Evaluating Nursing Students' Anxiety and Depression during Initial Clinical Experience

Nursing students suffer high levels of stress and anxiety during their education experiences. Clin ical training and first exposure in hospital clin ical training field more stress than class experiences. The purpose of this study was to evaluate the perceived level of stress and anxiety in undergraduate nursing students. In this crosssectional study, data were obtained from 30 students using a self-administered questionnaire "The zung anxiety status inventory (ASI), zung self-rating depression scale". Prevalence of Normal range of depression level was 90%, mildly depressed 6.7% and moderately depressed about 3.3%. However the Zung anxiety status inventory reported only 6.7% of the student had marked to severe anxiety levels. Significant variation in anxiety status was evident with the anxiety scores were ranked as mild or moderate in 53.3% of students. These findings call fo r introduction of stress management programs and psychiatric care into nursing health services of the University. Keywards Anxiety, Depression, Nursing Students, Clinical Area


Introduction
Stress has been identified as a 20th century disease and has been viewed as a co mple x and dynamic transaction between individuals and their environments [1]. Stress is a perceived concept, meaning that it can be caused by anything that one feels unbalances the harmony in life. Different types of stress produce anxiety, which results in feelings of apprehension that can ultimately lead to negative physical, emotional, cognitive and behavioural sympto ms [2]. An xiety and depressive mood are sometimes accompanied by modulation of neuroendocrine and immune functions [3].
College students are at a high risk for increased stress, strenuous academic pressure and limited social and personal time can add to the normal life stressors and begin to be a negative effect [4].
Nursing students and persons employed in the nu rsing profession hav e been identified as a populat ion with an elevated stress level. Stressors for student nurses, identified by Beck & Srivastava, 1991[5], included adjust ing to a rig o rous p rog ram o f theo ry , lo ng hou rs o f st udy and pressures of student clinical practice requiring emotional and personal maturity. The effects of stress on nursing students in clud e so matic an xiety , psych ic an xiety , dep ress ive symptoms, cognitive symptoms, and negatively impacts on academic success [6].
Clin ical experience has been always an integral part of nursing education. It prepares student nurses to be able "doing" as well as "knowing" the clinical princip les in practice. The clinical practice stimulates students to use their critical thin king skills for problem solving [7].
The Nursing student's experiences in their clin ical practice provide greater insight to develop an effective clinical teaching strategy in nursing education and anxiety as a result of feeling inco mpetent, and lack of professional nursing skills and knowledge to take care of various patients in the clin ical setting [8].
The practicum portion of nursing education was identified by nursing students as more stressful than didactic courses.
For nursing students these "real life" situations are stressful due to the fact that patients can be affected negatively or positively. The idea of causing harm, even death to a patient, is a fear for nursing students and nurses [9].
Initial clinical experiences (provid ing care, giv ing injections, co mmunicating with clients, and performing physical exams) was reported as stressful [10] Clin ical experience is a significant learning environ ment that presents challenges may cause nursing student experience an xiety. It is one of the most anxiety producing components of the nursing program which has been identified by nursing students. Lac k of clinical experience, unfamiliar areas, difficult patients, fear of making mistakes and being evaluated by faculty me mbers were expressed by the students as anxiety-producing situations in their init ial clin ical experience [11] The aim of current study is to evaluate nursing student level of an xiety and depression during their initial clinical experience.

Research Design
A cross-sectional study design will use.

Participants
The study was conducted on total number of 30 female nursing students (Level Five), aged fro m 20 to 22 years during first semester 1432-1433H academic year.

Setting
College of Medical Applied Sciences Mohali Asser-King Khalid Un iversity

Measurements
Two questionnaires were used for data collection related to this study, the tools was in Arabic language and reviewed by a group of 5 expert ise in the field of psychiatric nursing and medical surgical nursing to test its validity.
Questionnaire (1): consisted of two parts; part (1) socio demographic data (age, marital status, number of family me mbe rs). Part (2) the zung anxiety status inventory (ASI). It is a 20-item self-report assessment device which includes measures of state and trait anxiety. Answering the statements a person should indicate how much each statement applies to student. Each question is scored on a Lika rt-type scale of 1-4 (based on these replies: "a little o f the t ime," "some o f the time," "good part of the time ," "most of the time"). Overall assessment is done by total score (Zung, 1974) (2): consisted of two parts; part (1) socio demographic data (age, marital status, number of family me mbe rs). Part (2) the zung self-rat ing depression scale (SDS). Is a short self-ad min istered survey to quantify the depressed status of a patient. There are 20 ite ms on the scale that rate the rating affective, psychological and somatic symptoms associated with depression.
There are ten positively worded and ten negatively worded questions. Each question is scored on a scale of 1 through 4 (based on these replies: "a little o f the t ime," "some o f the time," "good part of the time," " most of the time").Scores on the test range from 20 through 80 (Zung, 1965) [13]. The scores fall into four ranges: • 20-49 Normal Range.

Procedure
Review of the current national and international related literature was done by the researcher; Data have been collected over a period of 2 months after approval has been obtained fro m Dean Co llege o f Medical Applied Sciences, Mohail Asser, King Khalid Un iversity.
Data was collected in the first weeks of clin ical application of two courses (matern ity nursing and medical surgical nursing (1), each student completed t wo questionnaires individually.

Ethical Considerati ons
Forma l consent was issued fro m the Co llege of Med ical Applied Sciences-Mohail Asser, King Khalid University.
Co mplete confidentiality of any obtained informat ion was ensured. The researchers have also assured the administration that the conduction of the study will not affect the work in the study settings.

Statistical Method for Analysis
Data entry analyzed using SPSS statistical software packages 0.18. Data presented using descriptive statistics in the form of frequencies and percentages for qualitative variables.

Results
The study included 30 students, depression scale questions illustrated in Table 1 about 43.3% of them did report feeling hopeful about the future plus most of them feel they are useful and needed in nursing branch. so that, this finding explained the total score of depression scale wh ich reported 90% of the sample study with in Norma l range frequencies ( Table 2). The reported rate for the occurrence of anxiety events ranged according to the Zung anxiety status inventory only 6.7% o f the student had marked to severe an xiety levels. Significant variation in an xiety status was evident with the anxiety scores were ranked as mild or moderate in 53.3% of students (table 3). Moreover the finding reported slightly less than one third got bad dreams that scare and Not all students were enjoying with clin ical study, since 56.7% of them did report feeling sick in stomach and feeling like vo miting (table 2).
More than half (53.3%) of study sample had mild to moderate an xiety level Fig. (1). While only 3% of study sample had moderate depression according to zung self-depression scale Fig. (2).

Discussion
The nursing students clearly identified that the initial clin ical experience is a cause of an xiety for the m. There has been limited research on clinical stress, anxiety and depression among Arab population [14]. In this study, the majority of students had Mild to moderate an xiety levels. This was similar to the finding of Bell and Ruth who found that nursing students have a higher level of an xiety [15]. Most studies identified the clinical learning environ ment as primary source of nursing students' stress [16]. Another study [17] carried out on Egyptian baccalaureate nursing students, anxiety reported 46.6% and depression 27.9%. the difference May be related to different age and financial problems.
Moreover Students feel anxious and this anxiety has effect on their performance [18]. In a descriptive correlational study by Beck and Srivastava reported that second, third and fourth year nursing students reported that clinical experience was the most stressful part of the nursing program [5]. In study done by Hart and Rotem stressful events for nursing students during clin ical pract ice have been studied. They found that the initial clinical experience was the most anxiety producing part of their clinical experience [19].
Stressors identified by the students in this study such as self-reported anxiety and depression, increased in first exposure to clin ical area and real situation are similar to what been described in previous studies of similar student groups [20]. Despite some similarity in the types of stressors identified on logistic regression analysis, High Stress was positively associated with number of stressors, and the global sickness index. A meta-analysis of 40 students on psychological distress among U.S. and Canadian college students explo red the relationship between level of perceived stress and student distress [21]. Similarly to the study results which conclude that clinical area will be uneasy or that something terrib le was going to happen.

Conclusions
It is clear that the Saudi student nurses surveyed were exposed to identify the detrimental effects of clin ical training stress on health and academic performance, college administrators should consider incorporating stress management training into orientation activities for nursing students. Other approaches may be the use of stress management, assertiveness skills, time management and counselling sessions, may be effective in reducing anxiety experienced by nursing students. More studies need to be considered at a mu lti-center level using more informat ive sociodemographic, psychosocial and institutional variables in order to confirm the present findings and to enlighten corrective interventions.