INTRODUCTION

In contemporary society, the psychological conditions of individuals have been a growing field of concern due to their impact on quality of life and human well-being. Among the main psychological conditions are stress, anxiety and depression. During graduation is not different, because the students go through changes and adaptations, which can trigger the appearance of these symptoms of mental disorders, and may, for example, negatively influence the learning process and, consequently, in the service that will be performed in the future⁽¹⁾.

According to the World Health Organization (WHO), stress is defined as any change that generates physical, emotional or psychological wear. This is because when a human being is under stress, the Central Nervous System triggers the "fight or scape" response system, causing the body to prepare itself to fight or flee from a threat. However, this is a natural physiological response of the human body to situations where it is necessary to act quickly, but when this occurs continuously, it affects other body systems such as skeletal muscle, respiratory, cardiovascular, gastrointestinal and others^(2,3).

Furthermore, according to the Ministry of Health, anxiety is defined as a normal emotional response, functioning with an alert mechanism in front of real or perceived threats, serving for our protection. Such a response, however, when it becomes exaggerated or disproportionate, can develop into a disorder. The symptoms of anxiety often include physical manifestations and are commonly accompanied by thoughts of uncertainty, prediction of difficulties or catastrophic ideas, which can lead to behavioral changes, avoiding situations that provoke fear. This condition can manifest as a symptom of psychiatric diseases as well as a non-pathological emotional reaction in various contexts of life. In addition, the global proportion of people with Anxiety Disorder (AD) worldwide is 3.6%; in Brazil, this proportion rises to 9.3%, covering the population with the highest number of cases of AD in the world⁽⁴⁾.

Another important psychological condition is depression, defined as a mental disorder marked by prolonged sadness and significant loss of interest in activities that were previously pleasurable and satisfying. Research indicates that, throughout life, up to 20% of women and 12% of men may present frequency of certain conditions. Studies show that continuous stress situations related to limited contact with pleasurable moments can generate feelings related to anxiety and depression^(4,5).

Some studies suggest that health academics may experience high levels of stress, anxiety and depression due to the need required by the course to perform theoretical practices, requiring proximity to the patient and his suffering without having preparation to deal with their own emotional, besides there is concern about the future insertion in the market^(6,7). These experiences can trigger psychological distress factors that hinder the teaching-learning process and compromise the development of decision-making capacity, creation of effective bond with the patient⁽⁸⁾, fear to help due to insecurity ⁽⁶⁾ and there is evolution with the use of psychoactive drugs⁽⁷⁾.

Nevertheless, students with anxiety and depression have lower self-esteem and self-efficacy rates than those who are not diagnosed. This aspect reflects the need for psycho-educational strategies to strengthen emotional skills and, in the future, the training of nurses with adequate emotional intelligence⁽⁹⁾.

In this scenario, the National Student Assistance Policy (NSAP) of 2024 discusses the Program for Attention to Students' Mental Health (ASMH), which envisions an academic life with more information and communication about mental health, and value a warm and compassionate education, especially for students who face mental distress⁽¹⁰⁾.

When educational institutions identify and intervene in situations of psychological stress, besides improving academic performance, they influence the long-term professional profile positively⁽¹¹⁾, especially when the intervention occurs in the first years of graduation⁽⁹⁾.

Therefore, it is essential to understand mental health as "a complex phenomenon that reflects the interaction between biological, psychological and social components", in addition to environmental⁽¹²⁾. Therefore, the importance of identifying, supporting and monitoring health students is highlighted, as they play a crucial role in promoting collective well-being.

Therefore, there is a need for more studies on the evaluation of the level of stress, anxiety and depression specific to the population of nursing academics, making it possible to expand the scientific evidence and explore effective strategies for health promotion even in undergraduate studies, so that, in the future, as nurses, they can take responsibility for the excellence of care of others, especially from the care of themselves.

Thus, the objective of this study was to verify the frequency of symptoms of anxiety, depression and stress in nursing students. The hypothesis was confirmed in the frequency of symptoms of anxiety, stress and depression in nursing students greater than 30%.

METHODOLOGY

For the conduct and reporting of this study, the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) was adopted, according to the guidelines of the EQUATOR network.

Design, study location and period

It is a research of the transversal type, with quantitative approach. Data collection took place in the graduation rooms of a public higher education institution (PHEI) during the months of October and November 2023, in the morning and afternoon.

Population and sample

The total population was 329 nursing students, and the study sample consisted of 199 students, regularly enrolled in the course from the first to the tenth period, recruited in a non-probabilistic way from an invitation made during the data collection period. It is noteworthy that the participation of students in the 9^th and 10^th periods was lower, because they were in a period of curricular internship, therefore absent from academic activities on site.

Inclusion and exclusion criteria

Students over 18 years old and who were regularly attending the nursing course in any of the 10 periods were included. Students who attended another concurrent undergraduate and pregnant were excluded, as it is a period in which the woman may be more sensitive and sensitized, a situation that can influence the results and be a potential bias. This decision-making was configured to reduce potential confounding factors.

Study protocol

Students were invited to participate in the survey through the WhatsApp application and face-to-face, aiming to reach as many students as possible. Most of the academics who agreed to participate in the study conducted the face-to-face survey, and only three students with impossibility of displacement participated in the live Google Meet application.

Thus, the operation of the research was presented in detail, with due formality and clarity, healing doubts that arose throughout the explanation. Then, a printed questionnaire was applied to characterize the sociodemographic, academic, lifestyle and mental health history data, in addition to the Depression Anxiety Stress Scale - 21 items (DASS 21), adapted and validated for the Portuguese language, except for the three academics who answered the electronic questionnaire. The choice of the scale was because other studies used it for data collection in university students of medicine and nursing^(13,14,15), given the vulnerability to negative emotional states, by the growing and required adaptations in this stage of life to the academic, personal and social environment, while aiming at the professional future.

In the questionnaire for characterization, are among the sociodemographic variables sex, ethnicity, has dependents, number of dependants, marital status, religion, income and financial support; while the academic factors include desperiodization, hours of daily study, time until the PHEI, performance of paid activity, academic pending and interest in leaving the course. On lifestyle, include regular use of alcohol and tobacco and physical activity. Regarding the clinical history of mental health, there is a prior diagnosis of anxiety and depression, regular use of medication for treatment and regular psychological monitoring.

The DASS-21 scale is of the Likert type ranging from 0 to 3 points, being: 0 – "did not apply at all", 1 – "applied in some degree or for a short time"; 2 – "applied in a considerable degree or for a good part of the time"; 3 – "applied much or most of the time". Thus, the score of each subscale of DASS-21 goes from 0 to 21, which must be multiplied by two to obtain the final scores, allowing the following classification: depression: normal from 0 to 9, mild from 10 to 13, moderate from 14 to 20, severe from 21 to 27, extremely serious 28 or greater; anxiety: normal from 0 to 7, mild from 8 to 9, moderate from 10 to 14, severe from 15 to 19, extremely severe 20 or greater; stress: normal from 0 to 14, mild from 15 to 18, severe from 19 to 25, extremely severe from 26 to 33. Therefore, this scale categorizes symptoms at different levels, ranging from normal to very severe, allowing a comprehensive assessment of the participants' mental health over the past few months.

Analysis of results and statistics

In this study, a comprehensive analysis of the data collected was carried out using descriptive statistical techniques and central trend measures to understand the distribution and centrality of the variables of interest. The continuous variables related to depression, anxiety and stress were submitted to a linear regression analysis to explore their interactions.

Ethical aspects

The research was conducted in accordance with the ethical guidelines of Resolution N 466/2012 of the National Health Council and approved by the Ethics Committee for Research, under CAAE N 70505623.4.0000.5147 and Opinion N 6.259.751. After meeting the inclusion criteria, the Terms of Free and Informed Consent (FIC) were distributed to participants. Only those who agreed to participate and signed up for the FIC were included in the study, ensuring the voluntary nature of participation and confidentiality of the information collected.

RESULTS

Participated in this study 199 academic of the nursing course, corresponding to 60.48% of students enrolled in the course, being 21 students of the 1^st period, 21 students of the 2^nd period, 24 students of the 3^rd period, 17 students of the 4^th period, 24 students of the 5^th period, 20 students of the 6^th period, 14 students of the 7^th period, 30 students of the 8^th period, 10 students of the 9^th period and 18 students of the 10^th period. The age ranged from 18 to 43 years old. The data regarding sociodemographic, academic, clinical and student workload variables are presented in table 1.

Table 1. Sociodemographic, academic and clinical characteristics of nursing students in a PHEI in the State of Minas Gerais.

Importar_tabla5265c64616

Source: Self-made (2024).

In addition, a large part of the participants (69/34.7%) have an income from 1 to 2 minimum wages. Regarding financial dependence, it was observed that the majority (115/57.8%) depended on financial support provided by parents, spouses or friends. Regarding the academic characterization, most (105/ 52.2%) did not work or perform any other activity remunerated with a scholarship offered by PHEI. Still, an expressive number (179/89.1%) had no pending in subjects. It is also noteworthy that 167 students (83.3%) did not express interest in leaving the course.

In addition, the weekly hours of the undergraduate nursing course vary according to the academic period. From the 1^st to the 8^th period, students have an average of 40 hours per week, which reflects the workload of theoretical and practical academic activities. In the last periods of the course, 9^th and 10^th, the weekly load varies between 30 and 40 hours, considering the greater emphasis on supervised internship practices and completion of the course, as established in the Curricular Pedagogical Project (CPP). The content addressed in each period, regardless of the workload assigned, was not considered as an intervening factor in the manifestation of the symptoms analyzed. Regarding lifestyle, 145 (72.9%) refused to regularly consume alcoholic beverages. As for tobacco (189/95%) and illicit drugs (190/95.5%), most of them said not to use these in their daily routine.

It was identified that, although most of the academics had a previous diagnosis of anxiety, only a minority (35/17.6%) used regular anxiolytics, and most of the academics (153/76.9%) did not perform psychological follow-up regularly.

The variables of stress, depression and anxiety were analyzed according to the authors' recommendation on the DASS-21 scale and are presented in tables 2 and 3.

Table 2. Frequency of Depression, Anxiety, and Stress Symptoms – 21 items (DASS-21) from 199 participants.

Importar_tabla5265c64616

Note: N PART - Number of participants; EXT. SEVERE - Extremely severe.

Source: Self-made (2024).

There is a high frequency of symptoms of depression and anxiety in moderate and extremely severe levels; as for stress, the moderate and severe levels were highlighted. It is important to emphasize that the sum of moderate, severe and extremely severe levels in any of the situations (depression, anxiety and stress) makes 52.76%, 67.83% and 62.81%, respectively.

Table 3. Average Depression, Anxiety, and Stress symptoms – 21 items (DASS-21) from 199 participants.

Importar_tabla5265c64616

Source: Self-made (2024).

Furthermore, through inferential statistical analysis, a significant association between the use of anxiolytics and increased stress was found (p=0.043), indicating that individuals who use these drugs have higher levels of stress. Additionally, the variable depression was associated with female sex (p=0.026), indicating a higher frequency of this diagnosis among women.

DISCUSSION

The results of the study showed characteristics that may be associated with high frequency of symptoms of anxiety, stress and depression among nursing academics, highlighting the female sex and use of anxiolytics.

Reflecting the historical inference that considers care as a female practice, often seen as an extension of domestic and maternal roles, the study presents, mostly women, unlike medical practices, which are observed as a male-centered practice and treatment, emphasizing a deep gender hierarchy and influencing the way these professions are perceived and valued in society⁽¹⁶⁾. In this context, the present study showed most women, then, it is crucial that the institutions of education in Nursing incorporate gender discussions in their curriculum to train nurses critical and aware of the dynamics of power that influence the profession, acting not only as agents of social change.

Daily use of psychoactive drugs by university students was prevalent in 22.3% of the participants of a study, who reported starting to use anxiolytics or antidepressants after entering the university. This finding suggests a connection between the university environment and the increase of symptoms such as anxiety, stress and depression among students, leading them to resort to psychiatric drugs as a strategy for managing these conditions. The use of these drugs throughout academic life may indicate that the period of adaptation and academic pressures are significantly contributing to the appearance or aggravation of these symptoms⁽¹⁷⁾. In addition, the results of this study indicate that the consumption of anxiolytics may be associated with high frequency of symptoms among nursing students, highlighting the need for interventions aimed at promoting mental health in this group.

Considering these factors that may contribute to adaptation and academic pressures, the maintenance of the student in the institution has a high cost due to the specific requirements of the nursing course as appropriate clothing, textbooks, instruments, Transportation to and from practices held in different places and institutions, among others. These conditions include challenges faced by students, especially those of low income, which can result in poor academic performance even in the withdrawal from the course⁽¹⁸⁾.

Therefore, the income profile of the study participants highlights a worrying reality in which a significant portion has low family income. Furthermore, most of the academics do not receive institutional scholarships or engage in paid activities compatible with their curricular workload, and most take a considerable time to the institution. Thus, it is urgent the importance of educational institutions to pay attention to adjust the institutional support offer, to meet the real needs of students.

It is known that the academic scenario is marked by intense levels of exhaustion, in sharp contrast with the short time for leisure activities, which provide well-being. This is particularly evident among students of health courses, such as Nursing, who are challenged by a few stressful situations throughout their educational journey, in which, from the beginning of the undergraduate, are immersed in extensive care practices and direct contact with patients, expanding the emotional and psychological demands of the course⁽¹¹⁾.

It was found in the present research that most students need additional study time to assimilate the content taught in the classroom, indicating the need to dedicate extra moments outside the institution, which could be used in leisure - such as the practice of physical activities. It should be noted that most of the study’s undergraduates do not perform such activities, representing an additional stress factor that can trigger symptoms of anxiety and depression⁽¹⁹⁾.

According to Trapé et al. (2022), data on mental health problems of university students are worrying, and Brazil leads the global list of cases of anxiety disorder, ranking fourth in relation to the number of people suffering from depression. The anxiety average was considered severe, and the stress and depression average was considered moderate among students, with most of the students already having a previous diagnosis of anxiety and a significant portion already had depression.

In addition, according to Leão et al. (2018), anxiety and depression rates among health students are higher than those of the general population. The follow-up of medical students over six years of training identified a high prevalence of depressive symptoms, anxiety and stress, with more than 50% of students presenting significant symptoms at some point during the course⁽²⁰⁾. However, first years of Physiotherapy, Psychology and Nutrition showed a marked prevalence of symptoms of stress, anxiety and depression, the latter being the most severe⁽²¹⁾. The study also highlighted that symptoms varied between courses, but there were no significant differences related to gender, income, age or number of children. These mental health conditions, recognized for their potential to incapacitate individuals, present significant risks, including suicide⁽²²⁾. Therefore, this problem highlights the need for care that academic entities must have in relation to students, especially those with previous diagnoses related to mental suffering.

Furthermore, during the years 2020 to 2022, society went through an atypical context with the pandemic of the SARS-CoV-2 virus, which causes the Covid-19 disease, which forced everyone to stay at home, isolated from the external environment. However, the academics needed to continue their distance learning and it was necessary to acquire new technological skills to accompany the process. Thus, the sudden change from traditional to online education impacted on the health and well-being of college students, triggering and aggravating symptoms of stress, depression and anxiety⁽²³⁾.

This need to master new skills during the global health emergency may have interfered in the results regarding the mental health of students, especially those who faced this scenario while doing the course and who, during the study, were between the 5th and 10th graduation period, representing most of the sample, which shows the possible long-lasting effects of the consequences of the pandemic.

In addition, looking to the future, the nurse-patient relationship is modulated by emotional skills, scientific knowledge and technical skills to recognize the needs of the patient and perform appropriate care. However, when any of these pillars, such as the emotional professional, is not well, the nurse will practice their tasks mechanically, with moral uncommitment and without empathy⁽²⁴⁾.

Thus, the search for alternative treatment and mental health promotion by the use of Integrative and Complementary Practices in Health (ICPH) is becoming more common in society, because they are based on the model of humanized care and include therapeutic resources that seek to understand and relate environmental and behavioral characteristics in health and disease processes, aiming to treat the individual as a multidimensional being, and low investment cost for its execution^{(25, 26, 27).}

There are reports that the use of ICPH allows students to perceive the human being (both themselves and future patients) in its entirety, reducing symptoms of anxiety, depression and stress⁽²⁸⁾. So, some examples of ICPH are the Meditation, which is a practice of harmonization of mental states and consciousness, which stimulates well-being, relaxation, reduction of stress, hyperactivity and depressive symptoms; Music therapy, which uses music and its elements to favor the creative, emotional and affective development, promoting relaxation, comfort and pleasure in social interaction; and Reiki, which is a practice of laying on hands that promotes harmonization between physical dimensions, mental and spiritual, helping in stress, depression and anxiety and other practices⁽²⁹⁾.

Therefore, it is necessary that, within the academic training, the students' mental state be taken into consideration, offering resources so that university students have more autonomy and can take care of themselves more and minimize these symptoms⁽³⁰⁾. Thus, it is the responsibility of the institution to discuss this issue and promote psychological support services to prevent injuries and promote a place that supports the mental well-being of its students, creating a healthy learning environment and meeting the health demands of the academic according to the guidance of Decree N 7.234 that provides on the National Student Assistance Program, ensuring adequate conditions for access, students' permanence and success in higher education⁽¹⁰⁾.

Study limitations

The analysis restricted to the relationship between variables is not able to establish or define causality. In addition, the sample was restricted to a single ICPH, which may have contributed to the high frequency of symptoms among students and associations. Therefore, it is recommended that further research be conducted in more than one institution and for a longer period, to define a cause relationship and expand the body of existing studies, analyzing the correlation of clinical symptoms, impacts on academic performance and comparing them with other courses, aiming to contribute more to the reduction of symptoms of depression, anxiety and stress among students.

Contributions to the area of Nursing, health or public policy

The results highlight the importance of integrating mental health into care to academics, suggesting the inclusion of content on stress management in nursing curricula. In addition, they highlight the need for specific interventions, such as self-care programs and psychological support, to prevent and reduce symptoms. These findings serve as a basis for the formulation of public policies that address the mental health of university students, promoting integrative and complementary practices in the ICPH guidelines. This approach is fundamental to create a healthy and inclusive academic environment that meets the students' mental well-being needs, contributing to the formation of more prepared and resilient professionals⁽¹⁰⁾.

CONCLUSION

When verifying the frequency of symptoms of anxiety, depression and stress in nursing students, the study revealed high levels of symptoms of depression, anxiety and stress among the students, confirming the research hypothesis, as well as an inference with the female sex and the use of anxiolytics. Therefore, there is a need for the development of interventions and adequate support by the Teaching Institution to reduce the frequency of these symptoms and promote a healthier and more inclusive context for nursing students. It is considered, then, the creation of support groups, extension projects focused on the theme and the inclusion of compulsory and elective courses that promote mental well-being in the curriculum as strategies for prevention and psychological support, highlighting the use of Integrative and Complementary Practices (ICPS) as tools for this care.

In addition, given the implication of the theme for mental health and training of health professionals, it is suggested that new studies be developed.

Acknowledgments:

There isn't.

Funding:

There wasn't.

Authors' contributions:

Conception and design of the research: Giulia Gabriela Silva Santos and Thaís Vasconselos Amorim; Data collection: Giulia Gabriela Silva Santos, Ana Carolina de Almeida Silva and João Marcelo Curty de Souza Vergilio; Analysis and interpretation of the data: Giulia Gabriela Silva Santos and Thaís Vasconselos Amorim

Writing of the manuscript: Giulia Gabriela Silva Santos; Critical revision of the manuscript for intellectual content: Thamara Aquino Duarte.

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Información adicional

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