Introduction
The world was facing unprecedented challenges in the face of a global pandemic. Corona virus 2019 has, to date, killed thousands worldwide. The data related to number of tests administered, positive cases, hospitalization, and deaths, changes on an hourly basis. Mounting concerns regarding the strain on health care systems globally are already occurring and likely to get significantly worse.1 This health crises impact not only front line staff and clinical leaders but all systems and communities. COVID 19 has also already disrupted Universities and academic institutions. Within the health, field, schools, nursing colleges are bracing for unique challenges related to their role in helping and to develop the next generation of care providers.1, 2
COVD 19 also causes a great challenge to health education system. During the first few weeks of pandemic children were kept away from clinical environment. In the later days preceding this decision, numerous questions and concerns where shared in online meeting, over conference call and in urgent emails among colleges while the majority learning is conducted online. Students in this program must complete clinical placement individually to fulfill the Bachelor of nursing degree requirements. If the students were exposed to COVID 19 while in a clinical setting, there is risk for their health and also to their family. Researchers also have to consider that the students could face the financial burden of being quarantined. Additionally, as a post-licensed program, if students were exposed, they would be unable to return to work, adding further strain to the health system.3
Students express concern about what an interruption in their nursing education would mean for their future careers as a registered nurse. Many students in clinical placement where focusing on the clinical practices and thus close to successfully completing their programmes. Some learners were only one or two courses away from completion of their BSc nursing degree. Since our health field is fighting against a pandemic, nursing students miss an opportunity to beat this pandemic along with our health system.3, 4 If the nursing students were able to enter clinics or graduate, this opportunity may help them to become a better version of themselves in providing care because in a present scenario the major problem faced by hospital setting is lack of nursing staff this can be the reason for lacking of future care resources too. So if nursing students can contribute somewhat it will help in gaining the resources. Now most of the hospitals need more staff due to this situation students cannot start to do jobs. In addition to cancelling their current clinical placement they have concern about progressing in the rest of their program. Some students may have felt selfish and were frightened about not reaching the career goals that they have worked so hard to obtain. Nurse educators may face difficult discussion on supporting the public and the clinical colleges. However, there also must be a consideration for the needs of current and future nursing students. Even with all the fear and anxiety there are lessons in hope. Students main concerns have been the health of patients and communities.3 Now the students have almost honest thoughts on the impact of this pandemic worldwide. They are studying about the role of registered nurses in online classes.
The study was conducted to assess the level of examination anxiety among B.Sc nursing students in a selected college at Coimbatore. The results revealed that there was a significant increase in examination anxiety among Undergraduate Nursing students.4
Nurses’ competence is based on the knowledge and skill taught to them. Nursing education is combined with clinical and theoretical learning. Due to emergence of COVID 19 pandemic, B.Sc nursing students had an anxiety about future due to lack of clinical practices. Investigators also felt anxiety regarding their course completion, clinical practices, examinations, financial constraints of their family; moreover there were only a few studies in this area. So it is decided to conduct a study to assess anxiety and its causes among Undergraduate nursing students during COVID 19 pandemic.
Materials and Methods
Study was conducted as a part of a research project, for the partial fulfillment of the requirement of 3rd year Undergraduate Nursing degree course. A quantitative approach, descriptive survey design was used. Study was conducted in Kerala India. The participants were 200 student nurses from Ernakulum District. Data collected in the month of March 2022.
The study participants were recruited using convenient cluster sampling method from three different private Nursing colleges of Ernakulam District, Kerala. Subjects were explained about the purpose of the study and were ensured that data collected would be kept confidential and would be used only for research purpose. The data collected using demographic data sheet for assessing the selected demographic variables, rating scale to assess anxiety during COVID 19 pandemic semi-structured questionnaire was given to assess the causes of anxiety among Undergraduate nursing students.
Tools of data collection
The tool comprised of anxiety rating scale and a semi structured questionnaire to find anxiety and its causes among Undergraduate nursing during COVID 19 pandemic in selected colleges of Ernakulam district.
Tool 1 – Anxiety rating scale
Section A: Socio - demographic data sheet consist of questions in relation to the socio demographic factors.
Demographic data includes gender, year of study, area of residency, place of residence, family income, parental occupation, source of funding.
Section B: Anxiety rating scale to assess anxiety among Undergraduate Nursing students.
Anxiety scale consist of 40 positive statements under the headings academic, theory and practical examination, skill acquisition, communication, finance, future career, disease transmission, physical problems carrying four options each ,which is never, sometimes, rarely, often, always Tool 2 – Semi-structured questionnaire to assess the causes of anxiety among B.Sc nursing students.
Data collection process
A formal administrative sanction to conduct the study was obtained from the authorities. Data collection was done from three private Nursing colleges of Ernakulam district. Convenient, quota sampling technique was used to select 200 subjects. Subjects were explained about the purpose of the study and were ensured that data collected would be kept confidential and would be used only for research purpose. The data collected using demographic data sheet for assessing the selected demographic variables, rating scale to assess anxiety during COVID 19 pandemic semi-structured questionnaire was given to assess the causes of anxiety among Undergraduate nursing students.
Results
Details of sample characteristics are given in Table 1, Table 2
Sample characteristics
Table 1
Demographic characteristics of the participantsN=200
Table 1 showed that all (100 %) of subjects were females and, about 25% of subjects were taken from each first, second, third and fourth years. Among them 87% of those subjects were living in urban area whereas 13%of them were in rural area. About 73.5% of them were day scholars and outside hostel include 16.5% and remaining 10.5% of them were residing at college hostel. From this it is understood that out of 200 subjects majority of subjects were females and 25% of each subjects were chosen from first, second, third and fourth years about 73.5% of them were day scholars and are from urban area.
Table 2
Frequency and percentage distribution of nursing students according to family income, parental occupation, source of funding for the study. N = 200
The data presented in Table 2 showed that about 33 % of the subjects had a family income of 99,999-50,000 whereas 28% of them were of the income in a range of 1,00,00-2,00,00 ,among them 17.5% of them had an income of less than 2,00,00.In the parental occupation 36% of the fathers were private employees, 21% of them were government employees, 26% of them work as daily wages and 18.5% of them does other jobs. Among mother’s 39.5% of them are house wife,16.5% of them are Govt employees and remaining 31% of them are private employees about 13.5% of them works for daily wages and 2.5% does other jobs. 46 % of them had other source of funding for the study, 26% of them had funding for the study by domestic educational loan, and 21% of them had karshika loan as the funding for the study. remaining 7% of them had gold loan.
Anxiety among undergraduate nursing students during COVID 19 pandemic
This section deals with data pertaining to the anxiety levels of Undergraduate nursing students during COVID 19 pandemic. The data was collected by anxiety rating scale and were graded as mild, moderate and severe anxiety. The data was analyzed and interpreted using descriptive statistics in terms of frequency and percentage distribution and is presented in.Figure 2
Figure 1
Pie diagram showing frequency and percentage distribution of nursing students based on level of anxiety.
Figure 1 depicts that the 50% of subjects had mild anxiety whereas 49.5 % had moderate anxiety and remaining. 5% had severe anxiety.
Causes of anxiety among undergraduate nursing students during COVID 19 pandemic
This section deals with the data pertaining to causes of anxiety among Undergraduate nursing students during COVID 19 pandemic. The data was collected by semi structured questionnaire. The data was analyzed and interpreted using descriptive statistics in terms of frequency and percentage distribution and is presented in Figure 2.
Figure 2
Bar diagram showing frequency and percentage distribution of causes of anxiety among nursing students related to technical issues.
Figure 2 showed that the 31.5% of students had problems of low speed internet, 35.5% of them had power cut issues, 39.5% of students had issues due to changes in weather that interrupt the classes, 62% of them had heavy battery consumption, 45% of them had insufficient data package to attend the classes, 51.5% of them had frequent disconnection issues, 62% of them had reduced storage spaces, 21% of students were sharing their phone with parents or siblings, 28.5% of them were not able to log in video and audio simultaneously.
Table 3
Frequency and percentage distribution of causes of anxiety among nursing students related to academic issues –online class. N=200
It is clear from the aboveTable 2 that 64.5% were not able to understand the topics, 45% of them were feeling bored with online classes, 32% reported that the information were too bulky, 33.5% of them were not able to understand the online demonstrations, 29% of them were not physically present even though they login to the classes, 44 % of them reported about lack of study materials and43.5% were not interested in online quiz and tests.34% of them had adaptation difficulties. 39.5% were having lack of facility to utilize library and distraction in online classes with pop up messages. 25.5% of the subjects were not having sincerity to search and refer contents adequately,58.5% of them had increased workload,51 % of the subjects reported that the influence of social media between the online classe, 36.5% of them had difficulties for uploading of assignments,21% were having lack of standardized patients clinical settings.
Figure 3
Pie diagram showing frequency and percentage distribution of causes of anxiety among nursing students related to academic issues- theory and practical examinations.
Figure 3 showed that 63.5% of the subjects had a concern regarding delaying of exams, about 60.5% of them had fear of postponement of examinations and unclear portions, whereas 50% of them had concern regarding lack of clarity in commencement of next academic years and 37 % of subjects reported that changes in manners in which exams were conducted and the remaining 17. 5% 3 of the subjects had lack of competitive spirit between peers
Table 4
Frequency and percentage distribution of causes of anxiety among nursing students related to academic issues-skill acquisition N=200
Table 4 showed that 18% of the subjects were not provided with required posting in respective clinical area and missed clinical exposure,18.5% of them had concerns about the ability to work independently as a nurse and 28 % of them were lacking practical skills, 34% had to complete the remaining practical before the completion of the course, 39 % of them had lack of familiarity with OSCE, 11% of students missed clinical exposures and was concentrated in lab practical’s, 28 % were unable to follow the right techniques, 20.5% were not having sufficient time in the academic year to complete 100% clinical experience,50.5% of students completed only 80% of practical requirements.
Figure 4
Bar diagram showing frequency and percentage distribution of causes of anxiety among nursing students related to communication and financial issues.
Figure 4 showed that 88.5 % of them had decreased interaction with teachers due to online classes, about 34.5 % of them had decreased interaction with peer group, 43% of them were unable to maintain nurse patient relationship effectively whereas 37.5% them had financial burden due to delay in course completion. 59% of them reported that increased expenses for PPE kit was a burden for them and 57% were unable to bear expenses of COVID tests. Among them 34.5% of them were unable to maintain healthy team relationship. 31.5% of them were unable to bear the expenses for internet data packages, 8.5% reported about jobless parents, 27.5% of them had insufficient salary of parents,19.5 % of them had increased debts and 21% of them were unable to repay loan on time.
Figure 5
Pie diagram showing frequency and percentage distribution of causes of anxiety among nursing students related to concerns of future career.
Figure 5 shows that, 29% of them had migration difficulties, 25 % of them were anxious about the changes in hospital routines and policies, about 14 % of the subjects had improper training, whereas 11% of them were feared about the malpractices in recruitment.
Figure 6
Frequency and percentage distribution of causes of anxiety among nursing students related to concerns of disease transmission.
Figure 6 showed that sixty-one percentage had fear of getting infection,59% of them had fear of transmitting infection and 52.5% of them had fear about missing classes and clinics due to infections that has lead to attendance problems, 36 % of them were not able to follow social distancing guidelines strictly and 38.5% were anxious about unsafe workplaces, 47% of them had unavailability of sufficient PPE kit, 18% of them had fear of death, 48.5% of the students were not confident about vaccination efficacy, 42.5% of them had fear of isolation from family and friends, 54.5% of them had self quarantine difficulties.
Discussion
The current study provided information regarding the anxiety and its causes among B.Sc Nursing students during covid 19 pandemic, 100 % of subjects were females and most of them residing in the college hostel and majority of subjects had financial crisis due to the loss of jobs of their parents. Most of the subjects had taken loan to meet the expense of their education.
These findings were consistent with the findings of an another study conducted in Pune, to assess the, anxiety levels and coping strategies among nursing students during the COVID-19 Pandemic. The sample size consists of 316 nursing students. Based on the socio-demographic characteristics female predominance was observed and most of them had financial crisis as their parents lost their job.5, 1, 3
The present study showed that 50% of subjects had mild anxiety whereas 49.5 % had moderate anxiety and remaining 0.5% had severe anxiety. These findings were consistent with the findings of another study conducted in Nepal to find out Anxiety among Nursing Students towards Clinical Placement during COVID-19.6
A cross-sectional study was conducted in Iran to assess the Prevalence of generalized anxiety disorder among nursing students in Iran during the COVID-19 pandemic. This study findings were similar to the present study as the majority of subjects were having mild, moderate and severe anxiety.7, 8, 9 Contradictory to this study, the present study does not have any subjects with no anxiety.
A web based study was conducted to assess the, Anxiety Levels and Coping Strategies among nursing students during the COVID-19 Pandemic in Saudi Arabia. Findings of study showed that 32.3% of the students had mild anxiety, 40.5% had moderate anxiety, 22.5% had high anxiety, and 4.7% had severe anxiety during the COVID-19 pandemic.10, 11, 12, 13 This study is similar to the present study as it had subjects with mild, moderate and severe anxiety.
The present study showed that 62% of them reported about heavy battery consumption and reduced storage spaces in their phone was a cause of concern too. About 64.5% of the subjects found the greater cause of concern in academic issues was inability to understand the topic that were taken in online classes. Among them 39% of the subjects had lack of familiarity with the OSCE examination. 88.5 % of them had decreased interaction with teachers due to online classes found the major cause of anxiety.62% of subjects found that the increased expenses of PPE kit was an issue whereas 25% of subjects were concerned about future career. Among them 61% of the subjects had concern regarding disease transmission.
These findings were similar with the findings of another study conducted among nursing students in Kerala, to determine attitude and related problems of online learning among Undergraduate Nursing students during COVID-19 pandemic. Study revealed that net issues and heavy battery consumption and related financial crisis was the major problems identified8. Similar findings was there in several other studies.14, 15, 12
Strength and limitations of the study
The study helped to reveal anxiety and its causes among B.Sc Nursing students during Covid 19 pandemic. The major limitation of the study was that it was conducted among Undergraduate Nursing students of only three private nursing colleges at Ernakulam which may not be a true representation of the target population. Data was collected through questionnaire and ratings scale technique used were self reporting and self rating in which there was an element of guessing that can influence the actual scores. So generalization should be done with caution
Conclusion
The study was focused to assess anxiety and its causes among Undergraduate nursing students during COVID 19 pandemic. The tool used were socio-demographic data sheet, anxiety rating scale to assess anxiety among Undergraduate nursing students and semi structured questionnaire to assess causes of anxiety. Convenient, cluster sampling was used to collect data from 200 subjects who met the inclusion criteria. Quantitative approach was used. Based on the study, the researchers realized 50 % of them are having mild anxiety, 49.5% of them are having moderate anxiety and remaining 0.5 % had severe anxiety were assessed through anxiety rating scale. Major causes of anxiety identified were technical issues while attending online classes, academic issues, lack of communication, financial crisis and future concerns. The study findings gave an insight to the nurse educators to pay attention to students problems during pandemics and other disasters.
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