DEPRESSION, ANXIETY AND STRESS ASSESSMENT AMONG

UNDERGRADUATE NURSING STUDENTS IN BABCOCK

UNIVERSITY

BY

AIGBEDE OSATOHANMWEN, 19/0205

ESSIEN TOBY ROLAND, 19/0240

IDOWU MOYINOLUWA JOAN, 19/0209

KADIRI NAOMI OCHUWARHE, 19/0312

LAWAL TEMITOPE OLUWASEGUN 19/0305

A PROPOSAL SUBMITTED TO THE DEPARTMENT OF COMMUNITY MEDICINE,

SCHOOL OF CLINICAL SCIENCES, BABCOCK UNIVERSITY

IN PARTIAL FULFILLMENT OF THE AWARD OF THE DEGREE OF

BACHELOR OF MEDICINE, BACHELOR OF SURGERY

(MBBS)
SUPERVISOR: DR BAMIDELE E.F.
 MARCH 2024-FEBRUARY 2025

CHAPTER ONE

1.0 INTRODUCTION

1.1 BACKGROUND

Anxiety refers to feelings of worry and unease about an unclear outcome, depression is an illness
marked by a persistently low mood that might cause impairment. These conditions are more
common in women than in men and rank among the most common mental health diagnoses
made globally. For many, starting university is a very transitional and frequently transformative
moment. There are others for whom this is a time of markedly elevated stress. Numerous
variables may contribute to this, which may then evolve into or exacerbate more serious illnesses
like anxiety and depression. A major cause of stress for students is an excessive workload in the
classroom, which has been linked to higher levels of stress among college students1.

Reaching a professional program's entrance signifies the start of achieving a professional

objective. But professional education might have rigorous requirements. Stress, depression, and
anxiety (SDA) can hinder academic achievement, learning, and clinical practice effectiveness.
Research indicates that among college and university students, mental health issues are
becoming more severe and widespread. The research on the mental health distress of nursing
students pinpoints personal and academic stressors as well as coping mechanisms, with a focus
on the worry and tension that come with clinical practice2.

According to a study done in 2018, A meta-analysis of 27 cross-sectional studies revealed that

34.0% of nursing students suffered from global depression. Compared to the general population,
which had a 4.7% frequency of depression, this indicates that nursing students have a higher rate
of depression3.
1.2 PROBLEM STATEMENT

Depression, anxiety and stress are the most common mental disorders found in students and
according to a cross-sectional study done in Hong Kong, there is a large percentage of these
mental disorders found among nursing students with a prevalence of 35.8% , 37.3% and 41.1%
for depression, anxiety, stress respectively32.

As opposed to other undergraduates in other programs, nursing students are compulsorily

required to have course work assignments, clinical practicum and skills examinations with
exhaustive evaluation processes all of which add extra strain on the students already intensive
work load32.

The assessment of depression, anxiety and stress is incredibly important not only because the
nursing student`s mental health is affected but subsequently their physical health is also affected
causing poor sleep, loss of appetite, weight changes and susceptibility to infections33. There is
also the fact that most of these mental disorders last a lifetime and will increase the psychiatric
morbidity burden32.

If these disorders are not promptly addressed, they will negatively interfere with the academic
performance of the nursing student33 and also impair their ability to be better equipped for their
profession upon graduation leading to poor patient care32.

Depression, Anxiety and Stress are major mental disorders hurting majority of nursing students33,
therefore it is of utmost importance to assess their prevalence, effects on academic performance
and patient care which this study aims to do.
1.3 JUSTIFICATION

As a result of the high rate of stress, the prevalence and co-morbidity of depression and
anxiety are, therefore, important conditions to look out for in nursing students as they
affect multiple facets of their lives. In addition, a better understanding of the prevalence and
comorbidity of depression and anxiety among nursing students is necessary as it will aid
planning of an adequate, less stressful and less depressing academic program for nursing
students1.

In order to support this vulnerable population, it is imperative that nursing students' mental
health be evaluated and mental health interventions put into place. Nursing students' personal
health, academic performance, and the standard of patient care they deliver can all be negatively
impacted by the stress, despair, and anxiety they encounter. Empathic interpersonal
communication is essential to the nursing profession. Anxiety and depression can affect
communication and cognitive functions, which can result in poor clinical decision-making and a
higher chance of medical errors in practice. Preserving the psychological health of aspiring
medical professionals is an essential component of nursing education. Furthermore, employee
psychological health directly affects job performance and employee turnover, making it a crucial
issue for the human resources management of the nursing staff4.

The mental health of undergraduate nursing students has become a critical area of concern in
higher education and healthcare settings. Nursing students are exposed to unique stressors,
including rigorous academic schedules, clinical rotations, and emotional demands from patient
care, which predispose them to mental health challenges such as depression, anxiety, and stress 34.
These issues not only affect their academic performance but also their ability to provide quality
care to patients during clinical practice35.

Studies indicate that nursing students often experience higher levels of depression, anxiety, and
stress compared to students in other disciplines36. This may be due to the dual burden of
academic and professional training demands, coupled with exposure to emotionally charged
situations during clinical placements37. Without timely assessment and intervention, these
psychological challenges may lead to burnout, poor coping mechanisms, and in extreme cases,
attrition from nursing programs38. In Nigeria, limited research has focused on the prevalence and
impact of mental health issues among nursing students, particularly in private universities like
Babcock University. Understanding the specific mental health needs of this population is
essential for tailoring interventions that promote resilience, enhance well-being, and improve
educational outcomes. Furthermore, Babcock University's unique faith-based approach to
education provides an additiona3l layer of influence on students' coping strategies, making it a
valuable context for this study39.

Assessing depression, anxiety, and stress among undergraduate nursing students will provide
evidence-based data to inform the development of support programs, such as counseling
services, stress management workshops, and mental health awareness campaigns. It will also
contribute to the body of knowledge on student mental health in Sub-Saharan Africa, addressing
a gap in global literature40.

This study is critical for fostering a healthier academic environment, improving the mental health
of nursing students, and ensuring they are well-prepared for the psychological demands of their
future careers.
1.4 OBJECTIVES

1.4.1 GENERAL OBJECTIVE:

To assess the prevalence of depression, anxiety and stress among nursing undergraduate students
in Babcock University

1.4.2 SPECIFIC OBJECTIVES:

The aims of this study are to:

(i) assess the prevalence of depression among undergraduate nursing students in Babcock
University;

(ii) assess the prevalence of anxiety among undergraduate nursing students in Babcock
University;

(iii) assess the prevalence of stress among undergraduate nursing students in Babcock
University;

(iv) assess factors associated with mental disorders among undergraduate nursing students in
Babcock University.
 CHAPTER TWO

2.0 LITERATURE REVIEW

2.1 DEPRESSION

2.1.1 DEFINITION OF DEPRESSION

Depression is a psychiatric disorder that affects mood, behaviour, and overall health. It causes
prolonged feelings of sadness, emptiness, or hopelessness, and a loss of interest in activities that
were once enjoyed. People with depression may also have changes in appetite (leading to
overeating or not eating enough), changes in sleeping patterns (sleeping too much or not being
able to sleep), loss of energy, and difficulty concentrating5.

According to the World Health Organization, Depressive disorder (also known as depression) is
a common mental disorder. It involves a depressed mood or loss of pleasure or interest in
activities for long periods of time. Depression is different from regular mood changes and
feelings about everyday life. It can affect all aspects of life, including relationships with family,
friends and community. It can result from or lead to problems at school and at work. Depression
can happen to anyone. People who have lived through abuse, severe losses or other stressful
events are more likely to develop depression. Women are more likely to have depression than
men6.

2.1.2 TYPES OF DEPRESSION

There are different types of depression, some of which develop due to specific circumstances;
Major depression includes symptoms of depressed mood or loss of interest, most of the time for
at least 2 weeks, that interfere with daily activities, Persistent depressive disorder (also called
dysthymia or dysthymic disorder) consists of less severe symptoms of depression that last much
longer, usually for at least 2 years, Perinatal depression is depression that occurs during
pregnancy or after childbirth. Depression that begins during pregnancy is prenatal depression,
and depression that begins after the baby is born is postpartum depression, Seasonal affective
disorder is depression that comes and goes with the seasons, with symptoms typically starting in
the late fall or early winter and going away during the spring and summer and Depression with
symptoms of psychosis is a severe form of depression in which a person experiences psychosis
symptoms, such as delusions (disturbing, false fixed beliefs) or hallucinations (hearing or seeing
things others do not hear or see)7.

2.1.3 SYMPTOMS OF DEPRESSION

During a depressive episode, a person experiences a depressed mood (feeling sad, irritable,
empty). They may feel a loss of pleasure or interest in activities6.

A depressive episode is different from regular mood fluctuations. They last most of the day,
nearly every day, for at least two weeks. Other symptoms are also present, which may include
poor concentration, feelings of excessive guilt or low self-worth, hopelessness about the future,
thoughts about dying or suicide, disrupted sleep, changes in appetite or weight and feeling very
tired or low in energy6.

Depression can cause difficulties in all aspects of life, including in the community and at home,
work and school. A depressive episode can be categorized as mild, moderate, or severe
depending on the number and severity of symptoms, as well as the impact on the individual’s
functioning6.

There are different patterns of depressive episodes including: single episode depressive disorder,
meaning the person’s first and only episode, recurrent depressive disorder, meaning the person
has a history of at least two depressive episodes and bipolar disorder, meaning that depressive
episodes alternate with periods of manic symptoms, which include euphoria or irritability,
increased activity or energy, and other symptoms such as increased talkativeness, racing
thoughts, increased self-esteem, decreased need for sleep, distractibility, and impulsive reckless
behaviour6.
2.1.4 DEPRESSION RISK ASSESSMENT

Nursing school can be exciting, both academically and personally. Learning life-saving
procedures and patient care techniques allows future nurses to gain the necessary experience to
save lives. However, maintaining good mental health in nursing school poses a challenge.
Depression in nursing students emerges from multiple stressors. The demands of nursing
programs often take a physical and mental toll. Many students simultaneously maintain
households, jobs, families, and social lives. Adding a rigorous academic program plus a
pandemic to this equation means an increased risk for depression6.

Nursing students face unique challenges during their education, which can put them at risk for
depression. Let’s explore some factors that contribute to this risk:

Academic Pressure: Nursing programs are rigorous and demanding. Students often experience
high academic stress due to exams, assignments, and clinical rotations. The pressure to excel
academically can lead to feelings of inadequacy and anxiety8.

Clinical Experiences: Nursing students directly interact with patients during clinical rotations.
Witnessing illness, suffering, and death can be emotionally taxing. The responsibility of caring
for patients and making critical decisions can cause stress and emotional strain8.

Workload and Time Constraints: Balancing coursework, clinical hours, and personal life can be
overwhelming. Lack of time for self-care, relaxation, and social activities can contribute to
feelings of isolation and burnout8.

Emotional Labor: Nursing involves empathy, compassion, and emotional support for patients.
Students may experience emotional exhaustion from this “emotional labour.” Suppressing
personal emotions while caring for others can take a toll on mental health8.

Transition to Clinical Practice: The transition from theory-based learning to real-world patient
care can be challenging. Fear of making mistakes or not meeting expectations can lead to anxiety
and self-doubt8.

Sleep Deprivation: Irregular clinical shifts, study sessions, and assignments often disrupt sleep
patterns. Chronic sleep deprivation affects mood and overall well-being8.
Financial Stress: Nursing education can be expensive. Students may face financial burdens,
leading to stress and anxiety8.

Social Isolation: Intense study schedules and clinical rotations may limit social interactions.
Isolation from peers and family can contribute to feelings of loneliness and depression8.

Stigma and Mental Health Awareness: Some nursing students hesitate to seek help for mental
health issues due to stigma. Lack of awareness about available resources can prevent timely
intervention8.

Personal Vulnerabilities: Pre-existing mental health conditions, family history, and personal life
stressors can increase the risk of depression8.

Addressing these challenges is crucial to supporting nursing students’ mental health. Universities
should provide counselling services, promote self-care, and create a supportive environment.
Additionally, students should prioritize self-awareness, seek help when need, and connect with
peers and mentors9.

2.1.5 KNOWLEDGE OF OTHER RESEARCHERS ON DEPRESSION

A cross-sectional analysis conducted in the English-speaking regions of Cameroon from January

– April 2018 was carried out. The overall prevalence of depression and major depressive
disorder in these students was 69.57 and 26.40% respectively. The conclusion was that the
prevalence of depression amongst nursing students in Cameroon was high. Determinants
proposed in this study require further assessment to facilitate early identification and
management of depression in this high-risk group, in order to limit the negative effects linked
with the condition10.

Similarly in Peru a cross-sectional, observational study was conducted on 1193 nursing students
on the effects of anxiety and depression. Regarding depression, the majority of students
presented a normal state although levels of mild, moderate, severe, and extremely severe
depression were found in a lower proportion in those students between 20 and 29 years of age,
female, single marital status without children, and who only dedicate themselves to study. A
correlation was found between the students’ age and depression, and it was also statistically
verified that it constitutes a risk factor for suffering depression. The majority of nursing students
do not suffer from depression; however, there was a significant association between age and the
presence of depression levels, as well as being a risk factor for this type of mental disorder11.

In April 2019, a questionnaire was administered to all the nursing students at University of
Palermo (Italy) of the three years of course, accompanied by informed consent. The sample
consists of 493 students who completed the questionnaire, and the average age of the sample
participants is 21.88 years. This study shows that belonging to the female gender, being further
along in the years of study, having a chronic illness and perceiving a low state of health are all
factors that can increase the risk of developing the symptoms of depression; rather, regular
physical activity, friendship and romantic relationships can be considered factors protecting them
from the risk of falling into depression that can undermine both the tudy and work
performance12.

A longitudinal research was conducted in the University of Akdeniz, Turkey aiming to monitor
the students at a nursing faculty in terms of stress and psychological indicators (psychological
distress, depressive symptoms, and anxiety) throughout certain timepoints in their educational
process. The number of students who initially enrolled and were accepted to participate in the
research in the first year was 202. The deterioration in psychological indicators during the
nursing education process showed that there is a need for interventions to reduce stress, anxiety,
and depressive symptoms in nursing students. It would be appropriate to provide one-on-one
counseling services by faculty members and to equip students with effective stress coping
methods. At the same time, peer mentoring by the upper classes can also contribute positively to
the process by experience exchange4.

In Nigeria a cross-sectional study was conducted. The study population consisted of all
undergraduate nursing students currently undergoing training at different levels in the Faculty of
Nursing Sciences. The total population of students in the nursing faculty is 581 (as at 2018/2019
academic session). However, using the Taro Yamane ‘s formula, a total of 237 undergraduate
nursing students were selected from the entire population. The study revealed a high level of
depression among undergraduate nursing students largely resulting from huge academic
workload. It is therefore recommended that the nursing curriculum be designed in a student
friendly manner to ease the burden of students. Also, the leadership of the school should design
programmes that cater for the mental health of students as well as suggested coping strategies
that would enable students scale through in their studies13.
2.2 ANXIETY

2.2.1 DEFINITION OF ANXIETY

The American Psychological Association (APA) describes anxiety as “an emotion characterized
by feelings of tension, worried thoughts, and physical changes like increased blood pressure.” It
can be easier to recognize and treat anxiety disorders if one knows the difference between
normal feelings of anxiety and conditions that call for medical [Link] is a
multifaceted reaction to perceived or actual threats. Changes in cognition, body, and behavior
may be involved14.

The brain releases adrenaline, a hormone and chemical messenger, in response to actual or
imagined danger, which sets off these anxiety-inducing reflexes known as the fight-or-flight
response. This reaction can happen to some people in socially awkward settings or when
significant decisions or events are happening. Sometimes, the length or intensity of anxiety
symptoms can differ significantly from the initial stressor event trigger. It's also possible for
physical symptoms to appear, such nausea and elevated blood pressure. These reactions elevate
anxiety to the level of an anxiety disorder. Anxiety can become disruptive to day-to-day
functioning once it reaches the stage of a disorder14.

2.2.2 TYPES OF ANXIETY

Generalized Anxiety Disorder (GAD): Symptoms (such as weariness and impaired attention)
associated with excessive concern and anxiety about a variety of events or activities that occur
on most days over a minimum of six months15.

Specific Phobia: A pronounced and ongoing fear of things or circumstances that are easily seen
(such as flying, heights, and animals)15.

Post Traumatic Stress Disorder: A terrible incident in which physical injury happened or was
threatened (such as rape, child abuse, war, or natural disaster), might cause flashbacks, persistent
frightening thoughts and memories, rage, or irritation15.

Social Phobia, also known as Social Anxiety Disorder: An immediate anxiety response is almost
always elicited by social or performance situations. This reaction can include palpitations,
tremors, sweating, gastrointestinal discomfort, diarrhoea, muscle tension, blushing, or confusion.
In severe cases, it can even meet the criteria for a panic attack15.

Obsessive-Compulsive Disorder; Obsessions: Persistent, inappropriate, and invasive thoughts,

ideas, impulses, or images that significantly increase worry or suffering are referred to as
obsessions. Obsessive people typically try to resist or dismiss these urges or ideas, or they try to
offset them with compulsive behaviors or other thoughts; Compulsions: repetitive actions (like
washing hands, arranging, or checking) or mental exercises (like counting, praying, or repeating
words) carried out ritualistically or in reaction to an obsession15.

Panic Disorder: Existence of frequent, unprovoked panic attacks, followed by at least a month of
ongoing anxiety about getting attacked again, worrying about the implications of the attack or its
outcomes, or worrying about a notable shift in behavior due to the attacks. Reexperiencing,
avoidance and numbing, and arousal are the three symptom clusters. Agoraphobia is a term used
to describe agoraphobia, which is the fear of or avoidance of locations or circumstances from
which escape could be uncomfortable or difficult, or from which assistance could not be
available in the event of a panic attack or panic-like symptoms. A distinct time of extreme dread
or discomfort is the fundamental component of a panic attack15.

2.2.3 SYMPTOMS OF ANXIETY

Although anxiety disorders can take many different forms, they all have the same primary
symptom: extreme or persistent fear or worry in circumstances where most individuals wouldn't
feel threatened, Depending on the kind of anxiety condition you have, there are different
symptoms16. The following are typical signs of an anxiety disorder:

Physical symptoms: Cold or sweaty hands, dry mouth, heart palpitations, nausea, numbness or
tingling in hands or feet, muscle tension, shortness of breath16.

Mental symptoms: Feeling panic, fear and uneasiness, nightmares, repeated thoughts or
flashbacks of traumatic experiences, uncontrollable obsessive thoughts16.

Behavioural symptoms: Inability to be still and calm, ritualistic behaviors, such as washing
hands repeatedly, trouble sleeping16.
2.2.4 ANXIETY RISK ASSESSMENT

Anxiety is one of the most common mental disorders that is becoming an increasing cause for
concern particularly among nursing students, this is due to the arduous nature of the course.
Numerous academic-associated risk factors make nursing students prone to high levels of
anxiety. The program is designed in such a tedious way, highly demanding with chaotic
schedules that include lecture attendance, assessment submission, oral presentations, practicum,
examinations, and the clinical aspects17. All of which can be quite overwhelming for the students
leading to mental exhaustion and anxiety17. The clinical aspect which has been reported to be
much more stringent than the academic training17 is another major factor that increases the
student anxiety as they are to apply what they have learned in theory in clinical practice. they are
expected to be familiar with medical equipment and face higher pressure because their mistakes
could harm patients18.

The academic level of study is also closely linked with anxiety. Some authors have found out
that with increasing years of study, the levels of anxiety also increase which is mostly due to the
increasing workload and the need to balance clinical work and their academic curriculum
requirements19.

Several demographic risk factors also predispose these nursing students to anxiety such as the
financial status of the family, age with younger people being unable to deal with the
overwhelming workload, and gender as females have been identified as being at a higher risk of
anxiety than males19. Furthermore, some non-traditional students have to manage and balance
nursing school, work, their spouses and children18.

2.2.5 KNOWLEDGE OF OTHER RESEARCH ON ANXIETY

Anxiety has been linked to a lot of adverse health outcomes, reduced quality of life, untimely
death, and a predisposing factor for several comorbidities but still little to no attention has been
paid to deal with this mental disorder19. In students, there has been an association with poor
academic performance, substance abuse, and low self-esteem all of which increases the risk of
failure to complete the program and practice nursing20.
Furthermore, several meta-analyses and systematic review studies have shown that about 32% of
nursing students experience anxiety21. A study done in China revealed an anxiety prevalence of
41.7%22, one of the other studies which found prevalence rates above 40%19. Also, clinical
anxiety has been seen in nursing students due to the fact that their institutions do not help with
the coping mechanism of their students, this is closely related to the fact that they have to stay at
a particular grade point for them to be able to continue in the extremely competitive nursing
curriculum18.

The COVID-19 pandemic has also played a major role in worsening the mental health of the
nursing student population19 as higher anxiety levels have been found among them, especially
during epidemics or pandemics as they thought themselves to be at a higher risk of getting
infected by the patients they care for during these pandemics17. Studies have also shown that
many of the nursing students show more signs of anxiety during these epidemics or pandemics
than the regular nursing clinical care31. The anxiety caused by the clinical care experience for
nursing students not only affects their care of patients negatively but also their training 18.
2.3 STRESS

2.3.1 DEFINITION OF STRESS

Stress is the mental and physical strain brought on by our reaction to external pressure. It is a
particular reaction that the body has to a stimuli that throws off regular operations. Any situation
or trigger that makes someone feel stressed out is referred to as a stressor23.
Stress refers to a dynamic interaction between the individual and the environment. In this
interaction, demands, limitations and opportunities related to work may be perceived as
threatening to surpass the individual’s resources and skills24.
Stress is characterized as a condition of anxiety or tension in the mind brought on by a
challenging circumstance. Stress is a normal human reaction that motivates us to deal with
obstacles and dangers in our lives. Tension, either bodily or emotional, is referred to as stress.
Although stress is a normal response to feeling unprepared for some situations and expectations,
prolonged stress can have negative effects on one's health and general [Link] demands
can originate from a person's job, relationships, finances, or other circumstances; in general,
stress can be brought on by anything that presents a genuine or imagined difficulty or risk to
one's wellbeing25.

2.3.2 TYPES OF STRESS

Broadly, there are four types of stress, which are: Acute Stress, Episodic Acute Stress, Chronic
Stress, and Post Traumatic Stress.

Acute stress is the body’s response to a short-term demand or change. This type of stress can last
anywhere from minutes, hours, days, and even weeks. The duration depends on how long you’re
exposed to an intense situation. Acute stress occurs when we need to fight off danger such as
having a near-fatal experience or completing a marathon.
2.3.3 SYMPTOMS OF STRESS

Physical Symptoms:– Tightened muscles or muscle tension, chest pain or discomfort, trembling
and shakiness, increased heart rate (heart palpitations), sweating more than normal, rapid breaths.

Emotional Symptoms: Anxiousness fearfulness, feeling overwhelmed or helpless; overwhelming

feelings of panic; irritability; restlessness; and/or difficulty concentrating.
Episodic Acute Stress

The body's reaction to a single, isolated stressful incident is known as episodic acute stress.
Events of this nature include accidents involving vehicles and other crises. They could also entail
a risk to one's physical safety. Stress that is time-limited or episodic may be brief or prolonged.
Depending on how you handle it on an emotional level. When your body is constantly subjected
to low-grade demands and threats, it is said to be under chronic stress. This could involve things
like delays or traffic jams, or arguing with a close friend or relative. Trying to make ends meet
while working several jobs can also lead to persistent stress. It's frequently brought on by the
strain you place on yourself to live up to your own standards. One mental health problem is post-
traumatic stress disorder. It is among the riskiest forms of stress. It may appear subsequent to
going through or witnessing terrible experiences. Natural disasters, violent crimes against people,
such as rape and mugging, and war are examples of traumatic occurrences26.

2.3.4 STRESS RISK ASSESSMENT

Nursing students face higher stress levels than students in other areas, and these levels are rising,
according to recent research on stress in healthcare-related fields. Clinical experiences for
student nurses may also have a negative impact on their academic progress, learning objectives,
general health, happiness, and quality of life, as well as their clinical routine and even suicidal
thoughts. A total of eighty thousand individuals try and complete suicide each year. Suicide is
still a perplexing problem despite developments in neuroscience and our understanding of the
pathophysiology of human behavior. Based on scientific research, suicide may be influenced by
the combined effects of heredity, external and endogenous stresses, epigenetic modifications, and
neuromodulators26.

Regarding nursing programs, multiple research findings suggest that students experience stress
related to both clinical and intellectual components of the program. Five key characteristics were
identified as sources of stress in the study by Timmins & Kaliszwer on third-year nursing
students at Trinity College, Dublin. First, stressors that are "academic." Relationships are the
focus of the second and third components; the former is with staff members who are involved in
education, and the latter is with the clinical experience. The final two elements imply that patient
mortality and financial matters are separate sources of stress23.
During their training, nursing students deal with stress at work in addition to stress in the
classroom. Research on stress at work has focused on stressors, or the causes of stress that
interact to cause stress in organizational contexts (Spielberger & Reheiser 2005).
Among the most frequent sources of stress are deadlines, workloads, decision-making, ongoing
changes, and financial errors at work24.

Numerous pressures affect students, including the pressure to perform well academically,
uncertainty about the future, and challenges assimilating into the system. In addition, the children
deal with family, social, emotional, and physical issues that could impair their capacity to study
and do well academically. The stresses associated with nursing education have come to light
more and more in recent years. Students in colleges are particularly vulnerable to stress because
of the transitional nature of college life, especially freshmen23.

2.3.5 KNOWLEDGE OF OTHER RESEARCHERS ON STRESS

After graduating from nursing school and entering the workforce, new nurses seem to be more
susceptible to stress. Stress is one of the most common reasons for nurses to change employment
within the first two years after graduation—34% of them do so(28). Research has also revealed
that occupations like nursing, which demand constant interaction with people, are vulnerable to
stress and burnout even before they start work. Students studying nursing, for instance, face
stresses specific to the nursing curriculum, including clinical training, in addition to standard
college student experiences, like test anxiety, which can lead to increased stress. In addition to
academic pressures, students may experience extreme stress as a result of juggling family,
financial, and other responsibilities. Currently, not much is understood on the relationship
between stress in nursing school and the likelihood of experiencing stress at work. Gaining
insight into how students cope with stress may enhance new nurses' performance and well-being,
which in turn may benefit patients' health28.

As to the National League for Nursing's annual Survey of Schools of Nursing (2012), basic
registered nurse (RN) programs enrol 29% of students in 2009, 27% of students in 2010, and
24% of students in 2011. Lo (2002) looked at 101 nursing students at the Athens Medical
School's perception and sources of stress, coping strategies, and self-esteem. Questionnaires were
used to gather data during class periods. According to the study's findings, nursing studies rank
first among stressors, followed by money troubles 61 (60%), lack of time for friends and family
49 (48.51%), and health concerns 37 (36.63%). The majority of students stated that problem-
focused coping, which includes social support, problem-solving, and recreation/sports, was how
they decompressed. Of the pupils, 73 (72.27%) had help from friends and family, whereas 4
(3.96%) had none at all29.

In the 18–19 age bracket comprised 46% of the individuals. Three percent of the individuals
were under the age of eighteen, another 19% were between the ages of nineteen and twenty, and
32% were over the age of twenty. The responders were all female. 97% of participants reported
moderate stress, while 3% reported severe stress, according to study [Link] examining the
main variables that were creating stress in the students, the results show that environmental
factors contributed the most to stress (40%) followed by intrapersonal factors (30%). Academic
elements contributed 19%, while interpersonal factors contributed the least, at 11%.As the
specific stressors are examined, "change in living environment" and "inadequate telephone
facilities" were the two factors which were perceived as stressor by all the subjects 23.

A quantitative investigation of nursing students at universities. Medical students in the Eastern

region of Nigeria are shown to be, however not significantly, more nervous and depressed than
nursing students, with 52.6% of nursing students reporting high levels of stress. nursing students
report higher levels of stress than medical students, with 47.4% reporting low levels. Likewise, a
student-organized study. The undergraduate nursing students in the Southwest had varying levels
of stress, depression, and anxiety based on their age and gender. Consequently, data from Nigeria
indicates that nursing students reported mild medical conditions, and that in order to maintain
their mental health, nursing students should be taught mild (50.2%), moderate (33.7%), and
severe (16.1%) coping mechanisms30.
 CHAPTER THREE

3.0 METHODOLOGY

3.1 STUDY AREA

This study will be carried out in Babcock University, a private tertiary institution owned and
managed by the Seventh-Day Adventist Church located in Ilishan-Remo, in the Southwest of
Nigeria in the Ikenne Local government Area of Ogun State. The university was initially
established as the Adventist College of West Africa(ACWA) in 1959 but was officially
inaugurated as Babcock University in 1999.

The university has 8 schools and 2 colleges which offer both undergraduate and post graduate
programs : the Veronica Adeleke School of Social Sciences, the Benjamin S. Carson Senior
College of Health and Medical Sciences, the school of Computing and Engineering Sciences,
the School of Education and Humanities, the School of Law and Security Studies, the School of
Public and Nursing Sciences, the School of Postgraduate studies. There are about 13,000
students enrolled in the University. The school of nursing was initially a department under the
faculty of science and technology but has now become a school of its own with about 35 faculty
and staff members and over 500 students.

3.2 STUDY DESIGN

This is a descriptive cross-sectional study that will be conducted to assess the prevalence of
depression, anxiety and stress among nursing students.

3.3 STUDY POPULATION

The undergraduate nursing students of Babcock University in Ogun State, Nigeria will
participate in this study.

3.3.1 INCLUSION CRITERIA

a. Nursing students who are at least 18 years of age

3.3.2 EXCLUSION CCRITERIA

a. Students who are ill at the time of the study.

3.4 SAMPLE SIZE CALCULATION

This will be calculated using the Cochran`s method, the formula for this method is

2
z pq
n= 2
d

Where,

n= the minimum sample size

Z= standard normal deviate set 1.96, which corresponds to a 95% confidence level

P= the expected prevalence

q= 1-p

d= error margin which is set at 0.05

P=0.747 according to a study conducted among nursing students in the Gauteng Province of
South Africa.

q= 0.253

2
1.96 x 0.747 x 0.253
n= 2
0.05

3.8416 x 0.747 x 0.253

n=
0.0025

n=290

Considering non-response factor which is 10% of sample size, it then becomes 290/0.9= 322
n= 322

3.5 SAMPLING TECHNIQUE

The multi-stage sampling technique will be used to select the participants.

Stage 1: the study population will be divided into groups based on their levels using the stratified
sampling technique.

100 Level: 150

200 Level: 170

300 Level: 152

400 Level: 170

500 Level: 147

Stage 2: the number of study participants from each level will then be gotten using the
proportionate sampling method with the formula:

(class size)/(population size) x sample size

100 Level = 150/789 x 322= 61

200 Level = 170/789 x 322= 69

300 Level =152/789 x 322 = 62

400 Level= 170/789 x 322 = 69

500 Level =147/789 x 322 = 60

Stage 3: the study participants from each level will be selected by simple random sampling.
3.6 STUDY INSTRUMENTS/ QUESTIONNAIRE

The DASS questionnaire was developed by Lovibond and Lovibond to assess the key symptoms
of depression, anxiety and stress and it has also been used to evaluate patient reaction to
treatment. The questionnaire has been proven to have adequate psychometric properties and is
equivalent to other accurate scales.

The Depression, Anxiety, Stress Scale -21(DASS-21) questionnaire is a standardized tool that
comprises 3 sections designed to measure the emotional states of depression, anxiety and stress.
The 21 items on the questionnaire comprise a set of 3 self-reported scales designed to assess
DASS, the 7 elements on the scales are graded on a Likert scale from 0 to 3

(0: “Did not apply to me at all”, 1: “Applied to me to some degree or some of the time”, 2:
“Applied to me to a considerable degree or a good part of the time”, and 3: “Applied to me very
much or most of the time”).

The depression scale assesses dysphoria, hopelessness, devaluation of life, lack of

interest/involvement, lack of pleasure and inertia.

The anxiety scale assesses autonomic arousal, skeletal muscle effects, situational anxiety, and
subjective experience of anxious affect.

The stress scale is sensitive to levels of chronic non-Specific arousal. It assesses difficulty
relaxing, nervous arousal, and being easily upset / agitated, irritable /Over-reactive and
impatient.

Scores for Depression, anxiety and stress are measured by summarising the scores of the related
items. Because the DASS-21, is a shorter version of the 42 item original DASS, the score for
each subscale must be multiplied by 2 to calculate the final score. The result ratings then are
classified as: “ normal, mild, moderate, severe, or extremely severe”.

Recommended cut-off scores for conventional severity labels (normal, mild, moderate, severe,
extremely) are as follows:
NB Scores on the DASS-21 will need to be multiplied by 2 to calculate the final score.

Depression Anxiety Stress

Normal 0-9 0-7 0-14

Mild 10-13 8-9 15-18

Moderate 14-20 10-14 19-25

Severe 21-27 15-19 26-33

Extremely Severe 28+ 20+ 34+

3.7 DATA COLLECTION

The data collection will be carried out using a structured self-administered questionnaire.
Questionnaires will be disseminated by the members of this research group.

3.8 DATA ANALYSIS

The data collected from the questionnaires will be inputed into the Statistical Package for Social
Sciences(SPSS) version 25. Frequency and percentages will be used to analyze descriptive
statistics such as stress, depression and anxiety while chi-square will be used to analyze
categorical variables such as gender, age, marital status and level of study. P<0.05 will be
statistically significant.

3.9 ETHICAL CONSIDERATION

Approval will be sought from the Babcock University Health Research Ethics
Committee(BUHREC). Informed consent will also be obtained from each participant, where they
will be assured of the confidentiality and told of the importance of this research. They will be
free to withdraw from this study at any time if they wish to do so.

3.10 LIMITATION
The anticipated limitation of this study may be the reluctance of the students to participate. This
will be handled by encouraging and telling them the importance of this study.
APPENDIX 1

INFORMED CONSENT FORM

Please read this document properly before you decide to participate in this study.

We are 600 level Medical Students from the Department of Community Medicine, Babcock

University, Ilishan-Remo, Ogun State.

The title of this research is DEPRESSION, ANXIETY AND STRESS ASSESSMENT

AMONG NURSING STUDENTS IN BABCOCK UNIVERSITY.

You will be expected to fill a questionnaire. Be informed that the time you will spend in

participating in this study will only be about 5-10 minutes.

Participation in this study has no risks, the potential benefit is to assess depression, anxiety and

stress among nursing students in Babcock University.

Please bear with us that no incentive or compensation will be given for participating in this

study.

Refusal to participate in this study will not attract any form of penalty. This also applies if you

decide to discontinue participating in the study after you have started.

Please note that your identity will be kept confidential. Any information given will be assigned a

code number which will be kept confidential, when this study is completed and the data has been

analyzed, your response sheet will be destroyed. Your name will not be used in any report or

publication and your participation is completely voluntary. Also note that there is no conflict of

interest in this study.

If you have any questions about this study, please feel free to contact

Name: Idowu Moyinoluwa

Department: Medicine & Surgery

Phone Number: 09058656488

Email address: moyinoluwa640@[Link]

If you wish to participate in this study, please sign in the space provided below.

Your signature will indicate a willingness to participate.

Participant`s initials (in capitals)

Signature

Date
APPENDIX 2

QUESTIONNAIRE ON DEPRESSION, ANXIETY AND STRESS ASSESSMENT

AMONG NURSING STUDENTS IN BABCOCK UNIVERSITY

Dear respondent, we are 600 level students studying Medicine & Surgery in Babcock University.

We are conducting a research on Depression, Anxiety and Stress assessment among nursing

students in Babcock University. Kindly provide responses as instructed in all the sections.

SECTION A: Socio-demographic Information

Fill in answers in the spaces provided. Circle the appropriate answers.

1. Age _____________________ (in years)

2. Sex (i) Male (ii) Female

3. Marital status (i) Single (ii) Married (iii) Co-habitation (iv) Others[specify] _________

4. Level of study (i) 100 (ii)200 (iii)300 (iv) 400 (v)500

5. Nationality (i) Nigerian (ii) Non- Nigerian

6. Religion (i) Christianity (ii) Islam (iii) Traditional (iv) Others[specify] _____________

7. Ethnic group (i) Yoruba (ii) Hausa (iii) Igbo (iv)Others[specify] _______________

Please read each statement and circle a number 0,1,2 or 3 which indicates how much the

statement applied to you over the past week. The rating scale is as follows:

0: did not apply to me at all

1: applied to me to some degree, or some of the time

2: applied to me to a considerate degree or a good part of time

3: applied to me very much or most of the time

SECTION B: ASSSESSMENT OF DEPRESSION

8. I could not seem to experience any positive feeling at all (a)0 (b)1 (c)2 (d)3

9. I found it difficult to work up the initiative to do things (a)0 (b)1 (c)2 (d)3

10. I felt that I had nothing to look forward too (a)0 (b)1 (c)2 (d)3

11. I felt downhearted and blue (a)0 (b)1 (c)2 (d)3

12. I was unable to become enthusiastic about anything (a)0 (b)1 (c)2 (d)3

13. I felt I was not worth much as a person (a)0 (b)1 (c)2 (d)3

14. I felt that life was meaningless (a)0 (b)1 (c)2 (d)3

SECTION C: ASSESSMENT OF ANXIETY

15. I was aware of dryness of my mouth (a)0 (b)1 (c)2 (d)3

16. I experienced breathing difficulty e.g excessively rapid breathing, breathlessness in

the absence of physical exertion (a)0 (b)1 (c)2 (d)3

17. I experienced trembling e.g in the hands (a)0 (b)1 (c)2 (d)3

18. I was worried about situations in which I might panic and make a fool of myself (a)0

(b)1 (c)2 (d)3

19. I felt I was close to panic (a)0 (b)1 (c)2 (d)3

20. I was aware of the action of my heart in the absence of physical exertion e.g sense of

heart rate increase, heart missing a beat. (a)0 (b)1 (c)2 (d)3

21. I felt scared without any good reason (a)0 (b)1 (c)2 (d)3

SECTION D: ASSESSMENT OF STRESS

22. I found it hard to wind down (a)0 (b)1 (c)2 (d)3

23. I tended to over-react to situations (a)0 (b)1 (c)2 (d)3

24. I felt that I was using a lot of nervous energy (a)0 (b)1 (c)2 (d)3

25. I found myself getting agitated (a)0 (b)1 (c)2 (d)3

26. I found it difficult to relax (a)0 (b)1 (c)2 (d)3

27. I was intolerant of anything that kept me from getting on with what I was doing (a)0

(b)1 (c)2 (d)3

28. I felt that I was rather touchy (a)0 (b)1 (c)2 (d)3
References

[Link]-Israel NA, Akinboye DO. Prevalence and Comorbidity of Depression and Anxiety among
Medical Students in Babcock University, Ogun State, Nigeria. Asian Journal of Medicine and
Health. 2021 May 24;46–55.

[Link] WM, Shapiro C. Stress, Depression, and Anxiety among Undergraduate Nursing
Students. International Journal of Nursing Education Scholarship. 2013 Jan 7;10(1):255–66.

[Link] YJ, Lo KKH, Ho RCM, Tam WSW. Prevalence of depression among nursing students: A
systematic review and meta-analysis. Nurse Education Today [Internet]. 2018 Apr;63:119–29.
Available from: [Link]

[Link], Y., Akdemir, M., Meydanlioglu, A., & Aktekin, M. R. (2023, February 21).
Psychological Distress, Depression, and Anxiety in Nursing Students: A Longitudinal Study.
Healthcare, 11(5), 636. [Link]

[Link] Library of Medicine. (2018, April 8). Medlineplus. Retrieved April 12, 2024, from
[Link]

[Link] Health organization. (2023, March 31). [Link]. Retrieved April 12, 2024,
from [Link]

[Link] Institute of Mental Health. (2024, March). [Link]. Retrieved April 12,
2024, from [Link]

[Link] prevalence in nursing students. (2023, October 13). Nurselabs. Retrieved April 12,
2024, from [Link]

[Link] and Factors Associated with Depression among Nursing Students. (2019, May).
International Journal of Science and Research, 8(5), 2 & 3.
[Link]

[Link], T., Mbanga, C., Mouemba, D., Makebe, H., Toukam, L., Kika, B., & Mulango, I.
(2020, April 17). Determinants of depression among nursing students in Cameroon: a cross-
sectional analysis. BMC Nursing, 19(1). [Link]
[Link] Diaz-Godiño, Luz Fernández-Henriquez, Florencia Peña-Pastor, Patricia Alfaro-
Flores, Gloria Manrique-Borjas, Frank Mayta-Tovalino, "Lifestyles, Depression, Anxiety, and
Stress as Risk Factors in Nursing Apprentices: A Logistic Regression Analysis of 1193 Students
in Lima, Peru", Journal of Environmental and Public Health, vol. 2019, Article ID 7395784, 7
pages, 2019. [Link]

[Link], O. E., Provenzano, S., Giordano, D., Alagna, E., Armetta, F., Gliubizzi, C.,
Terranova, A., D’Anna, G., Barresi, D., Grigis, D., Genovese, C., Squeri, R., & Firenze, A.
(2019, November 4). Nursing students and depressive symptomatology: an observational study
in University of Palermo. Mental Illness, 11(2), 25–31. [Link]
0006

[Link], P. P., & Omu, R. E. (2021, June 1). Prevalence rate of Depression among
Undergraduate Nursing Students of a Nigerian University. Ibadan Journal of Sociology, 12(1).
[Link]

[Link] A. Anxiety: Overview, symptoms, causes, and Treatments [Internet]. Medical News
Today. 2020. Available from: [Link]

15.A Report on Mental Illnesses in Canada A Report on Mental Illnesses in Canada A Report on
Mental Illnesses in Canada A Report on Mental Illnesses in Canada 4 4 4 A A A ANXIETY
NXIETY NXIETY NXIETY D D D DISORDERS ISORDERS ISORDERS ISORDERS
[Internet]. Available from: [Link]

[Link] Clinic. Anxiety Disorders [Internet]. Cleveland Clinic. Cleveland Clinic; 2020.
Available from: [Link]

[Link]-Zafra MD, Fernández-Muñoz JJ, Fernández-Martínez E, García-Sánchez FJ, Abreu-

Sánchez A, Parra-Fernández ML. Anxiety, perceived stress and coping strategies in nursing
students: a cross-sectional, correlational, descriptive study. BMC Med Educ. 2020
Dec;20(1):370.

[Link] FA, Alrashidi N, Mohamed RA, Asiri A, Al Ali A, Aly KH, et al. Satisfaction and
anxiety level during clinical training among nursing students. BMC Nurs. 2023 Jun 3;22(1):187.
[Link] M, Ntuli ST, Mokwena K, Maaga K. Prevalence and Risk Factors for Anxiety
Symptoms among Student Nurses in Gauteng Province of South Africa. Behav Sci. 2023 Jul
28;13(8):630.

[Link] Khaira M, Raja Gopal RL, Mohamed Saini S, Md Isa Z. Interventional Strategies to
Reduce Test Anxiety among Nursing Students: A Systematic Review. Int J Environ Res Public
Health. 2023 Jan 10;20(2):1233.

[Link] SB, Yesil Demirci P, Eskimez Z. The role of intolerance of uncertainty and anxiety
sensitivity on nursing students’ depression, anxiety, and stress levels. Nurse Educ Pract. 2022
Nov;65:103487.

[Link] C, Saikia H, Gupta K, Ohri P. Prevalence and correlates of Depression, Anxiety and
Stress among Nursing Students. Indian J Community Health. 2022 Jun 30;34(2):259–64.

23. Sharma, N., & Kaur, A. (2011, January). Factors associated with stress among nursing
students. Nursing & Midwifery Research Journal, 7(1), 12–21.
[Link]
24. Pulido‐Martos, M., Augusto‐Landa, J., & Lopez‐Zafra, E. (2011, September 5). Sources of
stress in nursing students: a systematic review of quantitative studies. International Nursing
Review, 59(1), 15–25. [Link]

25. Sushmitha, S., J., S., & Mathias, T. (2023, August 15). Stress, a Great Impact on Mental
Health. Asian Journal of Nursing Education and Research, 232–237.
[Link]
26. Reinfeld, J. (2024, February 7). Types of Stress That Impact Mental &#038; Physical Health.
Mantra Care. [Link]
27. Zheng, Y. X., Jiao, J. R., & Hao, W. N. (2022, August 5). Prevalence of stress among nursing
students: A protocol for systematic review and meta-analysis. Medicine, 101(31), e29293.
[Link]
28. Olvera Alvarez, H. A., Provencio-Vasquez, E., Slavich, G. M., Laurent, J. G. C., Browning,
M., McKee-Lopez, G., Robbins, L., & Spengler, J. D. (2019, August 8). Stress and Health in
Nursing Students. Nursing Research, 68(6), 453–463.
[Link]

29. Vyas, D. Y. (2020, December 1). LEVEL OF STRESS AMONG THE 1ST YEAR [Link]
NURSING STUDENTS. INTERNATIONAL JOURNAL OF SCIENTIFIC RESEARCH, 72–
73. [Link]

30. Olabisi, O., Bolaji, A., & Azeez, F. (2022, June 3). A comparative study on stress, anxiety,
and depression amongst medical and nursing students in a Nigerian private university. Tropical
Journal of Health Sciences, 29(1), 12–16. [Link]

31. Araújo AAC, De Godoy S, Ventura CAA, Silva ÍR, De Almeida EWS, Mendes IAC.
Reflections on nursing students’ fear and anxiety arising from clinical practicums. Investigación
Y Educación En Enfermería [Internet]. 2022 Nov 12;40(3).
32. Cheung T, Wong S, Wong K, Law L, Ng K, Tong M, et al. Depression, Anxiety and
Symptoms of Stress among Baccalaureate Nursing Students in Hong Kong: A Cross-Sectional
Study. International Journal of Environmental Research and Public Health [Internet]. 2016 Aug
3;13(8):779. Available from: [Link]

33. Depression, Anxiety and Stress among Undergraduate Nursing Students in a Public
University in Sri Lanka. DOAJ (DOAJ: Directory of Open Access Journals) [Internet]. 2016 Jan
1; Available from: [Link]

34. Labrague LJ, McEnroe-Petitte DM, Papathanasiou IV, Ançel G, Fronda DC. A literature
review on stress and coping mechanisms in nursing students. J Nurs Educ Pract. 2017;7(5):99-
107.

35. Shdaifat EA, Jamama AA. Stress and coping strategies among nursing students. Int J Adv
Nurs Stud. 2018;7(1):8-15.

36. Alzayyat A, Al-Gamal E. A review of the literature regarding stress among nursing students
during their clinical education. Int Nurs Rev. 2014;61(3):406-15.

37. Moscaritolo LM. Interventional strategies to decrease nursing student anxiety in the clinical
learning environment. J Nurs Educ. 2009;48(1):17-23.
38. Reeve KL, Shumaker CJ, Yearwood EL, Crowell NA, Riley JB. Perceived stress and social
support in undergraduate nursing students’ educational experiences. Nurse Educ Today.
2013;33(4):419-24.

39. Adebayo SO, Ayeni OO. Faith-based approaches to education: Examining stress
management among Nigerian university students. Afr J Psychol. 2020;8(2):55-67.

40. Olagunju AT, Owoeye AO, Durodola AO. Mental health research in Nigeria: A scoping
review of findings, challenges, and gaps. Afr J Psychiatry. 2019;22(1):15-25.