Among a cohort of undergraduate nurses who commenced their nursing training at a HEI in Scotland, a clear picture emerges of students experiencing deteriorating mental health over the course of their degree, and a decline in physical activity. Results for other health behaviours and associated outcomes were less clear cut, although alcohol consumption and smoking declined over the study period. Perhaps the most concerning result are the high proportions of students, increasing steadily over the course of the programme, self-reporting poor or very poor mental health. By the beginning of their third year, half of all students had a WEMWBS score indicative of a risk or high risk of major depression, or high risk of psychological distress. While, it could be that the survey was administered at a particularly stressful point in the programme, the clear trend over time belies this. The results of a linear regression analysis among a subgroup of 51 students confirm that the data are consistent with a real effect over time. There may therefore be a need for more targeted monitoring and support for the mental health of undergraduate nursing students. This is an international concern, and has prompted a study following up stress among nursing students in the US as they transition to their first job11. Potential poor psychological health among the nursing workforce is extremely worrying, given that they are likely to have longer careers than their predecessors, and require psychological capacity and resilience to provide high standards of nursing care.
The other health behaviour measure for which there was some evidence of significant worsening over time in the cross-sectional results was physical activity, but this was not evident among the subgroup of 51 students for whom data were available at all three time-points. Neither was it reflected in results for BMI, although there are unlikely to be substantial changes within the limited time frame of this study. Despite this, the current level of overweight/obesity among nurses in Scotland is 69%12 and it is worrying that a decline in physical activity is already evident among students before they have even left further education. Other studies among nursing students in the US13, Spain and Colombia14, Hong Kong15 and Thailand16 have also found the majority of students not meeting physical activity guidelines. We have carried out qualitative research among second year student nurses who report that they find it increasingly difficult to build physical activity into their daily lives, given the time pressures of studying, working and attending clinical placements.
Interestingly, there were some positive results such as a decline in smoking, with a suggestion that some daily smokers may have been reducing smoking frequency. While this was not evident among the sub-group of 51 students, in a separate (as yet unpublished) study some referred to the striking impact of observing the direct effects of smoking in clinical practice which may be a cue for action to behaviour change. This is important as meta-analysis indicates that smoking in nursing students is high worldwide17. However, in a study in Spain and Portugal the proportions of students smoking increased with each successive year18. Further research is needed on how to reverse this trend.
This study relied upon the use of a self-report questionnaire, the limitation being that the accuracy of student responses cannot be guaranteed. Student responses may have been influenced by social desirability bias, and/or by an increased awareness of the importance of health behaviours as a result of their undergraduate training. Many of the questions categorised respondents into relatively wide categories, although the survey was intended to identify broad areas of concern warranting further investigation or intervention, for which very sensitive measures were not necessarily required. One weakness of the study was the lower response rate among third year students. The survey was administered during a timetabled session. Either student turn-out was particularly low for this session, or many students decided not to return their questionnaire. The question is whether non-response was associated with poorer self-rated health or health behaviours; in which case we might expect students in better health to be more likely to attend class and therefore improved health among the third year group; this did not appear to be the case. Although we identified 51 students for whom data were available at three time-points, patterns observed in cross-sectional analyses were not observed in this smaller sub-group for smoking and physical activity. It is important to note though that these health behaviours appeared more favourable than in the entire cohort so these 51 students may not be representative of the entire cohort for health behaviours. In contrast, in their first year, their mean WEMWBS score (indicative of mental wellbeing), was similar to that of the overall cohort.
Our study has identified an important overall trend of declining mental health among undergraduate nursing students over time. Given the substantial body of evidence indicating that physical activity improves mental wellbeing19,20, it is likely that they would benefit from increased levels of physical activity.