South African nursing students' stress and resilience during the global COVID-19 health crisis

Abstract

The study aimed to investigate nursing students' psychological distress and their response to stress during the COVID-19 pandemic. Participants were 370 South African nursing students (female= 75%; mean age= 21.9 years, SD = 3.9 years). Students completed the following scales: Compassion Satisfaction and Fatigue, Kessler Psychological Distress, and Response to Stressful Experiences. Findings from the descriptive statistics and inferential statistical analyses indicated that students meeting the criteria for being well were likely to have higher resilience scores. Protective factors such as self-efficacy, active coping, and spirituality suggest higher resilience during COVID-19-related stressful events. Physiological factors such as self-reported medical conditions and lack of sleep were associated with poorer mental well-being. These findings provide a profile of nursing students' coping and adaptation to a community-spread pandemic. From these findings, nursing schools could manage students' well-being by providing needed resources in their current and future work health support programmes.

Keywords:

• pandemic challenges
• coping mechanisms
• mental health
• educational disruption

Introduction

Globally, the COVID-19 pandemic crisis put health services under strain (Aslan & Pekince, 2021; Chipps et al., 2022), including the training of health professionals managing new or unprecedented work-related stressors (Chipps et al., 2022; Filip et al., 2022; Mbunge, 2020). These included overcrowded hospitals (Bekker & Ntusi, 2021) and depleting supplies of personal protective equipment (PPE) (Chersich et al., 2020; Mbunge, 2020). Those health professionals undergoing training would be most vulnerable to the pandemic stressors as they are new to the work setting. In South Africa, after an initial removal from clinical facilities, nursing students returned to practice and needed to rely on their previous infectious disease training while balancing the demands of a stressed-out healthcare system with their academic goals (Aslan & Pekince, 2021; Chipps et al., 2022; Steenkamp & Chipps, 2023; Ulenaers et al., 2021). Few studies examined how South African nursing students managed their health and well-being during the pandemic.

Nursing students' vulnerabilities to the pandemic

During the pandemic, nursing students needed to confront a variety of difficulties, including academic pressure, fear of contracting the virus, seeing patients suffer, abrupt shifts to online learning, and disruptions in clinical placements (Aslan & Pekince, 2021; Chipps et al., 2022; Eloff, 2021; Jarvis et al., 2021; Manana et al., 2023; Nyar, 2021; Steenkamp & Chipps, 2023), worries about their safety and health, and having to conform to quickly evolving healthcare standards (Aslan & Pekince, 2021; Chipps et al., 2022; Savitsky et al., 2020; Ulenaers et al., 2021).

The pandemic contributed significantly to mental health distress among nursing staff (Li et al., 2020; Manana et al., 2023; Mbunge, 2020). Studies support this by reporting a significant increase in stress and anxiety levels among nursing students due to the pandemic (Kuru Alici & Öztürk Çopur, 2023; Manana et al., 2023; Savitsky et al., 2020; Steenkamp & Chipps, 2023; Visser & Law-van Wyk, 2021), explicitly risking mental health (Aslan & Pekince, 2021; Manana et al., 2023; Steenkamp & Chipps, 2023; Ulenaers et al., 2021; Visser & Law-van Wyk, 2021), vulnerability to burnout and compassion fatigue, and poor patient outcomes (Merino-Godoy et al., 2022; Schwartz et al., 2021). During the pandemic, nurses internationally adopted a variety of coping techniques, such as practising self-care, including mindfulness exercises, breathing exercises, and relaxation (Li et al., 2023), maintaining a healthy balance between work and personal life (Ching et al., 2020), and seeking out emotional support from friends, family, and educators (Ching et al., 2020). However, how nursing students managed their work well-being during the pandemic is less well-known.

Nurse training in South Africa

In South Africa, the nursing profession is regulated by the South African Nursing Council (SANC). To become registered as a professional Nurse and Midwife, student nurses need to complete an undergraduate programme offered over four years. This programme offers intense training at accredited higher education institutions, combining structured theoretical and clinical learning (Langtree et al., 2018; 1.1anana et al., 2023). Even without considering a pandemic, demands on students are considerable, risking their health and well-being (Dlamini & Visser, 2017; Engelbrecht, 2022; Van der Colff & Rathmann, 2014). Academic workload, long work hours, and exposure to a range of clinical disciplines add to the significant demands placed on nursing students (Eloff & Graham, 2020; Engelbrecht, 2022; Langtree et al., 2018; Manana et al., 2023; Naidoo et al., 2014). In addition, in South Africa, students studying at higher education institutions frequently face stressors related to financial limitations (Mason, 2017; Naidoo et al., 2014; Suliman et al., 2009; Visser & Law-van Wyk, 2021).

Compared to nurses in other countries, South African nurses are reportedly more likely to experience burnout due to the exceptionally stressful nature of their work situations (Gibson, 2004; Khamisa et al., 2015). Inadequate staffing and the lack of essential resources, such as treatment equipment, pharmaceuticals, and examination facilities, pose a threat to patient care, resulting in a negative effect on job satisfaction (Bvumbwe & Mtshali, 2018; Dlamini & Visser, 2017; Khamisa et al., 2015; Manana et al., 2023). Nurses are exposed to dangerous scenarios during their commutes and while on duty due to workplace security threats involving occurrences of violence and crime (Khamisa et al., 2015; Manana et al., 2023; Tshitangano, 2013). This exposure contributes to stress, leading to burnout (Dlamini & Visser, 2017; Khamisa et al., 2015; Manana et al., 2023; Tshitangano, 2013).

Amid the challenges faced by nursing students in South Africa, the pandemic introduced an additional burden on their well-being (Eloff, 2021; Jarvis et al., 2021; Manana et al., 2023; Steenkamp & Chipps, 2023). The current education system was disrupted, leading to adjustments in learning formats, increased academic workload, and a shift to virtual platforms (Chipps et al., 2022; Eloff, 2021; Engelbrecht, 2022; Manana et al., 2023; Visser & Law-van Wyk, 2021). The pandemic also increased students' financial and socioeconomic hardship (Nyar, 2021). Research among higher education students in South Africa found a significant incidence of anxiety and elevated levels of depression as they faced the difficulties presented by the pandemic (Eloff, 2021; Manana et al., 2023; Visser & Law-van Wyk, 2021). Nursing students had to deal with the inherent stresses of their academic and clinical training and the unexpected challenges posed by the pandemic (Eloff & Graham, 2020; Nyar, 2021). Conceivably, nursing students would be at high risk of burnout or emotional tiredness, alienation, and decreased personal success (Manana et al., 2023; Nyar, 2021; Sveinsdóttir et al., 2021).

Goal of the study

This study aimed to investigate the psychological distress, burnout, and resilience of nursing students in South Africa during the pandemic. Our specific research questions were:

1. What was the level of psychological distress among nursing students working during the COVID-19 pandemic?

2. What was the professional quality of life (burnout, secondary trauma, and compassion fatigue) of nursing students working during the COVID-19 pandemic?

3. What was the association between resilience and well-being in student nurses during the COVID-19 pandemic?

Findings would be important to nursing schools' preparedness to work with the wellness needs of nursing students and to build an environment that promotes resilience and improves overall well-being among nursing students in pandemic situations.

Method

Participants and setting

The study sample comprised 370 nursing students (Year 1 [n = 252] and Year 2 [n = 307]) from a university in the Western Cape, South Africa. The average age of the participants was 21.9 years (± 3.9, range 18 to 43 years), and most of the participants were female (294 [79.5%]), with 160 (43.2%) in the first year and 204 (55.1%) in the second year. Only 28 (7.6%) of the participants indicated that they were living alone. The remainder reported living with family, friends, or roommates (188 [50.8%]) and in university residences (145 [39.2%]). Only 33 (8.9%) participants indicated that they had a known medical condition. The average hours of sleep reported by the participants were 7.12 (±1.4), ranging from 3 to 12 hours per night. Only 28 (7.6%) of the participants reported a previous COVID-19 test, 10 (2.9%) reported a positive COVID-19 test, and only 14 (3.8%) had contacted support structures during the pandemic (Table 1.)

Table 1. Demographics and COVID-19 fear risk factors

Measures

The study used three validated scales: the Compassion Satisfaction and Fatigue Scale (Stamm, 2010), the Kessler Psychological Distress Scale (Kessler et al., 2002), and the Response to Stressful Experiences Scale (Johnson et al., 2011). In addition, demographic information and information on self-reported medical conditions, hours of sleep, and COVID-19 testing were collected.

Compassion Satisfaction and Fatigue Scale

The Compassion Satisfaction and Fatigue Scale is a 30-item self-report scale. The scale assesses two components, positive (compassion satisfaction) and negative (compassion fatigue), during the past four weeks. Compassion fatigue is divided into two categories: burnout and the negative effects of secondary trauma stress. The scale uses a 5-point Likert scale ranging from 1 = never, to 5 = very often. Example items include: “I am happy”; “I feel connected with others”; and “My work makes me feel satisfied”. In the present study, scores from the subscales showed good reliability [alpha = 0.83 (compassion satisfaction), alpha = 0.66 (burnout), alpha = 0.84 (secondary traumatic stress)].

Kessler Psychological Distress Scale

This is a 10-item scale measuring psychological distress, asking participants how frequently they experienced symptoms of psychological distress during the past 30 days. Items are scored on a 5-point Likert scale ranging from 1 = none of the time, to 5 = all of the time. Example items include: “In the last 30 days, how often did you feel tired for no reason?”; “Hopeless”; and “So restless you could not sit still”. The total scores range from 10 to 50, with low scores indicating low levels of psychological distress and high scores indicating high levels of psychological distress. In the present study, scores from this scale achieved high reliability (alpha = 0.89).

Response to Stressful Experiences Scale

The scale has 22 items measuring resilient coping activities using a 5-point Likert scale ranging from 0 = not at all like me, to 4 = exactly like me. Higher scores indicate more resilient responses to stressful events. Example items include: “During and after most stressful events, I tend to”; “Take action to fix things”; “Face my fears”; and “Expect that I can handle it”. In the present study, scores from this scale showed very good internal consistency (alpha = 0.86).

Procedure

Ethics approval was obtained from the university ethics committee (HS20/10/17). The university registrar and the nursing school director granted permission to conduct the study. Participants were informed of the study’s purpose, voluntary nature, and data privacy. Participants provided with written informed consent forms. The survey was conducted in February and March 2021, before the return of first- and second-year nursing students to clinical practice to complete their clinical practical requirements.

Data analysis

Data were captured and analysed in SPSS v28.0. Descriptive statistics were calculated to describe the level of psychological distress, burnout, compassion, secondary trauma, and response to stress. For the analysis, the Kessler Psychological Distress Scale items were summed out of 50 and classified as follows: < 20 = likely to be well, 20–24 = likely to have a mild, 25–29 = likely to have moderate, and ≥ 30 = likely to have severe psychological distress (Kessler et al., 2002). For the Compassion Satisfaction and Fatigue Scale, low, moderate, or high levels of satisfaction, burnout, and secondary traumatic stress were, calculated out of 50, with scores of ≤ 22 indicating low levels, scores 23–41 moderate levels, and > 41 high levels of stress (Stamm, 2010). For the Response to Stressful Experiences Scale, a score of 71 to 88 indicated having high resilience, 50 to 70 moderate resilience, and < 49 low resilience (Johnson et al., 2011). Kruskal-Wallis and Mann-Whitney U Independent Samples Tests were calculated to determine associations between demographic variables for the Compassion Satisfaction and Fatigue, Kessler-10, and Response to Stressful Experiences Scales items classifications, domains, and scores. The relationships between the scales were investigated using the Pearson’s product-moment correlation coefficient.

Results

Psychological distress, burnout, and secondary traumatic stress

There were moderate to low correlations between burnout and secondary traumatic stress (r = 0.578, p < 0.001) and burnout and psychological distress (r = 0.312, p < 0.001), with low and moderate psychological distress and secondary trauma associated with high levels of burnout. (Table 2).

Table 2. Mean, standard deviations, and Pearson Product-Moment correlations between scales

Note. **p < 0.001

The overall score for psychological distress was 19.38 (±7.12)/50, with over half of the participants scoring < 20, i.e., likely to be well (207, 55.9%), and nearly a quarter (75, 20.3%) meeting the criteria for mild psychological distress. Only 38 (10.3%) and 37 (10.00/o) met the criteria for moderate and severe psychological distress, respectively (Table 3).

Table 3. Kessler Psychological Distress Scale categories (n = 357)

The most common feeling reported was feeling nervous during the last 30 days (2.55 ±1.04), followed by feeling tired for no reason (2.49 ± 1.16). These two items were rated significantly higher than feeling worthless (1.55, ± 0.90) and so restless that they could not sit still (1.47, ± 0.85) (Table 4).

Table 4. Results of the Kessler Psychological Distress Scale item mean scores (n = 357)

Participants with self-reported medical conditions scored significantly higher in levels of psychological distress than those without any medical condition (23.69 ± 7.35 vs 18.95 ± 6.99 respectively, U = 3.70, p < 0.001). Similarly, participants with ≤ 7 hours of sleep reported comparatively higher levels of psychological distress than participants with ≥ 7 hours of sleep at night (20.72 ± 7.75 vs 18.72 ± 6.69 respectively, K = 7.78, p = 0.020).

Burnout and secondary traumatic stress

Burnout and Secondary Traumatic Stress are subscales of the Compassion Satisfaction and Fatigue Scale. The participants' score for burnout was 21.97/50 (± 5.40, range 10 to 41), with scores below 23 reflecting a positive feeling about the capability to perform effectively in one's job. No participants met the criteria for high levels of burnout, with nearly half 161 (43.5%) of the participants meeting the criteria for low burnout, and 146 (39.5%) for moderate levels of burnout (Table 4). Similarly, the participants' score for secondary traumatic stress was 23.91/50 (± 7.43, range 10 to 50), with higher scores (> 41) indicating feelings of fear towards or withing the work environment. Moderate secondary traumatic stress was reported by 157 (42.4%) participants, with 141 (38.1%) meeting the criteria for low secondary traumatic stress. (Table 5).

Table 5. Burnout, and secondary traumatic stress categories

Female participants had significantly lower burnout scores than male participants (21.61 ± 5.39 vs 23.31 ± 5.13, U = −2.50, p = 0.012). Year 2 participants had higher burnout scores than Year 1 participants, though not significant (22.44 ± 5.62 vs 21.33 ± 4.99, U = 1.62, p = 0.150), but had significantly higher secondary traumatic stress scores (24.76 ± 7.34 vs 22.89 ± 7.64, U = 2.43, p = 0.015). Participants with a known medical condition reported significantly higher burnout scores than those with no medical condition (23.68 ± 4.93 vs 21.77 ± 5.44, U = 2.03, p = 0.043).

Compassion and resilience

Compassion and resilience among the participants were measured using the Compassion Satisfaction subscale from the Compassion Satisfaction and Fatigue Scale. The participants reported moderate to high compassion satisfaction scores (41.01/50, ±5.89, range 21-50), with a score > 42 indicating positive feelings towards satisfaction relating to the ability to be an effective caregiver in the workplace, with 144 (38.9%) reporting high and 148 (40.00/o) moderate compassion satisfaction scores (Table 6).

Table 6. Compassion Satisfaction categories (n = 293)

Resilience and response to stressful situations

The participants had a high response to stress scores (71.71/88, ± 11.31) and over half of the participants met the criteria for high resilience 179 (56.11%), followed by 127 (39.81%) for moderate resilience, and only 13 (4.08%) met criteria for low resilience (Table 7).

Table 7. Response to Stressful Experiences Scale categories (n = 319)

Year 1 participants had significantly lower resilience scores (within the moderate range) than Year 2 participants, with scores in the high resilience range (70.01 ± 11.74 vs 73.17 ± 10.62, U = 2.24, p = 0.025 respectively). Participants who reported a known medical condition had lower resilience scores than those without any medical conditions (67.27 ± 12.91 vs 72.23 ± 11.04, U = −2.13, p = 0.033).

In analysing the different strategies used to respond to stress, spirituality was rated the highest (3.36/4, ± 0.88), followed by self-efficacy (3.34/4, ± 0.64), meaning-making (3.26/4, ± 0.56), active coping (3.24/4, ± 0.66), and cognitive flexibility (3.05/4, ± 0.92), with no significant differences between these strategies. However, there were significant differences in these strategies, with male participants scoring significantly higher for active coping (3.38/4, ± 0.54 vs 3.20, ± 0.54, U = 2.5, p = 0.011) and significantly lower for spirituality (3.07/4, ± 1.03 vs 3.40, ± 0.82, U = 2.7, p = 0.008). There were also significant differences in the Year levels, with Year 2 participants scoring higher in all strategies with significantly higher cognitive flexibility (3.17, ± 0.71 vs 2.92, ± 0.84, U = 2.7, p = 0.006).

A moderate negative correlation was found between burnout and compassion satisfaction (r = 0.500, p < 0.001) and a low negative correlation with resilience (r = -0.302, p <0.001), and a low correlation between resilience and compassion satisfaction r = -0.312, p < 0.001) (Table 2). The association of psychological distress and resilience was significant, with participants who were more likely to be well having higher scores of resilience, compared to the participants with levels of distress (74.68, ± 9.83 vs 69.51 ± 11.70 (mild); 65.91 ± 13.59 (moderate); and 66.94 ± 11.77 (severe distress)). There was no significant impact of psychological distress on compassion satisfaction (K = 27.93, p < 0.001). Participants likely to be well had significantly lower burnout and secondary traumatic stress scores, which increased as psychological distress increased.

Discussion

This study found that the participants were likely well or experienced only mild psychological distress. Several factors, such as the novelty of the pandemic, may explain this. When the pandemic emerged, it was a new, unknown health crisis (Heilferty et al., 2021; Wallace et al., 2021) and reported resilience may have been influenced by inadequate knowledge of the severe adverse effects COVID-19 on health (Danet, 2021; Mendoza Bernal et al., 2023) and high perceived levels of self-efficacy as a coping strategy utilised by students during the initial stages of the pandemic (Mendoza Bernal et al., 2023). High self-efficacy encourages higher motivation levels to overcome difficult situations and respond resiliently (Melendez et al., 2019; Mendoza Bernal et al., 2023).

This study identified self-efficacy, active coping, and spirituality as highly rated responses to stressful circumstances. Similarly, optimism and self-efficacy were investigated as valuable personal resources for decreasing perceived stress in medical students (Kupcewicz et al., 2022; Majrashi et al., 2021; Wu et al., 2019). Students with stronger self-efficacy are healthier mentally and physically, and optimism is linked to greater psychological health scores (Heinen et al., 2017; Krageloh et al., 2015; Torres & Solberg, 2001).

A second strategy highly rated by participants was active coping, which is the practice of thinking and acting in ways that try to change one's response to internal or external causes of stress (Baluwa et al., 2021; Hwang et al., 2021; Johnson et al., 2011). This is also supported by studies of medical students with reports of active coping to control their stress throughout their first year of medical school (Heinen et al., 2017; Moffat et al., 2004).

The highest-rated strategy was reliance on faith or spirituality, the belief in a higher power, greater than oneself, that may guide, influence, and provide meaning for one's life (Cochran et al., 2020; Johnson et al., 2011). Strong religious beliefs have often been associated with improved coping skills and mental well-being, and religion offers a sense of purpose and comfort during challenging times (Cochran et al., 2020).

Lastly, our study supported the known correlations between psychological distress and burnout and resilience and compassion satisfaction. Resilience can contribute to increased compassion satisfaction and reduced burnout (Cochran et al., 2020; Jeong & Shin, 2023; Spurr et al., 2021) and is a strong predictor of people's coping skills, particularly among nursing students, in dealing with a variety of difficulties, such as the pandemic. Studies showed that students who demonstrated resilience were able to acknowledge their limitations, identify sources of stress, and develop strategies for self-regulation (Ching et al., 2020; Keener et al., 2021; Roldan-Merino et al., 2022) and students having high levels of anxiety tending to have lower resilience (Berdida & Grande, 2023; Zhang et al., 2020).

Limitations and future recommendations

The sample was unrepresentative of South African nurses. Moreover, the study was implemented during the first phase of the pandemic and findings would not be representative of later phases. Further research with a probability sample and also sampling a cross-section of pandemic phases is needed to guide the development of specific support programmes to reduce distress in students' work lives.

Conclusion

This study provided evidence of the resilience of nursing students during the early stages of the COVID-19 pandemic through a profile of psychological distress and resilience of nursing students. We found self-efficacy, active coping, and spirituality were protective of student nurse well-being by their higher resilience during COVID-19-related stressful events. By contrast self-reported medical conditions and sleep deprivation were associated with poorer mental well-being among the nurses. The study findings highlight the important role of personal factors in nursing students' work well-being.

Author contributions

Both authors contributed equally.

Declaration of conflict interests

The authors declare that they have no conflict of interest.

Acknowledgements

We would like to thank all students who volunteered to participate in this study.

Data availability

The authors confirm that the data supporting the findings of this study are available within the article and its supplementary materials.