KEYWORDS: MENTAL HEALTH/ NURSING STUDENTS/ VIETNAM/ EMOTIONAL QUOTIENT/ SELF-ESTEEM/ SOCIAL SUPPORT BUI THI LOAN: FACTORS RELATED TO MENTAL HEALTH AMONG VIETNAMESE NURSING STUDENTS.. The
Trang 1VIETNAMESE NURSING STUDENTS
BUI THI LOAN
A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE MASTER DEGREE OF NURSING SCIENCE
(INTERNATIONAL PROGRAM) FACULTY OF NURSING BURAPHA UNIVERSITY OCTOBER 2015 COPYRIGHT OF BURAPHA UNIVERSITY
Trang 2ACKNOWLEDGMENT
With heartfelt gratitude and appreciation, I would like to express my deep
appreciation to many persons who did not only support me in completing this thesis, but also in my journey to become a Master student of Nursing Science
Firstly, I would like to sincerely thank my major advisor, Assistant Professor
Dr.Pornpat Hengudomsub, who was always besides me, encourage, and support me a lot throughout my process of writing this thesis She has been a great mentor This thesis
would not complete without her enthusiastic guidance My sincere thanks also go to my co-advisor, Associate Professor Dr.Nujjaree Chaimongkol for her excellent comments and suggestions
I am grateful to the Dean of Faculty of Nursing, as well as Chairperson of Master
of Nursing Science Program (International Program), all of lectures and staffs in Faculty of Nursing, Burapha University who provide the excellent teaching and supporting
environment during my study time in Thailand
My special thanks go to the Health Human Resource Development project under the Ministry of Health of Vietnam andthe director of Hai Duong Medical Technical
University who gave me a great opportunity to pursue Master of Nursing Science Program
at Faculty of Nursing, Burapha University, Thailand I also would like to thank the
baccalaureate nursing students who participated in this study from Faculty of Nursing at Hai Duong Medical Technical University, Vietnam
Last but not least, I wish to express my love and gratitude to my awesome family and friends I sincerely thank them for their support and encouragement throughout my study
Trang 3
56910479: MAJOR: NURSING SCIENCE; M.N.S
KEYWORDS: MENTAL HEALTH/ NURSING STUDENTS/ VIETNAM/
EMOTIONAL QUOTIENT/ SELF-ESTEEM/ SOCIAL SUPPORT BUI THI LOAN: FACTORS RELATED TO MENTAL HEALTH AMONG
VIETNAMESE NURSING STUDENTS ADVISORY COMMITTEE: PORNPAT
HENGUDOMSUB, Ph.D., NUJJAREE CHAIMONGKOL, Ph.D 90 P 2015
Mental health is one of the significant components of health and associated with both individual and environmental factors The purposes of this descriptive cross sectional study were to examine mental health and test its relationships with related factors including education achievement indicated by Grade Point Average (GPA), emotional quotient, self-esteem, and social support among nursing students (Year 1 to Year 4) who are studying at one of a university in Vietnam The sample included 110 baccalaureate full time nursing students who registered in academic year 2015 Simple random sampling technique was used to recruit the sample Self-report questionnaires were used to collect data which
included questionnaire about nursing students’ characteristics, GPA, the Schutte Emotional Intelligence Scale (SEIS), the Rosenberg Self-esteem Scale (RSES), the Personal Resource Questionnaire 2000 (PRQ2000), and the Mental Health Inventory: 18-item version (MHI-18) The scales of SEIS, RSES, PRQ2000, and MHI-18 yielded Cronbach’s alpha of 83, 81, 86, and 80, respectively Data were analyzed using descriptive statistics and Pearson’s product moment correlation coefficient
The results showed that the mental health of these nursing students was at a
moderate level with a mean score of 64.91 (SD = 7.57) Mental health was positively
correlated with GPA (r = 24, p < 01), emotional quotient (r = 26, p < 01), self-esteem (r = 33, p < 01), and social support (r = 37, p < 01)
This study results provided baseline information regarding mental health and its related factors among Vietnamese nursing students It could be used to develop for proper strategies or program aimed at enhancing students’ academic achievement, emotional
intelligence, self-esteem and social support among these nursing students
Trang 4CONTENTS
Page
ABSTRACT v
CONTENTS vi
LIST OF TABLES viii
LIST OF FIGURE ix
CHAPTER 1 INTRODUCTION 1
Background and significance of the problem 1
Research objectives 7
Research hypotheses 7
Scope of study 7
Research framework 7
Definition of terms 9
2 LITERATURE REVIEWS 11
Overview of mental health 11
Mental health among nursing students 14
Factors related to mental health in nursing students 18
Conclusion 22
3 RESEARCH METHODOLOGY 24
Research design 24
Setting of study 24
Population and sample 24
Research instruments 26
Psychometric properties of instruments 30
Ethical considerations 31
Data collection procedures 32
Data analyses 32
4 RESULTS 34
Trang 5
CONTENTS (cont.)
CHAPTER Page Description of nursing students’ characteristics 34
Description of mental health among nursing students 35
Description of factors related to mental health among nursing students 36
Description of relationships between mental health and its related
factors among nursing students 37
5 CONCLUSION AND DISCUSSION 39
Summary of the study findings 39
Discussion 40
Study implications 48
Limitations of study 49
Recommendation for future research 49
REFERENCES 50
APPENDICES 63
Appendix 1 64
Appendix 2 67
Appendix 3 70
Appendix 4 74
Appendix 5 81
Appendix 6 88
BIOGRAPHY 90
Trang 6LIST OF FIGURE
Research framework……… 9
Trang 7LIST OF TABLES
Tables Page
1 Number of sample in each year of this study 26
2 Demographic characteristics of nursing students 35
3 Description of mental health among nursing students 36
4 Description of education achievement, emotional quotient, self-esteem
and social support 37
5 Correlation coefficients of mental health score with other measures 38
6 Interpretation for the size of correlation coefficient 89
7 One-way analysis of variances of mental health score among nursing students 89
Trang 8
CHAPTER 1 INTRODUCTION
Background and significance of the problem
Nursing occupies an important position in the healthcare system Nursing students are the future professional health care providers who play important roles in providing care
as well as supporting patients physically and psychologically Thus, they themselves should also have good mental health, which is one of the significant health components (Ni et al., 2010).Nursingstudents are not only facing with the challenges like most of other college students including accommodation, interpersonal relationships, financial burden, parental pressure as well as their concerns about the future, but they also have to face with more stressful academic learning and psychological stressors (Dutta, Pyles, & Miederhoff, 2005; Sreeramareddy et al., 2007; Vaez, Ponce de Leon, & Laflamme, 2006)
Specifically, with the aims of equipping necessary skills for the students after
graduation,nursing students across the nations and Vietnam in particular have to learn both theory-based classes and also practice in the clinical settings In the first year of their
studies, heavy academic pressure, concerns about examinations, worrying about grades are cited as a major source of stress for some students (Huong, Hengudomsub, &
Suppaseemanont, 2011; Shaban, Khater, & Akhu-Zaheya, 2012) In their subsequent years
of study, the students begin specific courses and start practicing in clinical settings such as
in the hospitals (Huong et al., 2011) This time period may be the most stressful for some of the nursing students (Moscaritolo, 2009) The students are also required to have continuous interaction with a variety of individuals including patients, their family members, and other health care providers (Reeves, 2005) The students must be concern about their mistakes which can seriously harm the patients, even cause death to the patients Therefore, the
students are required high responsibility, circumspection, and discretion Moreover, during practical experience in hospital, they may encounter with conflicts between health staffs, suffering situation of patients, such as pain, cancer disease in young patients, even death sometimes (Augusto-Landa, López-Zafra, Berrios-Martos, & Pulido-Martos, 2012;
Gibbons, Dempster, & Moutray, 2009; Pryjmachuk, 2004) All of these cause stressful
situations for them, and these may lead them to have to physical and mental health
problems (Sreeramareddy et al., 2007)
Trang 9There have been various studies that explored mental health among nursing
students worldwide (Liu & Jia, 2008; Wu, 2005) Mental health encompassed of positive mental health or psychological well being and negative mental health which in other
words were psychological distress or mental health problems The prevalence of mental health problems or negative mental health among this population was varied According to the data from some epidemiologic studies among nursing students in China, 7.7 % to 28.7
% of the students experienced mental health problems (Liu & Jia, 2008; Wu, 2005)
Another study was conducted to examine the mental health of 1,686first-year medical
science students in Iran using the General Health Questionnaire-28 (GHQ-28) The results revealed that 35.7 % of these students had mental health problems Among them, nursing students showed the highest percentage of those who experienced mental health problems (Lotfi, Aminian, Ghomizadea, & Noorani, 2009) Depression and anxiety have been
documented as the most common mental health problems among nursing students in
several studies (Cook, 2005; Moscaritolo, 2009; Vatanasin, 2005) A high prevalence of depression was found among nursing students in the China, Kenya and India (Chatterjee et al., 2014; Othieno, Okoth, Peltzer, Pengpid, & Malla, 2014; Xu et al., 2014) Other studies also found a high prevalence of anxiety among this population in the United States and Iran (Cook, 2005; Moscaritolo, 2009)
Mental health problems not only caused negatively impacts on the students’ lives, but also on their families and society As for the students themselves, there were some
studies which demonstrated a relationship between mental illness and academic problems (Breslau, Lane, Sampson, & Kessler, 2008; Hunt, Eisenberg, & Kilbourne, 2010)
Specifically, the students who reported depressive symptoms tended to pay less attention in their studies, decreased abilities for study concentration Moreover, elevated anxiety which produced a state of physiological arousal also indicated as a factor leading to the
impairment of their abilities to concentration on others (Wood, 2006) All of these can lead
to low academic performance among these nursing students
In addition, the poor quality of student's life is also reflected as loss of interest in leisure activities, having eating and sleeping disturbances, and evensuicidal thoughts
(Vatanasin, 2005) According to Hawton, Agerbo, Simkin, Platt, and Mellanby (2011),
nursing students were at higher risk for suicide than other college students A statistics from Pennsylvania State University found that more than 30 % of students who seek services for
Trang 10mental health issues reported that they had considered attempting suicide at some point in their lives, up to be about 24 % in the year 2010 (Novotney, 2014) Another study was
conducted of 142 nursing students of the Technological Educational Institute of
Thessaloniki in Greece (Melissa-Halikiopoulou, Tsiga, Khachatryan, & Papazisis, 2011), and it revealed that 43.9 % of them reported depressive symptoms Also, 10.6 % said that they had suicidal ideation, but they didn’t act on them, while two students (1.4 %) declared that they could have done it if they had the chance to do so In terms of profession, students have regular contacts and direct patient care, so quality of care provided for the patients may also be reduced On the other hand, mental health problems among nursing students can also create burden to their family caregivers and society as a whole Families of the students who experienced mental health problems may worry and stress about the illness of their children They also may feel guilty that they might contribute to the development of their children's problems (Dzurec, Allchin, & Engler, 2007) These may lead them to isolate themselves from friends, community, and social support networks that the families used to have due to the fear of stigma or prejudice In relation to financial burden, families of
mental illness persons also faced with financial problems and needed more support from society Due to high incidence of mental health problems and its related negative
consequences, it should be concerned about mental health among nursing students and the issue of mental health and mental health problems are deserved more attention
From literature review, mental health of the individuals related to both individual and environmental factors (Lazarus & Folkman, 1984; Ni et al., 2010; Vatanasin, 2005) These two factors serve as important factors contributing to mental health in both positive and negative aspects For this study, the three most promising individual factors associated with mental health among nursing students include educational achievement (Parvizrad, Charati, Sadeghi, Mohammadi, & Hosseini, 2014), emotional quotient (Tsaousis &
Nikolaou, 2005), and self-esteem (Ni et al., 2010) In addition, for the environmental factor which has a significant impact on mental health of this population is social support (Jensen, 2007; Luo & Wang, 2009)
Educational achievement is an indicator reflecting learning outcome of students Grade point average (GPA) is considered as one of an indicator reflecting academic
achievement The positive correlation between GPA and mental health among nursing
student has been found in some studies (Floyd, 2010; Xu et al., 2014) Nursing students
Trang 11who had poor educational achievement are more likely to be stress According to Vatanasin (2005), when the high level of stress among nursing students lasted for a long time, it might lead to depression or other mental problems According to the studies conducted by Beck, Hackett, Srivastava, McKim, and Rockwell (1997) and Parvizrad et al (2014), better GPA was significantly associated with less mental health problems among nursing students
Emotional quotient (EQ) represents a person’s emotional intelligence (EI) which can be defined as an individual’s ability to perceive, assess, and regulate his or her own
emotions and also understand the emotions of others (Mayer, Salovey, & Caruso, 2000).This is an issue that can impact directly on individual’s life and make him or her has better adjustment and adaptation to a new situation (Bar-on & Parker, 2000) Batooland Khalid (2009) indicated that adaptive value of emotional intelligence served as a significant factor contributed to maintaining and promoting individual’s mental health Mood swings and other psychological problems could be occurred if an individual is unable to understand and manage his or her own emotion In addition, inability to form strong relationships with
others may cause these individuals feel lonely and isolated Although, there have been only few studies examining the emotional intelligence among nursing students, the results
obtained from these studies showed consisting results which affirmed that there was a
significant relationship between emotional intelligence and mental health Individuals with better EI reported less subjective stress and experienced better mental health (Donaldson-Feilder & Bond, 2004; Tsaousis & Nikolaou, 2005) This means that nursing students who acknowledge their own emotions and able to regulate their emotions somehow have lower stress in their tasks or studies (Limonero, Tomas-Sabato, & Ferna´ndaz-Castro, 2004)
Thus, they are less likely to be at risk to develop mental health problems
Self-esteem is another significant individual factor associated with mental health (Merianos, Nabors, Vidourek, & King, 2013) Nursing students who have high self-esteem tend to have positive evaluation towards themselves and have more confidence
Conversely, those with low self-esteem are more likely to admit weaknesses and feel that their lives are not worthwhile (Ootim, 1998) Negative appraisal towards themselves may lead them to have distortion in their thinking structures and mental health problems
(Lazarus & Folkman, 1984) According to the study conducted by Ni et al (2010), there was a significant relationship between self-esteem and mental health among nursing
students, and a high level of self-esteem served as a protective factor which helps promote
Trang 12positive mental health Specifically, fewer days of mental health problems per month were reported by those with higher levels of self-esteem than those with lower self-esteem
Remarkable, Rosenfield, Lennon, and White (2005) indicated that mental health problems including anxiety and depression were closely related to low self-esteem Various studies also revealed a negative association between self-esteem and depression among nursing students (Furegato, Santos, & Silva, 2008; Huong et al., 2011; Vatanasin, 2005)
Finally, social support has been found to have association with mental health
among nursing students Indeed, Maville and Huerta (1997) reported that nursing school may possibly induce stress among nursing students Social support has been an important factor in helping nursing students to cope with stress during their nursing education (Huong
et al., 2011; Luo & Wang, 2009) Luo and Wang (2009) conducted a study to examine
mental health of 288 college nursing students in China by using social support
questionnaire and Symptom Checklist 90 (SCL-90) to identify both positive and negative mental health.The findings indicated that social support was negatively correlatedwith
psychological symptoms (r = -.135, p < 05) The students who had more social support
reported better positive mental health and lesser negative mental health (Jensen, 2007;
Montes-Berges & Augusto, 2007) In contrast, less social support placed nursing students at higher risk for mental health problems such as depression (Huong et al., 2011) This was also reported in studies of Ratanasiripong (2012) and Vatanasin (2005)
From the aforementioned reviews, it can emphasize that mental health problems among nursing students are commonly found along with its negative impacts Even though, there have been various studies around the world focusing on mental health of nursing
students, there have been only few studies that have placed an emphasis on exploring
mental health in both facets whether positive or negative mental health of these students Those few studies conducted with Vietnamese students included the studies of Do (2007), Nguyen (2009), Thai (2010) and Huong et al (2011) In the study of Do (2007) which
conducted with 351 first year medical students in Ho Chi Minh city, the results revealed that 39.6 % of these students had scores indicating depression or negative mental health In addition, the prevalence of psychological distress or negative mental health including
depression, and anxiety showed the prevalence of 26.3 %, and 16.2 %, respectively In the study of Thai (2010), there were 1,226 students in Ho Chi Minh city participated in this study Notably, the percentages of these students who had had suicidal idea and some of
Trang 13them reported attempted suicide during the past 12 months were 6.3 %, and 5.8 %
respectively Based on literature review for the study conducted in Vietnam, only one
study investigated depression among 261 Vietnamese nursing students, and indicated that 45.6 % of the students reported mental health problem reflected by depression (Huong et al., 2011)
Because of the importance of nursing students who will be the professional care providers in the near future, as well asthe alarming issue regarding mental health problems experienced by nursing students across the countries, this study would like to conduct the study in order to examine mental health and to test its relationships with related factors among Vietnamese nursing students Findings obtained from this study would serve as
baseline data for the prevalence of mental health among Vietnamese nursing students as well as guidance for developing program or intervention aimed at promoting mental health among the nursing students
1 GPA is positively related to mental health among Vietnamese nursing students
2 Emotional quotient is positively related to mental health among Vietnamese nursing students
3 Self-esteem is positively related to mental health among Vietnamese nursing students
4 Social support is positively related to mental health among Vietnamese nursing students
Trang 14of the threat in the transaction, and the relative power of the environmental demands
compared with the abilities of the persons to prevent or manage such harm (Lazarus &
Folkman, 1984).Selected factors associated with mental health among nursing students examined in this study include both individual and environmental factors The individual factors included education achievement, the emotional quotient, and self-esteem For
environmental factor, social support was examined
Individual factors can affect the way that the person confronts stressful situations and also how she or he reacts to such stressor Nursing students may confront a variety of stressors The evidence showed that mental health was associated with academic success among these students (Higginson, 2006; Shaban et al., 2012; Sreeramareddy et al., 2007) The students who had low GPA are more likely to develop negative mental health, such as having negative attitudes and behaviors, sadness, hopelessness, depression, and even
suicidal ideation (DeSimone, 2010) In addition, emotional quotient was found to be related
to mental health of nursing students (Brown & Schutte, 2006; Khosro & Khanzadeh, 2007) The students who had good mental health were those who had better emotional quotient They were able to appraise and effectively regulate their own emotional state (Tsaousis & Nikolaou, 2005) Whereas, those students who had a low level of emotional quotient
reported more negative mental health or psychological distress (Birks, McKendree, & Watt, 2009) Self-esteem was also another factor found to have relationship with mental health According to DeLongis and Folkman (1988), individuals with low self-esteem were more vulnerable to develop mental health problems than those with higher self-esteem Nursing students with good self-esteem were more likely to understand themselves and accept the problems realistically They also had feeling of self-worth, which made them feel satisfied, and which resulted in fewer mental health problems Conversely, the individuals with low self-esteem are more likely to have pessimistic ideas and feelings of guilt toward
Trang 15themselves, which can cause a distortion in ideas and have an effect on their mental health Furthermore, social support was indicated as an environmental factor that serves as a
protective factor It provided vital resources that the individual can draw upon to survive and flourish (Baqutayan, 2011; Lazarus & Folkman, 1984) Social support helped to
strengthen an individual’s ability against the stressors and helped to reduce negative effects
of mental health problems (Lazarus & Folkman, 1984) Faced with stressful life conditions, people feel better if they have more social support (Jensen, 2007; Luo & Wang, 2009)
Nursing students with more social support reported better mental health (Montes-Berges & Augusto, 2007) In contrast, a lack of social support placed the students at a higher risk for mental health problems
In sum, nursing students who had good educational achievement (GPA), had a sense of self-worth (self-esteem), had good interaction with others (emotional quotient) and received good support from others (social support) had good mental health The research framework of this study is summarized in Figure 1
Figure 1 Research framework
Definition of terms
Mental health refers to a nursing student’s state of well-being which includes the
facets of positive mental health (i.e psychological well-being) and negative mental health (i.e psychological distress) The Mental Health Inventory, 18-item version (MHI-18) which was modified from the original 38-item scale developed by Veit and Ware (1983) was used
to examine mental health in both facets
Emotional quotient
Self-esteem
Mental health Educational achievement
Social support
Trang 16Educational achievement refers to the level of education success attained by
nursing student as reflected by cumulative grade point average (GPA) from the first
semester to the recent semester According to GPA scores, the highest score that nursing student can obtained is 4 and the lowest score is 0
Emotional quotient refers to the capacities of nursing students to recognize their
own feelings, and those of others, able to motivate themselves and have well management
of their own emotions as well as in the relationship with others It was measured by using the Schutte Emotional Intelligence Scale (SEIS) developed by Schutte et al (1998)
Self-esteem refers to overall sense of self-worth or personal value of nursing
students In this study, self-esteem was measured using the Rosenberg Self-esteem Scale developed by Rosenberg (1965)
Social support refers to the perception of nursing students towards the
availability of instrumental, informational, and emotional support they have These would lead them to believe that he/ she is cared for and loved, esteemed and valued, and that he/ she belongs to a society It was measured by using the Personal Resource Questionnaire
2000 (PRQ2000) developed by Weinert (2003)
Trang 17CHAPTER 1 INTRODUCTION
Background and significance of the problem
Nursing occupies an important position in the healthcare system Nursing students are the future professional health care providers who play important roles in providing care
as well as supporting patients physically and psychologically Thus, they themselves should also have good mental health, which is one of the significant health components (Ni et al., 2010).Nursingstudents are not only facing with the challenges like most of other college students including accommodation, interpersonal relationships, financial burden, parental pressure as well as their concerns about the future, but they also have to face with more stressful academic learning and psychological stressors (Dutta, Pyles, & Miederhoff, 2005; Sreeramareddy et al., 2007; Vaez, Ponce de Leon, & Laflamme, 2006)
Specifically, with the aims of equipping necessary skills for the students after graduation,nursing students across the nations and Vietnam in particular have to learn both theory-based classes and also practice in the clinical settings In the first year of their
studies, heavy academic pressure, concerns about examinations, worrying about grades are cited as a major source of stress for some students (Huong, Hengudomsub, &
Suppaseemanont, 2011; Shaban, Khater, & Akhu-Zaheya, 2012) In their subsequent years
of study, the students begin specific courses and start practicing in clinical settings such as
in the hospitals (Huong et al., 2011) This time period may be the most stressful for some of the nursing students (Moscaritolo, 2009) The students are also required to have continuous interaction with a variety of individuals including patients, their family members, and other health care providers (Reeves, 2005) The students must be concern about their mistakes which can seriously harm the patients, even cause death to the patients Therefore, the
students are required high responsibility, circumspection, and discretion Moreover, during practical experience in hospital, they may encounter with conflicts between health staffs, suffering situation of patients, such as pain, cancer disease in young patients, even death sometimes (Augusto-Landa, López-Zafra, Berrios-Martos, & Pulido-Martos, 2012;
Gibbons, Dempster, & Moutray, 2009; Pryjmachuk, 2004) All of these cause stressful
situations for them, and these may lead them to have to physical and mental health
problems (Sreeramareddy et al., 2007)
Trang 18There have been various studies that explored mental health among nursing
students worldwide (Liu & Jia, 2008; Wu, 2005) Mental health encompassed of positive mental health or psychological well being and negative mental health which in other
words were psychological distress or mental health problems The prevalence of mental health problems or negative mental health among this population was varied According to the data from some epidemiologic studies among nursing students in China, 7.7 % to 28.7
% of the students experienced mental health problems (Liu & Jia, 2008; Wu, 2005)
Another study was conducted to examine the mental health of 1,686first-year medical
science students in Iran using the General Health Questionnaire-28 (GHQ-28) The results revealed that 35.7 % of these students had mental health problems Among them, nursing students showed the highest percentage of those who experienced mental health problems (Lotfi, Aminian, Ghomizadea, & Noorani, 2009) Depression and anxiety have been
documented as the most common mental health problems among nursing students in
several studies (Cook, 2005; Moscaritolo, 2009; Vatanasin, 2005) A high prevalence of depression was found among nursing students in the China, Kenya and India (Chatterjee et al., 2014; Othieno, Okoth, Peltzer, Pengpid, & Malla, 2014; Xu et al., 2014) Other studies also found a high prevalence of anxiety among this population in the United States and Iran (Cook, 2005; Moscaritolo, 2009)
Mental health problems not only caused negatively impacts on the students’ lives, but also on their families and society As for the students themselves, there were some
studies which demonstrated a relationship between mental illness and academic problems (Breslau, Lane, Sampson, & Kessler, 2008; Hunt, Eisenberg, & Kilbourne, 2010)
Specifically, the students who reported depressive symptoms tended to pay less attention in their studies, decreased abilities for study concentration Moreover, elevated anxiety which produced a state of physiological arousal also indicated as a factor leading to the
impairment of their abilities to concentration on others (Wood, 2006) All of these can lead
to low academic performance among these nursing students
In addition, the poor quality of student's life is also reflected as loss of interest in leisure activities, having eating and sleeping disturbances, and evensuicidal thoughts
(Vatanasin, 2005) According to Hawton, Agerbo, Simkin, Platt, and Mellanby (2011), nursing students were at higher risk for suicide than other college students A statistics from Pennsylvania State University found that more than 30 % of students who seek services for
Trang 19mental health issues reported that they had considered attempting suicide at some point in their lives, up to be about 24 % in the year 2010 (Novotney, 2014) Another study was
conducted of 142 nursing students of the Technological Educational Institute of
Thessaloniki in Greece (Melissa-Halikiopoulou, Tsiga, Khachatryan, & Papazisis, 2011), and it revealed that 43.9 % of them reported depressive symptoms Also, 10.6 % said that they had suicidal ideation, but they didn’t act on them, while two students (1.4 %) declared that they could have done it if they had the chance to do so In terms of profession, students have regular contacts and direct patient care, so quality of care provided for the patients may also be reduced On the other hand, mental health problems among nursing students can also create burden to their family caregivers and society as a whole Families of the students who experienced mental health problems may worry and stress about the illness of their children They also may feel guilty that they might contribute to the development of their children's problems (Dzurec, Allchin, & Engler, 2007) These may lead them to isolate themselves from friends, community, and social support networks that the families used to have due to the fear of stigma or prejudice In relation to financial burden, families of
mental illness persons also faced with financial problems and needed more support from society Due to high incidence of mental health problems and its related negative
consequences, it should be concerned about mental health among nursing students and the issue of mental health and mental health problems are deserved more attention
From literature review, mental health of the individuals related to both individual and environmental factors (Lazarus & Folkman, 1984; Ni et al., 2010; Vatanasin, 2005) These two factors serve as important factors contributing to mental health in both positive and negative aspects For this study, the three most promising individual factors associated with mental health among nursing students include educational achievement (Parvizrad, Charati, Sadeghi, Mohammadi, & Hosseini, 2014), emotional quotient (Tsaousis &
Nikolaou, 2005), and self-esteem (Ni et al., 2010) In addition, for the environmental factor which has a significant impact on mental health of this population is social support (Jensen, 2007; Luo & Wang, 2009)
Educational achievement is an indicator reflecting learning outcome of students Grade point average (GPA) is considered as one of an indicator reflecting academic
achievement The positive correlation between GPA and mental health among nursing
student has been found in some studies (Floyd, 2010; Xu et al., 2014) Nursing students
Trang 20who had poor educational achievement are more likely to be stress According to Vatanasin (2005), when the high level of stress among nursing students lasted for a long time, it might lead to depression or other mental problems According to the studies conducted by Beck, Hackett, Srivastava, McKim, and Rockwell (1997) and Parvizrad et al (2014), better GPA was significantly associated with less mental health problems among nursing students
Emotional quotient (EQ) represents a person’s emotional intelligence (EI) which can be defined as an individual’s ability to perceive, assess, and regulate his or her own
emotions and also understand the emotions of others (Mayer, Salovey, & Caruso, 2000).This is an issue that can impact directly on individual’s life and make him or her has better adjustment and adaptation to a new situation (Bar-on & Parker, 2000) Batooland Khalid (2009) indicated that adaptive value of emotional intelligence served as a significant factor contributed to maintaining and promoting individual’s mental health Mood swings and other psychological problems could be occurred if an individual is unable to understand and manage his or her own emotion In addition, inability to form strong relationships with
others may cause these individuals feel lonely and isolated Although, there have been only few studies examining the emotional intelligence among nursing students, the results
obtained from these studies showed consisting results which affirmed that there was a
significant relationship between emotional intelligence and mental health Individuals with better EI reported less subjective stress and experienced better mental health (Donaldson-Feilder & Bond, 2004; Tsaousis & Nikolaou, 2005) This means that nursing students who acknowledge their own emotions and able to regulate their emotions somehow have lower stress in their tasks or studies (Limonero, Thomas-Sabato, & Ferna´ndaz-Castro, 2004) Thus, they are less likely to be at risk to develop mental health problems
Self-esteem is another significant individual factor associated with mental health (Merianos, Nabors, Vidourek, & King, 2013) Nursing students who have high self-esteem tend to have positive evaluation towards themselves and have more confidence
Conversely, those with low self-esteem are more likely to admit weaknesses and feel that their lives are not worthwhile (Ootim, 1998) Negative appraisal towards themselves may lead them to have distortion in their thinking structures and mental health problems
(Lazarus & Folkman, 1984) According to the study conducted by Ni et al (2010), there was a significant relationship between self-esteem and mental health among nursing
students, and a high level of self-esteem served as a protective factor which helps promote
Trang 21positive mental health Specifically, fewer days of mental health problems per month were reported by those with higher levels of self-esteem than those with lower self-esteem
Remarkable, Rosenfield, Lennon, and White (2005) indicated that mental health problems including anxiety and depression were closely related to low self-esteem Various studies also revealed a negative association between self-esteem and depression among nursing students (Furegato, Santos, & Silva, 2008; Huong et al., 2011; Vatanasin, 2005)
Finally, social support has been found to have association with mental health
among nursing students Indeed, Maville and Huerta (1997) reported that nursing school may possibly induce stress among nursing students Social support has been an important factor in helping nursing students to cope with stress during their nursing education (Huong
et al., 2011; Luo & Wang, 2009) Luo and Wang (2009) conducted a study to examine
mental health of 288 college nursing students in China by using social support
questionnaire and Symptom Checklist 90 (SCL-90) to identify both positive and negative mental health.The findings indicated that social support was negatively correlatedwith
psychological symptoms (r = -.135, p < 05) The students who had more social support
reported better positive mental health and lesser negative mental health (Jensen, 2007;
Montes-Berges & Augusto, 2007) In contrast, less social support placed nursing students at higher risk for mental health problems such as depression (Huong et al., 2011) This was also reported in studies of Ratanasiripong (2012) and Vatanasin (2005)
From the aforementioned reviews, it can emphasize that mental health problems among nursing students are commonly found along with its negative impacts Even though, there have been various studies around the world focusing on mental health of nursing
students, there have been only few studies that have placed an emphasis on exploring
mental health in both facets whether positive or negative mental health of these students Those few studies conducted with Vietnamese students included the studies of Do (2007), Nguyen (2009), Thai (2010) and Huong et al (2011) In the study of Do (2007) which
conducted with 351 first year medical students in Ho Chi Minh city, the results revealed that 39.6 % of these students had scores indicating depression or negative mental health In addition, the prevalence of psychological distress or negative mental health including
depression, and anxiety showed the prevalence of 26.3 %, and 16.2 %, respectively In the study of Thai (2010), there were 1,226 students in Ho Chi Minh city participated in this study Notably, the percentages of these students who had had suicidal idea and some of
Trang 22them reported attempted suicide during the past 12 months were 6.3 %, and 5.8 %
respectively Based on literature review for the study conducted in Vietnam, only one
study investigated depression among 261 Vietnamese nursing students, and indicated that 45.6 % of the students reported mental health problem reflected by depression (Huong et al., 2011)
Because of the importance of nursing students who will be the professional care providers in the near future, as well asthe alarming issue regarding mental health problems experienced by nursing students across the countries, this study would like to conduct the study in order to examine mental health and to test its relationships with related factors among Vietnamese nursing students Findings obtained from this study would serve as
baseline data for the prevalence of mental health among Vietnamese nursing students as well as guidance for developing program or intervention aimed at promoting mental health among the nursing students
5 GPA is positively related to mental health among Vietnamese nursing students
6 Emotional quotient is positively related to mental health among Vietnamese nursing students
7 Self-esteem is positively related to mental health among Vietnamese nursing students
8 Social support is positively related to mental health among Vietnamese nursing students
Trang 23of the threat in the transaction, and the relative power of the environmental demands
compared with the abilities of the persons to prevent or manage such harm (Lazarus &
Folkman, 1984).Selected factors associated with mental health among nursing students examined in this study include both individual and environmental factors The individual factors included education achievement, the emotional quotient, and self-esteem For
environmental factor, social support was examined
Individual factors can affect the way that the person confronts stressful situations and also how she or he reacts to such stressor Nursing students may confront a variety of stressors The evidence showed that mental health was associated with academic success among these students (Higginson, 2006; Shaban et al., 2012; Sreeramareddy et al., 2007) The students who had low GPA are more likely to develop negative mental health, such as having negative attitudes and behaviors, sadness, hopelessness, depression, and even
suicidal ideation (DeSimone, 2010) In addition, emotional quotient was found to be related
to mental health of nursing students (Brown & Schutte, 2006; Khosro & Khanzadeh, 2007) The students who had good mental health were those who had better emotional quotient They were able to appraise and effectively regulate their own emotional state (Tsaousis & Nikolaou, 2005) Whereas, those students who had a low level of emotional quotient
reported more negative mental health or psychological distress (Birks, McKendree, & Watt, 2009) Self-esteem was also another factor found to have relationship with mental health According to DeLongis and Folkman (1988), individuals with low self-esteem were more vulnerable to develop mental health problems than those with higher self-esteem Nursing students with good self-esteem were more likely to understand themselves and accept the problems realistically They also had feeling of self-worth, which made them feel satisfied, and which resulted in fewer mental health problems Conversely, the individuals with low
Trang 24self-esteem are more likely to have pessimistic ideas and feelings of guilt toward
themselves, which can cause a distortion in ideas and have an effect on their mental health Furthermore, social support was indicated as an environmental factor that serves as a
protective factor It provided vital resources that the individual can draw upon to survive and flourish (Baqutayan, 2011; Lazarus & Folkman, 1984) Social support helped to
strengthen an individual’s ability against the stressors and helped to reduce negative effects
of mental health problems (Lazarus & Folkman, 1984) Faced with stressful life conditions, people feel better if they have more social support (Jensen, 2007; Luo & Wang, 2009)
Nursing students with more social support reported better mental health (Montes-Berges & Augusto, 2007) In contrast, a lack of social support placed the students at a higher risk for mental health problems
In sum, nursing students who had good educational achievement (GPA), had a sense of self-worth (self-esteem), had good interaction with others (emotional quotient) and received good support from others (social support) had good mental health The research framework of this study is summarized in Figure 1
Figure 1 Research framework
Mental health Emotional quotient
Self-esteem
Educational achievement
Social support
Trang 25Definition of terms
Mental health refers to a nursing student’s state of well-being which includes the
facets of positive mental health (i.e psychological well-being) and negative mental health (i.e psychological distress) The Mental Health Inventory, 18-item version (MHI-18) which was modified from the original 38-item scale developed by Veit and Ware (1983) was used
to examine mental health in both facets
Educational achievement refers to the level of education success attained by
nursing student as reflected by cumulative grade point average (GPA) from the first
semester to the recent semester According to GPA scores, the highest score that nursing student can obtained is 4 and the lowest score is 0
Emotional quotient refers to the capacities of nursing students to recognize their
own feelings, and those of others, able to motivate themselves and have well management
of their own emotions as well as in the relationship with others It was measured by using the Schutte Emotional Intelligence Scale (SEIS) developed by Schutte et al (1998)
Self-esteem refers to overall sense of self-worth or personal value of nursing
students In this study, self-esteem was measured using the Rosenberg Self-esteem Scale developed by Rosenberg (1965)
Social support refers to the perception of nursing students towards the
availability of instrumental, informational, and emotional support they have These would lead them to believe that he/ she is cared for and loved, esteemed and valued, and that he/ she belongs to a society It was measured by using the Personal Resource Questionnaire
2000 (PRQ2000) developed by Weinert (2003)
Trang 26CHAPTER 2 LITERATURE REVIEWS
In this chapter, the researcher presents overview of mental health, mental health in nursing students, and factors related to mental health in nursing students
Overview of mental health
Definition of mental health
The definition of mental health can be classified into two approaches, including
traditional and modern approaches
For traditional approaches, mental health has long been described as the absence
of psychopathology, which refers to both internalizing disorders and externalizing disorders (Maddux, 2005) Internalizing disorders are characterized as problems based on
―overcontrolled‖ symptoms, for instance depression, anxiety This means that the
individuals try to maintain maladaptive control over their internal cognitions and emotions Externalizing disorders derived from poor self-regulation or ―undercontrolled‖ symptoms (Merrell, 2008), such as hyperactivity/ attention deficit disorder, etc (American Psychiatric Association [APA], 2013) Therefore, in this traditional approach, mental health becomes considered in the absence of mental illness and ignores positive factors and markers of
Nowadays, WHO also focuses on mental health as a positive state and defined mental health as ―a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community‖ (World Health Organization [WHO], 2014) Specifically, a state of well-being reflects emotional components
(emotional well-being) In addition, the individuals' realization about their own potential
Trang 27and abilities to cope with the stress of life reflects psychological well-being component And finally, elements of optimal functioning in social life (social well-being) are reflected
in aspects in work and contribution to community Individuals are considered to be having good mental health when they experience all of components including psychological,
emotional, and social well-being Such, in this positive sense, mental health is the
foundation for well-being and effective functioning for an individual and for a community rather than merely the non-appearance of mental illness
Assessment of mental health
Assessment of mental health is one of important steps to understand mental health needs and make an effective treatment plan In general, this assessment can be conducted
by psychiatrist, psychologist, mental health nurse, and therapist
As for traditional approaches, based on the presence of specific symptoms of
mental disorders, the Diagnostic and Statistical Manual for Mental Disorders (DSM) has been used to classify and diagnose individuals with mental illness The first DSM was
based on the medical model which viewed behavioral and emotional problems as mental disease Although recent revisions of DSM have substantial modification, the focus is still primarily on the presence of illness and problems within the environment and social
relationships (APA, 2013) With this system, a person is assumed to be mentally healthy if individual lacks the criteria for a disorder This classification system often used within the field of psychology which focus on the assessment and intervention of pathological
symptoms and ignores markers of well-being that can support to the prevention and
treatment of mental health problems (Seligman, 2005) At present, the assessment of
individual’s mental health often is based on the measures From literature review, some of the main measures used as the comprehensive assessment tools mental health include the following measures:
The Mental Health Continuum-Short Form (MHC-SF) is a self-report
questionnaire It contains 14-item, which measures three dimensions: emotional well-being (items 1 to 3), psychological well-being (items 9 to 14), and social well-being (items 4-8) Participants rate the frequency of every feeling in the past month on a 6-point Likert scale (never, once or twice a month, about once a week, two or three times a week, almost every day, every day) The internal reliability of the overall MHC-SF Scale was 0.74 (Keyes et al., 2008)
Trang 28The Warwick-Edinburgh Mental Well-being Scale was developed by researchers
at Warwick and Edinburgh Universities in 2007 It measures well-being of adolescent and adults with 14 items, in which all items are worded positively and address aspects of
positive mental health Each item is assessed on a five-point Likert scale ranged from 1 (none of the time) to 5 (all of the time) Total score ranges from 14 to 70, with higher
scores of WEMWBS representing higher levels of mental well-being The Cronbach's alpha
of this instrument was 89 (Stewart-Brown & Janmohamed, 2008)
The General Health Questionnaire (GHQ) was designed by Goldberg in 1970 It is
a self-administered questionnaire to identify psychological distress among adolescents and adults in primary care settings The original version comprised of 60 items with a four-
point scale and subsequently various versions of different length have been constructed item, 28-item, 20-item and 12-item versions) The reported Cronbach’s alpha coefficient for the GHQ is a range of 82 to 86 (Lorraine & Brian, 2014) This instrument is considered as reliable and has been translated into 38 different languages
(30-The Kessler Psychological Distress Scale (K6) developed by Kessler et al (2003)
to assess incidence of serious mental illness It consists of 6-item on feelings of depression, hopelessness, and nervousness that related to mental health of the respondent in the past 30 days Each item is assessed on a five-point Likert-type scale ranged from 1 (all of the time)
to 5 (none of the time) The total score ranged from 6 to 30, with higher scores on the K6 are indicative of higher mental health risk The reported reliability of this scale was α of 89
to 92 (Kessler et al., 2003)
The Symptom Checklist-90 Revised (SCL-90-R) is an instrument for measuring subjects’ psychological symptoms and psychopathologic characteristics It consists of 9 primary symptom dimensions: Obsessive-compulsive, summarization, interpersonal
sensitivity, anxiety, depression, hostility, phobic anxiety, psychoticism, paranoid ideation Each question is rated on a 5-point Likert distress scale from 1(no distress) to 5 (extreme distress) This questionnaire has been shown to have a good to excellent psychometric
properties (McGough & Curry, 1992) The higher the total score indicates lower the total level of mental health Coefficients of internal consistency have been reported for subscales
of the SCL-90-R and global indexes across different patient populations with Cronbach’s alpha ranged from 79 to 90 (Horowitz, Rosenberg, Baer, Ureno, & Villasenor, 1988)
Trang 29The Mental Health Inventory (MHI) was developed by Veit and Ware (1983) It encompasses 38-item which assesses 5 dimensions of mental health including anxiety,
depression, behavioral control, positive affect, and general distress Each item is scored on
a 6-point Likert scale Total scores are calculated by summing up the scores of all items with higher scores indicating better mental health The MHI has been studied extensively in
a variety of populations including with the nursing students (Means-Christensen, Arnau, Tonidandel, Bramson, & Meagher, 2005; Snyder, Lopez, Shorey, Rand, & Feldman, 2003; Susana, José, & Shane, 2011) According to the National Multiple Sclerosis Society, this instrument has a Cronbach's alpha of 93 with full-length version MHI-38 while its
abbreviated version MHI-18 has Cronbach's alpha of 82 Until now, MHI had 3 versions: MHI-38, MHI-18, and MHI-5
In this study, the Mental Health Inventory 18-item version (MHI-18) was selected
to assess mental health of nursing students This is a short version of the original 38-item scale and reported good psychometric properties It measured both psychological distress and psychological well-being aspects while MHI-5 only used for screening depression The MHI-18 has been used to assess mental health in general population, including in nursing students (Angelone, Mattei, Sbarbati, & Orio, 2011; Susana et al., 2011) Specifically,
MHI-18 was used to assess mental health among students of the University of Tehran, Iran (Meybodia et al., 2011) and reported good reliability and yielded coefficient alpha of 93 The MHI-18 was used to assess mental health among nursing students of the University of L’Aquila, in Italy (Angelone et al., 2011)
Mental health among nursing students
From literature review, there were several studies conducted to examine mental health among nursing students worldwide The prevalence of mental health problems
among this population was varied Lotfi et al (2009) studied in 1,686 first year medical sciences students in Iran indicated that of 35.7 % of the students have mental health
problems, and nursing students occupied the highest percentage Other data from some epidemiologic studies among nursing students in China indicated that 7.7 % to 28.7 % of the students experience mental health problems (Liu & Jia, 2008; Wu, 2005) As for
regards Vietnam in particular, there was very little, if any, research that direct deal with mental health in nursing students However, a review literature indicated that nursing
Trang 30students are at high risk of mental health problems (Huong et al., 2011) Baqutayan (2011) stated that the college years are times of significant challenges and considerable stress
Most of nursing students whose ages ranged from 18 to 23 are undergoing an important transition period from adolescence to adulthood (Vatanasin, 2005) This may be one of the most stressful times in a person's life (Buchanan, 2012) In this is period, individuals
continue emotional to grow physically, cognitively, having mental and emotional
instability, which prone them to emotional disturbances Moreover, in examining the term effects of early stress on the hypothalamic-pituitary-adrenal (HPA) glands, hormone changes in females is possibly contributing to an increased vulnerability to mental health problems (Furegato et al., 2008) The fact that studies showed the prevalence of
long-psychological distress as well as some mental disorders, such as depression and anxiety in women are higher than men (Chen, Wang, Gao, & Hu, 2007; Kulkarni, 2008; Mokhtari, Ghasembaklo, Mohammadyari, Mohammadzadeh, & Behestani, 2012) There has been unprecedented increasing in prevalence of college student mental health problems including depression, anxiety, substance abuse issues, and eating disorders (American College Health Association [ACHA], 2009; Soet & Sevig, 2006; Watkins, Hunt, & Eisenberg, 2011) A survey in the United States was conducted also indicated that over 95 % of directors of campus psychological counseling centers reported experiencing a rise in the number of cases that exhibited serious psychological problems among students (Gallagher, 2008) Thus, nursing students who are also in transition period from adolescence to adulthood are included in group that identified as at high risk of mental health problems
In addition, entering in the nursing field, along with facing with the same
developmental challenge as most college students, nursing students often find the culture of nursing colleges to be quite different from their expectations (Thomas & Burk, 2009) The students may be considered to be at risk for developing mental health problems (Jimenez, Navia-Osorio, & Diaz, 2010) A study of Higginson (2006) was done in the school of care sciences at the University of Glamorga, United Kingdom found that first year nursing
students experienced more common with worries and stresses They worried and stressed not only about what they would experience in the clinical area, such as dealing with dying and death, but also about classroom examinations and personal finances The similar results were also found in a study of Shaban et al (2012) In addition, in subsequent years of
study, nursing students begin specific courses and have experiences clinical practice in
Trang 31hospitals Moscaritolo (2009) suggested that this is the most stressful period in a student’s education The situations easily cause stress such as encountering with suffering situations, conflicts between health care staffs can have cumulative negative effects on health and
well-being of students These may become resources of stresses for these students and can lead to mental health problems after that (Sreeramareddy et al., 2007)
Based on the aforementioned studies, it can be seen that mental health in nursing students is significant problem and frequently found.Previous researchers have pointed out that prevalence of mental health problems among this population to be quite high Lotfi et
al (2009) conducted their study with 1,686 first year medical sciences students in Iran and revealed that among 35.7 % students who had mental health problems, and the highest
GHQ scores were seen in nursing students (40.8 %) Similarly, by using the Symptom
Checklist-90 (SCL-90), Liu and Jia (2008) carried out a study to examined mental health in
108 nursing students in China and found that 28.7 % of them had score of SCL-90 higher than Chinese adult norm
Regarding the nursing students in Vietnam, up until now, nursing profession is still recognized as one of a valued profession among the young generation Every year, numerous high school students enroll for this profession In addition, in the recent years, many nursing schools applied new training method based on credit system instead of
traditional training method-academic year system applied in previous years The
characteristics of academic year system are all students have same academic schedule and they have no choice for courses Additionally, amount of time for studying of the students mostly is in classes Conversely, with the new training method, the learners could benefit from selecting courses, reducing amount of time studying in classes, and having more time for self-study etc Nevertheless, according to policy of the credit system, if the students have certain low learning outcome, they will be placed on academic warning and cannot enroll for some certain subjects in the next semester which will influent to their times for graduation All of these have invisibly caused pressure and stress to the students (Aselton, 2012; Xu et al., 2014) Furthermore, similar as most studying nursing context in other
countries, during clinical practice time, the students are required high responsibility,
discretion, and circumspection They also may encounter with suffering situation of
patients, such as cancer disease in young patients, even death sometimes etc As Sreeramareddy et al (2007) stated, all of these may become sources of stress for these
Trang 32students and these have effects on the mental health among the nursing students At present, there are few studies examines mental health among nursing students in Vietnam For most
of the studies found, they examined stress and mental health problems among students in the South of Vietnam Specifically, in a study of Thai (2010) which conducted with 1,226 students in Ho Chi Minh city The prevalence of psychological distress, depression, and anxiety found in this study were 36 %, 26.3 %, and 16.2 %, respectively In addition,
another study conducted in Can Tho University of Medicine and Pharmacy by Nguyen
(2009) found that the number of students that had been considered suicide was high Of which, 6.6 % of them had seriously considered suicide during the past 12 months, and 1.2
% having made a suicide plan In the recent study of Huynh (2009) which collected data from 410 university students in Ho Chi Minh City, they revealed ranges of suicide ideation from 9.2 % to 10.6 % There was only one study by Huong et al (2011) which examined depression among 261 Vietnamese nursing students, and found that 45.6 % of the students reported scores indicating depression Details mentioned thus far affirmed that mental
health problems among nursing students are is also an alarming issue for Vietnamese
nursing students as well
When nursing students have mental health problems, there can be effects on the students themselves, their families, and society For nursing students themselves, mental health issues can negatively impact on the health and academic performance of college students (Regehr, Glancy, & Pitts, 2013) The students may lose concentration in their
study (Wood, 2006) and they may lose of interest in their study and be unable to catch up to class All of these can lead to results in low academic performance In addition, the poor quality of student's life also is mentioned with lose of interest in leisure activities, eating and sleeping disturbances, even suicidal thoughts Nursing students may be at higher risk for suicide than other college students A recent study of Melissa-Halikiopoulou et al
(2011) on 142 Greek nursing students revealed that 10 % reported suicidal thoughts and 1.4
% stated that they might attempt suicide if they had the chance Depression and anxiety are among the strongest risk factors for both attempted and completed suicide (Choi et al.,
2011; Wang, Lai, Hsu, & Hsu, 2011) Similarly, Downs and Eisenberg (2012) studied in
8155 students from 15 U.S universities found that 6.75 % reported suicidal ideation and 5
% reported a suicide attempt in the past year On the other hand, linked to particularities of
Trang 33professional, students have frequent contacts and patient care directly, so quality of patient care also will be reduced
From the review of literature, it can be concluded that nursing students constitute
a group of students who may also vulnerable to develop mental health problems The
mental health problems have adverse effect to nursing students themselves, their families, nursing profession and society In Vietnam at present, there is only few studies focus on investigating mental health in nursing students Therefore,this study aimed at describing mental health of the Vietnamese nursing students and testing its relationships with related factors Data obtained from this study could contribute to better understanding toward
mental health status of nursing students as well as build up baseline data for development
of interventions which help prevent and alleviate mental health problems among the
students is very necessary
Factors related to mental health in nursing students
As mentioned in chapter one, this present study aims to describe the mental health and examine its related factors among Vietnamese nursing students including educational achievement, emotional quotient, self-esteem and social support The further detail was explained as follows:
Educational achievement
Educational achievement refers to the learning outcome of the students that is determined by their performance during classroom activities, assignments, presentations and examinations (Ong & Cheong, 2009) GPA can be used to divide students into groups
by their abilities Education achievement can be seen as a source of their stress (Lazarus & Folkman 1984) This is because entering an academic environment, the students have to struggle to meet the expectations of their parents, of society, which include expectations related to their academic performance (Ang & Huan, 2006; Smith & Renk, 2007) As a result, the students are indirectly subjected to a variety of stressors mainly linked to
academic success (Sreeramareddy et al., 2007) Thus, when students have low GPA, they are more likely developing a negative attitude and behaviors such as sadness, hopeless, depression and even suicidal ideation (DeSimone, 2010) Some other coping strategies also have been used by students, for instance alcohol/ drug abuse and behavioral disengagement
Trang 34(Sreeramareddy et al., 2007) All of these for long period of time can lead to mental health problems
In addition, even the students have better academic achievement may feel worth, proud of themselves and seem to have less mental health problems, they may more likely to pose themselves for higher expectation about their academic success than those have lower GPA Meanwhile, they want to spend more time for their studying and miss leisure activities such as exercise, talking with friends, etc All of these things could also be risks for developing mental health problems (Huong et al., 2011) A study of Parvizrad et
self-al (2014) conducted in 334 medical sciences students in Iran, indicated that academic
achievement of students were related to their mental health (p ≤ 001) Regarding to nursing
students, Beck et al (1997) suggested that examinations and GPA were found as one of cause of stress and related to mental health of nursing students Likewise, Xu et al (2014) conducted a study in 763 college nursing students in China and also indicated that better academic performance was significantly associated with less depression among the students
(p < 05) Based on aforementioned review of literature, it can lead to conclusion that
educational achievement was related to mental health of nursing students Educational
achievement will be selected as one of the factors to be examined in this study
Emotional quotient
Emotional quotient indicates a person’s emotional intelligence, which refers to ability to perceive and express emotion, and regulate emotion in self and others’ (Mayer et al., 2000) It is considered as an important factor in personal mental health (Lok & Bishop, 1999) Remarkable, the importance of EQ has been emphasized increasingly over the last few years (Freshwater & Stickley, 2004) Ciarrochi, Dean, and Anderson (2002) conducted
a study in 302 university students to measure relationship between emotional intelligence, daily hassles, depression, hopelessness, and suicidal ideation The findings indicated that emotional intelligence has also been linked to stress management and mental health There existed a significant relationship of emotional intelligence with mental health in students (Brown & Schutte, 2006; Khosro & Khanzadeh, 2007) A person with high level of EQ will cope better with life's challenges and control one's own emotions more effectively and
contributes to better mental health (Lazarus & Folkman, 1984; Tsaousis & Nikolaou,
2005) In contrast, low level of EI was seen to correlate with some psychiatric disorders such as depression, and educational failure (Birks et al., 2009) Regarding to nursing
Trang 35profession, in addition to gain the knowledge of self, the characteristics of profession
require nursing students to interact with the patients, colleagues and the health care workers constantly Especially, the interactions between nursing students and patient are not only conversations, but also is a complex process that involves the student’s perception and
understanding of the patient's emotions and utilization of the perceptions to manage patient situations towards the goal of effective patient care Thus, emotional quotient needs to be considered In spite of just few studies on emotional intelligence in nursing students, the studies revealed that the inclusion of emotional intelligence in nursing education leads to an increased nursing performance in the possible future profession (Codier, Kooker, &
Shoultz, 2008) It as a prerequisite for effective supervision, appropriate performance in nursing, quality results in clinical nursing Therefore, it considers that emotional quotient can be one of important factors that can influence to mental health of nursing students
Self-esteem
Rosenberg (1965) defined self-esteem as attitudes or ideas of individual toward themselves It is very important because people react to self and others according to their self-perception This is a key component in restoring and maintaining mental health A
number of studies have been indicated that self-esteem was associated with mental health problems (Hubbs, Doyle, Bowden, & Doyle, 2012; Trzesniewski, Donnellan, & Robins, 2003) Specifically, individuals with higher self-esteem can understand themselves and resist negative pressures, and making friends Conversely, with individuals have low self-esteem, they may have pessimistic ideas and feelings of guilt about themselves, resulting in lack of self-worth All of these can lead them to more vulnerable to develop mental health problems (DeLongis & Folkman, 1988) Research findings have indicated that there is
negative association between self-esteem and mental health among college students (Aarif
& Mishra, 2009; Mattanah et al., 2010; Merianos et al., 2013) Regarding to professional,
Ni et al (2010) studied in 515 nursing students in China and found that self-esteem was positively associated with mental health Specifically, high level of self-esteem could
reduce risk of mental health problems among nursing students In Vietnam, Huong et al (2011) investigated factors related to depression in 261 Vietnamese nursing students and
also indicated that self-esteem was negatively related to depression (r = -.33, p < 01)
Trang 36All the above studies have led to a conclusion that self-esteem has correlation with mental health Nursing students in general are in period of late adolescence and early adulthood with traditional aged (Vatanasin, 2005) when they are searching for their
identity Therefore, self-esteem is considered important for them Even though there is few studies report relationship between self-esteem and mental health among nursing students,
it can be seen that self-esteem is one of important factors associated with mental health of nursing students
Social support
Cobb (1976) stated that social support as information leading a person to believe that he or she is cared for and loved, esteemed and valued, and belongs to a network of communicated and mutual obligations It is important for adaptation of individuals Larazus and Folkman (1984) indicated that besides helping people meet their social needs, social support aided people’s ability to respond to stress in daily life Social support is closely related to mental health (Krok, 2014; Thoresen, Jensen, Wentzel-Larsen, & Dyb, 2014) It can decrease individual's mental health problems and increase their ability to against stress (Cobb, 1976; Thoits, 2011) On the other hand, when there is lack of social support, it is very easy for the individuals to feel rejected as they perceive selves as losers, failure or outcast So they become depressed and isolate self (LaFleur, 2010) If these conditions last for long time, they could lead to mental health problems During college years, social
support has been proven as a buffer against major health problems among college students (Merianos, King, & Vidourek, 2012) Regarding to nursing professional, there have been numerous studies indicated that high levels of social support improve mental health and link to lower levels of stress in nursing students (Jensen, 2007; Luo & Wang, 2009;
Montes-Berges & Augusto, 2007) Another study of Jensen (2007) examined the
relationship between social support and distress among 92 baccalaureate nursing students at the University of San Francisco The findings revealed that social support was negative
associated with distress (r = -.27, p < 01) The students who reported lower distress level
were more satisfied with their social support Similarly, Montes-Berges and Augusto
(2007) carried out a study with 119 students of first grade of nursing studies at the
University of Jaén, Spain and found that nursing students with more social support reported better mental health Notably, a lack of social support placed nursing students at a higher risk for depression (Ratanasiripong, 2012)
Trang 37A review of literature of mental health and relevant studies has indicated that
social support was associated with mental health As for nursing students who have high risk of mental health problems, social support is considered very important The students who have enough social support for their needs, they are more likely to deal with stress of life Conversely, the students have low social support are more proven to develop mental health problems
Regarding to sources of social support for nursing students, various studies
indicated that the major sources for social support for the students were their family,
especially their mothers (Ohrt, 2002), friends (Olson, 2010), and society (Huong et al.,
2011) Thus, in this study, social support is considered as emotional support that nursing students received from their family, friends, and society
Conclusion
From the review of relevant literatures related to mental health and its related
factors among nursing students, it can be seen that mental health has been a growing
concern topic in colleges and universities Good mental health can help the students cope with stressors and enjoy life, while poor mental health can cause significant impacts on the students themselves, their families as well as nursing profession and society Nursing
students are the future professional health care providers who play an important role in caring for the patients physically and psychologically Thus, being healthy in both physical and mental health aspects in order to equip themselves knowledge and skills necessary to
be able to provide the best quality of care for the patients after graduation should be
promoted Even though a lot of studies around the world focused on mental health among these nursing students, there were only few studies placed an emphasis on exploring mental health among nursing students in Vietnam Most of the studies found were conducted in the South of Vietnam The findings of existing studies reported prevalence of mental health problems and the alarming issue regarding mental health problems experienced by these students It is expected that the findings obtained from this study would provide baseline data which can be used to inform educational administrators in developing a nursing
curriculum and provide learning experiences for nursing students targeting on alleviating negative mental health and enhancing positive mental health among the nursing students
Trang 38From that the students would able to maximize their full potentials to become competent nurses who could provide effective care to the patients.
Trang 39CHAPTER 3 RESEARCH METHODOLOGY
of Nursing provides nursing education to Vietnamese students who come from all over the country
The nursing curriculum in this study is four year education In the first year, the students learn basic sciences For second year, the study program focuses on subjects
related to nursing profession and start their practicum in laboratory For the third and fourth years, the students study theoretical classes and also practice in clinical and community settings In addition, the evaluation of education achievement is based on standard set by Hai Duong Medical Technical University
Population and sample
Trang 40Sample in this study was nursing students who met the following inclusion
criteria:
1 Age at least 18 years old
2 Have no history of mental illness as diagnosed by psychiatrist such as
k = number of variables examined in this study
Based on the formula, it was calculated as [10(5) + 50] = 100 Since the data
collection for study was based on self-report questionnaires, the researcher included an addition 10 % of the sample needed (Lemeshow, Hosmer, Klar, & Lwanga, 1990) Thus, the final sample size of this study was 110 nursing students
Sampling technique
The simple random sampling method was used to recruit nursing students Firstly, the number of sample from each year (Year 1 to Year 4) was calculated in proportion to get exact number of nursing students for each year Then, simple random sampling was used to recruit the sample from each year The number of sample in each year is shown in Table 1
Table 1 Number of sample in each year of this study
Year of study Number of population Number of sample