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Psychosocial stress factors among mental health nursing students in KSA

Objectives Although existing evidence suggests that nurses may experience significant stress during their training, less is known about the key elements responsible for the distress experienced by mental-health nursing students. This study has examined the psychosocial stress factors that influence mental-health nursing students in a Saudi University. Methods This study has adopted a qualitative interpretive approach, using semi-structured interviews with 10 female fourth-year mental-health nursing students. After the interviews were digitally recorded and transcribed, they underwent content analysis using the NVIVO 10.1 application, generating the themes that emerge in this study. Results The results of the present study make it possible to conceptualise the dynamics that impede the progress of students nearing the end of their final academic year. The analysis focuses on four main themes: (a) the clinical learning context; (b) discrimination against nurses; (c) interpersonal relationships; and (d) social challenges. The statements made by students were analysed for emerging themes; their experiences were subsequently grouped into eight sub-themes. Conclusions The study findings highlight the importance of encouraging students to strengthen peer relationships, improve their own psychological wellbeing, and embrace strategies for managing both personal and academic stress levels. They also reveal that understanding the expectations of students can provide a platform for recognising stressors. Effective interventions can be adopted to improve understanding of stress factors and subsequent stress responses among mental-health nursing students. These results may help to improve students' clinical, social, and academic outcomes.


Abstract
Objectives: Although existing evidence suggests that nurses may experience significant stress during their training, less is known about the key elements responsible for the distress experienced by mental-health nursing students. This study has examined the psychosocial stress factors that influence mental-health nursing students in a Saudi University.
Methods: This study has adopted a qualitative interpretive approach, using semi-structured interviews with 10 female fourth-year mental-health nursing students. After the interviews were digitally recorded and transcribed, they underwent content analysis using the NVIVO 10.1 application, generating the themes that emerge in this study.

Results:
The results of the present study make it possible to conceptualise the dynamics that impede the progress of students nearing the end of their final academic year. The analysis focuses on four main themes: (a) the clinical learning context; (b) discrimination against nurses; (c) interpersonal relationships; and (d) social challenges. The statements made by students were analysed for emerging themes; their experiences were subsequently grouped into eight sub-themes.

Conclusions:
The study findings highlight the importance of encouraging students to strengthen peer relationships, improve their own psychological wellbeing, and embrace strategies for managing both personal and academic stress levels. They also reveal that understanding the expectations of students can provide a platform for recognising stressors. Effective interventions can be adopted to improve understanding of stress factors and subsequent stress responses among mental-health nursing students.

Introduction
There is a large body of research on the implications of distress among nurses and nursing students and its subsequent effect on their overall wellbeing. 1 Although there is also a growing literature on stress and its implications for nurses and nursing students, few studies have focused on the sources or factors that could help to prevent such stress. Stress has been shown to be strongly associated with attrition among mental-health nursing students. 2, 3 Tankink and Bubenzer 4 have explained that stress results from challenging situations that individuals fail to resolve. Although it can be elicited and aggravated by various physical or psychological catalysts, stress varies across individuals based on their own perspective. Perceived stress can therefore be defined as an event believed to stimulate stress. 5 As Clement et al. 6 have pointed out, stress-inducing events are usually subjective. Culbert, Racine, and Klump 7 have suggested that stress consists of the following phases: the context, the behavioral response stage, and the emotional reaction phase. Evidence from studies conducted by Van Gordon et al., 8 Galvin et al., 9 and Morse 1 indicates that little research has been carried out globally on the issue of stress among mental-health nursing students. However, a few studies have addressed issues related to the antecedents of stress among mental-health nursing students. 10 In their study of undergraduates, Jameson and Fusco 11 found that many students experienced stress throughout the academic year. Other studies have highlighted the extent to which the shortage of nurses has contributed to a worsening situation for the world's population. 12,13 These problems are further compounded by the high rates of stress reported by mental-health nurses. 14, 15 Dardas and Ahmad 16 have argued that a heightened stress response will cause the physical and mental health of mental-health nursing students to deteriorate. Stress causes nursing students to feel more detached and apathetic, contributing to their failure to manage and resolve situations. 10 Chou et al. 17 have supported these findings, suggesting that stress inevitably influences problem-solving, memory, attention to detail, and learning processes.
Al-Zayyat and Al-Gamal 18 have identified other stressors experienced by nursing students, including interactions with colleagues, the fear of making errors, a poor work and life balance, financial issues, and family problems. Chernomas and Shapiro 19 have discussed instances where mental-health nursing students found it difficult to manage situations or felt unable to confide in others. The severe stress experienced by mental-health nursing students underlines the need to understand the factors that increase their stress levels.
The literature review found no previous studies on the sources of stress among mental-health nursing students in KSA. Given the identified stressors that impact this group, and the lack of research on these stress factors among nurses, further research is needed to understand the different types and levels of stress experienced by nurses in the Middle East and KSA. The present study aims to determine the psychosocial stress factors that impact mental-health nursing students attending the King Saud University College of Nursing in Riyadh, KSA. Rich and Nugent 20 and Almalki, FitzGerald, and Clark 21 have argued that well-trained healthcare workers are particularly needed in KSA, where the performance of nursing students tends to be affected by social stress.

Research design
This study has adopted an interpretive qualitative approach. According to Lewis,22 interpretive qualitative research explores the perceptions, interests, and experiences of research subjects. As Brooks and Normore 23 have pointed out, phenomenology is the key to describing experiences, as it reveals not only the perceptions, but also the thought processes of individuals experiencing various phenomena. In this approach, interviews are the main method used to collect data.

Setting/participants
The participants were selected from a cohort of fourth-year mental-health nursing students at the King Saud University College of Nursing in Riyadh, KSA. The participants were 10 women with a mean age of 24; all were in their final year. Four participants reported that they shared a house with peers, while six lived with their parents. Six participants stated that their income was almost equivalent to their expenses, while the remainder had expenses that exceeded their income. No participant involved in the study was currently working or married.

Data analysis
The collected data were analysed using NVivo 10.1 software. 22 Themes derived from this analysis identified factors that affected individuals in the mental-health nursing department. These themes were subsequently divided into 8 sub-themes. Thick description, using narratives obtained from the students, was used to illuminate the themes.

Saturation
The present study used theoretical sampling; interview probes, based on data from previous interviews, were continuously revised to explore emerging themes. Each interview was ended when the participant stopped expressing any new inductive codes, as this indicated saturation.

Data collection instruments
A tailored information form was used during the interview process to collect data from the students. As Creswell et al. 24 have noted, the use of individual, face-to-face, semistructured interviews has the greatest potential for obtaining, not simply the respondents' views, but also their underlying motivations.
During the interviews, the participants were asked openended questions. One of the general questions was 'what are some of the sources of stress affecting students within the clinical context?' Additional questions in the questionnaire were based on the research participants' statements and responses. 25 When the interviews were completed, the audio recordings were transcribed as written narratives. Each interview (lasting an average of 55 min) was held in a meeting room in the mental-health nursing department of the nursing college. The interviews continued until data saturation was achieved. 26

Methodological rigor
Throughout this study, all necessary steps were taken to ensure the credibility, dependability, confirmability, and transferability of the investigation. Interviewer bias and expectations were managed, and a degree of subjectivity was adopted during the data review and coding process, thereby safeguarding what Palinkas et al. 27 have referred to as the interpretive epistemology of the findings.
During the interviews, the subjects were asked for additional explanations to ensure that their answers were clearly salient. A parallel, partial data evaluation conducted by the authors validated the results and identified embryonic narratives; a subsequent reappraisal of the transcripts eliminated error and ensured reliability. The authors carried out a comparative assessment and substantiated the coding classifications, as well as carrying out routine consistency checks of both coding and subject areas. Following the six-week period when data were amassed, two researchers reviewed the data codes and categories to reach agreement on their importance and implications. Questions concerning the generalisability of results were addressed by offering a meticulous summary of the investigation and its context. Semi-structured interviews and unstructured dialogues generated valuable insights into the interviewees' opinions, perceptions, and subjective interpretations. For these reasons, it was possible to gain a wide-ranging appreciation of the participants' experiences.

Results
Four over-arching themes were derived from the content analysis and 8 sub-themes. These themes encompassed the students' own views of psychosocial stress and issues related to their own experiences (Table 1).

A-Clinical learning context A1. Skills need
In their responses, most students characterised the clinical learning context as a place where the skills needed to care for patients were learned. Some of these skills were categorised as basic healthcare skills, which, if not acquired, would have a negative effect on quality of care. One of the students said, 'I think that throughout the training period we received inadequate training, and the information given was not substantive enough. Thus, most students refrain from taking on patients and only work on the nursing procedures'.

A2. Insufficient knowledge and training
Many participants made the point that nursing students needed access to scientific sources to build confidence e before being deployed to training centres. When questioned on this topic, one student maintained that 'there is a need to evaluate the source periodically, as most students lack the uninterrupted training to enhance their knowledge'.
These findings indicate that mental-health nursing students experience distress and become overwhelmed when they encounter new experiences in the clinical learning context. The participants attributed the stress they experienced to the complexity of providing care to patients. As one student recalled, 'I was in much distress, and I was scared of providing any care to the patient for fear of causing harm. For example, when giving the patient some medication, I was frightened and prayed for him to stay alive'.

B-Discrimination against nurses B1. Feeling underappreciated
The mental-health nursing students also reported having experienced discrimination. One participant said that she felt underappreciated in KSA. Another, who had encountered this problem with some of her friends, said, 'I have a feeling that the nursing role does not play any significant role in society or in the hospital because what we do is only taking orders from the doctor'.

B2. Society lacks confidence in the nursing role
Another student stated that society perceived the actions of nurses negatively. When society lacks confidence in nurses, the situation worsens. For example, when conducting followup appointments with patients, one student observed, 'our society fails to give nurses, particularly the Saudi women, respect and fails to utilise them or even to seek their advice regarding patient care needs'.

C-Interpersonal relationships C1. Family interpersonal stress
Most participants revealed that they were stressed as a result of interpersonal relationships. In the words of one Most of the mental-health nursing students revealed that they were stressed by aspects of the educational environment. As one participant said, 'most of the stress impacting me came from the educational setting, such as in school and from my peers'. D-Social challenges D1. Financial constraints Some participants highlighted factors associated with social challenges as a source of stress. One participant cited financial constraints as a social challenge, saying: 'in addition to the social responsibilities I had from my family, I experienced challenges as there were competing expenses I needed to sort out but I could not manage because I did not have enough money and this left me stressed'.

D2. Social pressure
Another participant implicated social pressure: 'the issue of committing myself to attending certain activities and events has not been fruitful'. Both social and educational activities were understood to be a source of psychological pressure for most mental-health nursing students.

Discussion
In summary, the qualitative data revealed several factors associated with psychosocial stress among mental-health nursing students. These factors related to four thematic areas, namely, the clinical learning context, discrimination against nurses, interpersonal relationships, and social challenges. This finding confirms the work of Vivekananda-Schmidt, 28 who recognised that the actual experience of psychosocial stress must be taken into account. For this reason, the prevalence of psychosocial stress among mental-health nursing students is an important topic. Most of the experiences uncovered in this study were consistent with the evidence presented in Singh, Sharma, and Sharma 29 and Chernomas and Shapiro, 19 who identified clinical and academic learning, financial support, relationships, and environmental social stress factors as stressors. It is evident from the results of the current study that these themes are significant and endorsed by the present participants. They are also consistent with the work of Bahadır-Yılmaz, 30 who observed the impact of these factors among Turkish mental-health nursing students. Their stress levels were linked to psychological and behavioural issues, as well as to poor clinical and academic performance. Research has shown that mental-health nursing students experience a different level of stress from medical, graduate, or undergraduate students. 31,32 The findings of the current study also corroborate elements of the work of Jimenez et al. 33 and Gibbons, Dempster, and Moutray. 35. These studies reported that the academic environment, social distress, financial constraints, and interpersonal relationships were sources of stress among mental-health nursing students. It is important to note that the present findings are likewise consistent with research conducted in the Philippines, where similar levels of stress were reported by students. 35 The findings of the present study confirm outcomes reported by Adriaenssens, De Gucht, and Maes, 36 who studied mental-health nursing students in the UK. Szpak and Kameg 37 have highlighted factors that affect nursing performance, such as financial constraints, health problems, and interpersonal complications. Previous studies have also supported the current finding that stress factors affect the learning performance of students and even practicing nurses. 38 Nurses encounter challenges, including work conflicts with staff members, the care of critical patients, and patients with interpersonal problems. 39,40 According to Christiansen and Bell 41 and Connor et al., 42 mental-health nursing students are likely to experience stressors while developing their clinical skills. Other stressors are associated with the learning context, for example, failures to adopt or learn practical skills. 34,43,44 Tight deadlines during placements, coupled with evaluations and frequent performance activities, also cause stress. This finding is consistent with studies that have identified nursing-staff attitudes as a source of stress for students on placement. 32,45,46 Further evidence indicates that placement organisations fail to address the source of stressors typically found in such institutions. 46,47 The participants experienced discrimination during their clinical training, which contributed to their psychosocial stress. Further research is needed to illuminate the multifaceted impact of discrimination on individuals, and its psychological, social, and biological consequences. It is well established that health is negatively affected by discrimination. Additional evidence shows that health and wellbeing are adversely impacted by discriminatory interactions, such as ill-treatment in educational settings and when seeking employment, housing, or healthcare. 48 Individuals with unconscious prejudices may display discriminatory behavior. 49 Interactions may cause other individuals to internalise discrimination, which is known to have severe repercussions for health, including restriction of social networks, 50 poorer quality of life, 51 low self-esteem, 52 signs of depression, 53 and loss of job and income. 54 Furthermore, studies of discrimination have highlighted the importance of predicting chronically triggered psychological stress reactions that can disrupt interpersonal social interactions. 55 The participants in this study noted that interpersonal relationships and social and financial constraints contributed to their psychosocial stress. This is consistent with Murff, 56 Zhao et al., 57 Tovar, 58 and Sa´nchez et al., 59 who confirmed that existing responsibilities and social relationships were key stress factors for individuals. The present study also confirms Ghaderi and Rangaiah's 60 research on Indian and Iranian mental-health student nurses, who associated stress with social challenges and responsibilities. However, Reeve et al. 61 and Gro¨pel, Kuhl, and Work 62 have shown that social support derived from family and friends can help mental-health nursing students manage their stress, reducing poor academic performance.
The participants in this study described various ways in which financial stress affected them in the academic environment. Garrosa et al., 63 Goff,47 and Kang, Choi, and Ryu 64 have likewise shown that financial constraints can have a major negative impact on mental-health nursing students, engendering poor academic performance. Academic achievement is affected by financial problems, workload, socio-personal relationships, and emotional factors. 43,65 Numerous studies have highlighted personal sources of stress, associated primarily with financial concerns and tight deadlines. 42,44,45 While these issues are common among all students, they are more prominent among mental-health nursing students, as Adriaenssens et al. 36 have shown, due to specific issues relating to family commitments, change processes, and career demands.

Study limitations
This study does have some limitations, due to the nature of the research design and the sample selected. For this reason, its findings may not be easily generalisable to nurses in other specialties. Nevertheless, the present study provides new information on the stress experienced by mental-health nursing students in KSA.

Conclusion
The study participants identified problematic instances of psychosocial stress associated with their chosen field of study. The forms of stress experienced by mental-health nursing students have been grouped into the following four thematic areas: the clinical learning context, discrimination against nurses, interpersonal relationships, and social challenges. Findings have revealed the interactions among stress factors, attributing many of the students' challenges and feelings of distress to stress factors and their respective causes. 37 It is thus essential to provide students with a clear work-life balance, so that they can maintain good relationships with family and friends. Programmes must adopt a clear strategy to provide physical and psychological management strategies to those experiencing stress. Future research is needed to explore the implications of stress within this cohort. The present study findings concur with literature on the factors that link stress and the wellbeing of mentalhealth nursing students. 30 Students are advised to use social and peer relationships to relieve and cope with stress. Future studies may focus on student concerns, showing empathy and providing guidance. 66

Source of funding
None declared.

Conflict of interest
The author has no conflict of interest to declare.

Ethical approval
Permission and approval for this study were granted by the Institutional Review Board of King Saud University, which also permitted interviews to be recorded during the research process. Before taking part, participants were briefed on the purpose of the study and informed that their information and personal details would be kept confidential and anonymous. All participants signed an informed consent form, which confirmed that they could withdraw from the study at any time, could not be identified by their responses, and would have enough time to complete the process; in addition, their participation or non-participation would not affect any academic assessment. The researcher has obtained the approval of king Saud University internal review board to collect the data.