Relationships and Predictors of Resilience, Social Support, and Perceived Stress among Undergraduate Nursing Students

1.1. Significance and Research Questions

Several studies explored the levels and predictors of resilience, social support, and perceived stress among nurses and university students. Moreover, few studies assess the levels of resilience, social support, and perceived stress among nursing university students. However, there are very few research studies that assess those concepts among Jordanian nursing students. Therefore, this study was conducted to assess the levels, relationships and predictors of those variables in a sample of undergraduate Jordanian nursing students. More specifically, this study aimed to:

1. Assess the levels of resilience, social support, and perceived stress among Jordanian undergraduate nursing students.

2. Examine the relationships among resilience, social support, and perceived stress among Jordanian undergraduate nursing students.

3. Detect any differences in resilience, social support, and perceived stress with selected demographic variables among Jordanian undergraduate nursing students.

4. Assess the predictor variables of resilience, social support, and perceived stress among Jordanian undergraduate nursing students.

2.1. Design

A descriptive, correlational design was used.

2.2. Instruments

The questionnaire consisted of four parts. The Arabic versions were used.

2.3. Sample

Prior to data collection, G*Power software was used to estimate the minimum required sample size. For a multiple linear regression of 12 variables, using a small effect size (0.15), a power of 0.80, and an alpha of 0.05, the minimum required sample size was 127 [39]. All Jordanian undergraduate nursing students studying nursing in 2022 were invited to participate in the study by completing a survey designed in Google Forms.

2.4. Setting

The setting was all Jordanian universities that offered nursing programs. There are 14 universities that offer a Bachelor's degree in nursing. The Bachelor’s nursing education system in Jordan is approximately consistent across all universities and is designed into four academic years with approximately 132 credit hours.

2.5. Ethical Consideration

This study was approved by the Institutional Review Board (IRB) of Hashemite University, where the primary research was conducted (No:9/1/2021/2022). The survey link was sent to nursing deans in each university, and they were asked to post it in college groups. In the introduction, participants were told about the study's purposes and that their participation was voluntary. The introduction also contained a statement regarding informed consent, indicating that filling out and submitting the survey indicated their consent for participation. The confidentiality of data and anonymity of participants were assured and protected.

2.6. Data Collection

Using an online electronic survey (using Google Forms), data were collected from a convenient sample during April, 2022. Students were asked to take part in the study voluntarily. An online invitation to participate in the study was sent to nursing student groups in each university. The online survey was posted on nursing students’ groups on official portals and social media (Facebook and Microsoft Teams).

2.7. Data Analysis

Data analyses were performed by the Statistical Package for Social Sciences (SPSS, version 24). Descriptive statistics were used to describe sample characteristics, levels of resilience, social support, and perceived stress. Pearson's correlation coefficient was used to measure the relationships between studied variables. Independent sample t-test and one-way analysis of variance (ANOVA) were used to examine the differences in the mean scores between demographics and the study variables. Multiple linear regression analyses were performed to detect the predictor variables of resilience, social support, and perceived stress.

3.1. Demographic Variables

The sample consisted of 150 Jordanian undergraduate nursing students; 60% (n=90) of them were females. Their age ranged from 18 to 23 years (mean=20.00, SD=1.34). The average family income ranged from 220 JD to 3000 JD (mean=655.7, SD=429.94). Few students (n=21, 14.0%) had thoughts of discontinuing nursing studies, and 19 (12.7%) reported being unsatisfied with nursing studies. Other demographic variables are shown in Table 1.

3.2. Levels of Resilience, Social Support, and Perceived Stress

The total mean score of resilience was 71.61 (SD=15.71). Only 51 (34.0%) students were resilient (scores of 80 and above), and 99 (66.0%) were not (scores of less than 80). Using quartiles, the prevalence of low, moderate, and high resilience levels were: 24.7% (n=37, participants’ scores less than 63), 28.0% (n=42, participants’ scores between 63-72), and 47.3% (n=71, participants scored above 37), respectively. The total mean score of social support was 58.18 (SD=16.17), and the items’ average mean score was 4.84, indicating a moderate level of social support. The highest source of social support was from friends (mean=20.27, SD=5.89). Regarding levels of social support, 8.0%, 45.0%, and 47% had low, moderate, and high levels of social support, respectively, indicating that the highest percentage had moderate to high levels of social support. The total mean score of perceived stress was 22.32 (SD=5.41), indicating a moderate level. Regarding levels of perceived stress, 6.0%, 78.0%, and 22.0% had low, moderate, and high-stress levels, respectively, indicating that the highest percentage of nursing students have a moderate level of stress (Table 2).

3.3. Resilience, Social Support, and Stress: Correlations, Differences, and Predictors

Resilience was positively correlated with social support (r=0.438, P<0.001) and satisfaction with nursing study (r=0.171, p<0.05), and negatively with perceived stress (r=-0.271, p<0.001), taking well-balanced diets (r=-0.299, p<0.001), and performing exercise regularly (r=-0.175, p<0.05) (Table 3). Higher resilience was found among students who were smokers, taking well-balanced diets, performing exercise, and were satisfied with the nursing study (Table 4). Resilience was predicted by one variable (social support) and accounted for 26.2% of the variance (Table 5). Social support was positively correlated with income level (r=0.251, p<0.001) and resilience (r=0.438, p<0.001) and negatively with perceived stress (r=-0.188, p<0.05) and smoking status (r=-0.203, p<0.001). Higher social support was found among smokers with higher income levels. Social support was predicted by six variables (resilience, age, income, sleeping hours, smoking status, and year of study) and accounted for 29.3% of the total variance. Perceived stress was positively correlated with income level (r=0.276, p<0.001) and negatively with resilience (r=-0.271, p<0.001) and social support (r=-0.188, <0.05). Higher perceived stress was found among students with lower sleeping hours and those not taking well-balanced diets. Perceived stress was predicted by one variable (well-balanced diets), accounting for 11.3% of the variance.

4.1. Levels of Resilience, Social Support, and Perceived Stress

The results of this study showed that the total mean score of resilience was 71.61 (SD=15.71), with only 34.0% being resilient. There are no studies that measure the overall resilience level among nursing students using CD-RISC-25. However, there are few studies that measured the overall resilience level among university students and nurses [10, 12, 37]. A study that measured resilience among university students found that the level was 64.59 [10], which was lower than our results. Also, studies that measured resilience among nurses found the level to be lower than our results. For example, among Iranian, Turkish, and Pakistani nurses, resilience levels were 61.21, 64.28, and 64.59, respectively [10, 12, 37]. In the current study, the prevalence of low, moderate, and high resilience were: 24.7%, 28.0%, and 47.3%, respectively. Our results were relatively consistent with the results of other studies that measure resilience among nursing students using CR-RISC-25. For example, Sahu et al. [19] found that the prevalence of low, moderate, and high resilience among Indian nursing students was 19.6%, 59.8%, and 20.6%, respectively. In the same line, the prevalence of resilience among another sample of Indian nursing students was 4.0%, 42.7%, and 53.3% for low, moderate, and high levels of resilience, respectively [40].

Results of this study showed that the total mean score of social support was 58.18 (SD=16.17), which was lower than what was found in most similar studies [14, 27-33]. In these studies, the level of social support among nursing students using MSPSS ranged between 64.0 to 68.9. Results of the current study showed that the highest source of social support comes from friends, then from significant others, and lastly from family members. This is incongruent with what was found in literature, that the highest source of social support comes from family, then friends, and lastly from significant others [14, 28, 29].

The results of this study showed that the total mean score of perceived stress was 22.32 (SD=5.41), indicating a moderate level. This result is slightly higher than the results of most studies that found that the perceived stress level among nursing students was around 18.0-20.0. For example, perceived stress was 19.8 among USA students [41], 20.94 among UK students [17], 18.92 among Indian students [42], and 21.29 among Malaysian students [8]. However, very few studies have similar results, such as studies by Onieva-Zafra et al. [1] and Mendes et al. [18], who found that the perceived stress was 22.78 and 22.68, respectively. It is worth mentioning that two studies found higher levels of perceived stress. Brown and Vargas [13] found it 32.2 among USA students, and it was 27.91 among Singapore students [4].

4.2. Resilience: Correlations, Differences, and Predictors

It is well documented in the literature that both resilience and social support correlated negatively with perceived stress [10, 14, 18, 37, 41, 43]. In a sample of Indian nursing students, a negative correlation (-0.196) was found between resilience and perceived stress [19]. Also, perceived stress correlated negatively with social support (-0.220) among Spanish nursing students [1]. Furthermore, in a study that included UK and Chinese nursing students, perceived stress correlated negatively with resilience (-0.152) [17]. Regarding resilience and smoking, Wang et al. [44] examined the role of negative emotions in mediating the link between stress and smoking and whether it could be modified by resilience. Results confirmed that resilience interacts with stress and negative emotions to affect the risk of tobacco use. Concerning physical activity, studies found that physical activities build up resilience, which, in turn, improves mental health. A study conducted by Ho et al. [45] showed that physical activity level was significantly correlated with mental well-being, self-efficacy, and resilience. Moreover, resilience was found to mediate the positive association between physical activity and mental well-being.

4.3. Social Support: Correlations, Differences, and Predictors

The results of this study showed that social support was higher among smokers and students with lower income levels. Results of the current study concerning social support and smoking were congruent with the results found by Yun et al. [46], who found that smokers had high levels of social support and social networks as compared to those who are non-smokers; it was also found that the high social support group were likely to be of smokers. One explanation is that university students sit and chat with each other frequently (i.e., as a form of social support) and encourage each other to smoke in an attempt to reduce stress. Also, our results were consistent with the results of a study conducted by Weyers et al. [47], who found that people with lower income levels more often reported poor social networks and social support.

4.4. Perceived Stress: Correlations, Differences, and Predictors

Our results were congruent with the results of a previous study that measured the effect of appropriate dietary habits on both resilience and perceived stress. The researchers pointed out that the appropriate dietary habits (that contain fruits, vegetables, whole-grain products, and plant and animal protein) are necessary for good health and appropriate functioning of the immune system, which, in turn, increase resilience and reduce stress levels [48]. Also, our results regarding the relationship between resilience and perceived stress were consistent with the results found in several studies [10, 13, 17-19, 41]. For example, Brown and Vargas [13] found a strong negative relationship between perceived stress and resilience.

Contrary to what was found in most studies that female students have higher levels of perceived stress compared to their male counterparts [1, 7], our results showed no differences in perceived stress in relation to gender. However, the results of a few studies found no relationship between both perceived stress and resilience in regard to gender [13], which was consistent with the results of the current study. Several studies found a negative relationship between perceived stress and satisfaction with nursing study as a future career [8]; however, in the current study, there were no significant differences between perceived stress and satisfaction in nursing study.

4.5. Limitations and Recommendations

Although this study provides valuable information about resilience, social support, and perceived stress, it has a few limitations. First, a cross-sectional design was employed; therefore, a causal relationship could not be drawn. Longitudinal studies directed toward students in their entire academic years could provide a more in-depth understanding of their resilience, social support, and perceived stress from a developmental point of view. Second, bias and subjectivity may be an issue due to using a survey questionnaire to collect data. Students may respond in a socially desirable manner rather than their actual responses. Lastly, the study included only nursing students, so results cannot be generalized to all Jordanian university students. Future studies may include students from different colleges.

4.6. Nursing Implications

The results of the study highlighted the importance of resilience and social support in reducing and coping with perceived stress. Nursing curricula should contain details about improving resilience among nursing students and enhancing ways of coping with perceived stress. Also, nursing educators and administrators should be aware of the necessity of improving students’ psychological health. Furthermore, nursing researchers are encouraged to conduct interventional studies that foster resilience among nursing students.