 2.59 → Disagree
1.00 – 1.79 → Strongly Disagree
Part I. Mental Health Status (Please check or fill in the blanks.)
1. Name (Opt
2. Year Level:
Strongly Agree Barely Disagree Strongly
Agree Agree Disagree
A. Stress
1. I feel too much
pressure from my
nursing classes and
clinical duties.
2. I have a hard time
relaxing after
studying or clinical
duty.
3. I feel tense most of
the time.
4. I have trouble
sleeping because of
school work.
5. I feel I cannot finish
all my school tasks
on time.
6. I feel tired from
balancing school
and personal life.
7. I feel physically or
mentally drained
after clinical
rotations.
8. I feel stressed
about meeting
deadlines.
9. I feel overloaded
with school and
clinical tasks.
10.I worry that I cannot
keep up with all my
responsibilities.
A. Anxiety
1. I feel nervous
before exams or
clinical work.
2. I worry about my
grades even when I
study hard.
3. I feel uneasy when
doing new clinical
tasks.
4. I think too much
about mistakes I
made in class or
clinical work.
5. I get tense or shaky
before exams or
clinical duties.
6. I feel stressed when
unexpected
problems happen in
clinical work.
7. I am afraid of being
judged by teachers
or classmates.
8. I feel nervous when
talking to patients.
9. I feel restless when
deadlines are
coming.
10.I worry a lot about
my school or
clinical
performance.
C. Depression
1. I often feel sad for
no reason.
2. I am no longer
interested in
activities I used to
enjoy.
3. I feel exhausted
and hopeless about
nursing school.
4. I feel discouraged
when I cannot do
well in school or
clinical work.
5. I feel too tired or
unmotivated to do
my tasks.
6. I feel lonely or
isolated from
classmates.
7. I feel I am not good
enough as a
nursing student.
8. I feel that my efforts
are not recognized.
9. I often feel low even
after finishing tasks.
10.I feel overwhelmed
by negative
thoughts about
school or clinical
duties.
Part II. Academic Adjustment
Strongly Agree Barely Disagree Strongly
Agree Agree Disagree
A. Study Habits
1. I set a specific time
for studying each
day
2. I can focus well
when I study.
3. I avoid distractions
while studying.
4. I review my lessons
before quizzes or
exams.
5. I take notes that
help me understand
the lessons.
6. I study ahead
instead of
cramming.
7. I can manage my
study time well.
8. I make a study plan
when needed.
9. I try to understand
lessons instead of
memorizing.
10.I ask help from
classmates or
teachers if I don’t
understand a topic.
B. Workload Management
1. I can handle the
number of school
tasks I receive.
2. I finish my
requirements on
time.
3. I know how to
prioritize urgent
tasks.
4. I divide big tasks
into smaller steps.
5. I avoid
procrastinating on
school work.
6. I balance my school
tasks with my
personal life.
7. I can manage
stress from heavy
workloads.
8. I feel confident
completing multiple
tasks.
9. I use my free time
wisely to work on
requirements.
10.I stay organized
with my deadlines
and schedules.
C. Motivation
1. I am motivated to
do well in my
nursing subjects.
2. I feel excited to
learn new lessons.
3. I push myself even
when tasks are
difficult.
4. I want to improve
my performance
every semester.
5. I feel inspired to
study because of
my goals.
6. I stay positive even
when I face
academic
challenges.
7. I try my best in all
school activities.
8. I feel determined to
finish all my tasks.
9. I believe my effort in
studying will pay off.
10.I feel motivated
because I want to
become a good
nurse.
Part III. Clinical Adjustment
Strongly Agree Barely Disagree Strongly
Agree Agree Disagree
A. Clinical Performance
1. I can follow clinical
procedures
correctly.
2. I apply what I
learned in class
during duties.
3. I can perform skills
with confidence.
4. I follow safety and
infection-control
rules.
5. I complete my
clinical tasks
properly.
6. I can adapt quickly
to new clinical
situations.
7. I can work well with
my clinical
instructor.
8. I can use medical
equipment safely.
9. I follow instructions
accurately.
10.I can stay calm
during stressful
situations in the
hospital.
B. Patient Interaction
1. I communicate
politely with
patients.
2. I listen carefully
when patients talk.
3. I show empathy
and understanding
to patients.
4. I explain
procedures to
patients clearly.
5. I respect patient
privacy and
comfort.
6. I stay patient with
difficult or anxious
patients.
7. I can build trust with
patients easily.
8. I make patients feel
safe and cared for.
9. I maintain
professionalism
when talking to
patients.
10.I can handle patient
concerns with
confidence.
C. Time Management
1. I arrive on time for
clinical duties.
2. I finish my assigned
tasks within the
duty hours.
3. I know how to
prioritize clinical
tasks.
4. I can balance
patient care and
documentation.
5. I manage my time
well during busy
duty hours.
6. I avoid wasting time
during clinical
rotations.
7. I prepare my
materials before
duty starts.
8. I stay organized
even when tasks
pile up.
9. I adjust well when
unexpected tasks
happen.
10.I complete tasks
without feeling
rushed.