**5. Stress and mental disorders**

Mental illnesses are a health problem with high prevalence in the young adult population [59, 60]. Within this population, students are highly vulnerable, especially in the areas of health sciences. Careers as medicine, dentistry, and nursing are very demanding physically, intellectually, and emotionally for the students, who are exposed to high levels of stress during their formation. Particularly, in the last year of student training, they are exposed to severe emotional stress and exhaustion. The stressors they face come from different ways such as academic factors, the demands of proper performance in clinical practice, academic assessments, and future expectations about employment [60]. In addition, social, emotional, and physical pressures, as well as family and personal problems, affect student's learning ability and academic performance [61] and predispose the young students to the development of mental disorders such as anxiety and depression [62–64]. The impact of stress on nursing students can affect the nurse–patient relationship; nurses have more interaction during and after an intervention with the patient. Similarly, being exposed to environmental stressors could lead to dissatisfaction and burnout in nursing staff [65–67].

It is estimated that up to 55% of young adults report depressive symptoms, burnout, and increased frequency of alcohol consumption during their life as student [68, 69] and about 42% of students develop a mental disorder, a situation that predominates in the female gender with a prevalence of 62% of this population, with an average age of onset of 23.5 years [70]. The most common mental disorders affecting students are anxiety disorders, particularly in women [60], and they also report higher levels of stress than men [71]. Seventy-five to ninety percent of medical students, including nursing, increase alcohol and tobacco consumption particularly in the last year of their medical education [72]. Most of the cases (72%) feel a state of emotional well-being that helps to cope with the experienced psychological stress they are exposed to, despite being aware of the consequences of excessive alcohol and tobacco consumption [72]. Something similar has been reported in nursing students, where stress, environmental influences, social acceptance, and easy availability of alcohol, as well as anxiety generated by the difficulty of the educational program, are factors that increase alcohol consumption in this population [73]. In the general population of these students, 44.4% report feeling emotionally stressed and develop some mental disorder.

On the other hand, subjects exposed to stressors but with a network of emotional support reported feelings of happiness; so, it is suggested that support networks help to decrease susceptibility to develop mental disorders [70]. The absence of such emotional support networks in students increases the risk of developing some mental disorder; students reported having some physical illness or mental disorder diagnosed by a psychiatrist with no significant differences on prevalence between careers of the health science, such as medicine, dentistry, and nursing [70]. Additionally, it has been observed that factors such as religious practice are a potential factor for resistance to mental disorders, such as alcoholism, anxiety, depression, suicide rate [74, 75], and burnout [68].

These data support the idea that there is a strong relationship between the physical and psychosocial stresses to which nursing students and other health careers are exposed, with the susceptibility to develop some mental disorder, and that the presence of some religious beliefs and social support networks, such as the family, diminishes the susceptibility to the development of such disorders.

## **6. Conclusion**

effects. All together, these findings suggest that salivary cortisol measures in healthy nursing

Finally, in a study on 69 health professionals from a palliative care unit, including 32 nursing assistants and 30 nurses that met the burnout criteria with the *Maslach Burnout Inventory-Human Services Survey* (MBI-HSS), the average levels of salivary cortisol in the group with one dimension of burnout (14.17 nmol/L) were higher than non-burnout group (8.83 nmol/L) [56]. High levels of salivary cortisol are also observed in nursing students with high scores of depression, anxiety, and stress [46]. These findings suggest that cortisol is a useful biomarker

of emotional health deterioration due to stress in nursing students and professionals.

**4.2. Effects of anti-stress interventions on endocrine responses of nursing students**

exercise in the brain functions at the preclinical level [47].

to measure stress in a simulated prehospital environment [58].

**5. Stress and mental disorders**

Several anti-stress interventions have been implemented with the aim to reduce stress in nursing students and professionals, but most of these works are based in self-reports of a decrease in symptoms of stress, and they lack of physiological measures as stress-related hormones. In this sense, few works have explored the effects of anti-stress manipulations on endocrine responses in students to test the efficacy of these interventions. For example, nursing students (16–20 years old) from a nursing college in Taiwan which have scored 8 points or higher on the *Depression Mood Self-Report Inventory for Adolescence* (DMSRIA) were randomly assigned to a control group (n = 40) and an experimental group (n = 31) that was exposed to Chinese five-element music for 40 min twice a week for 10 weeks. Saliva samples were collected before music exposure and during weeks 1, 5, and 10 of music at 11 am. Music treatment reduced cortisol levels on weeks 5 and 10; however, these changes did not reach statistical significance [57]. It is also important to note that music was played in a group setting, while control groups had no manipulation; thus, the effect of music cannot be isolated from any possible effect of being part of a group when listening to the music, a possibility that remained to be explored. It has been reported that physical activities can ameliorate the impact of stress. For example, 18 nursing students who practiced a traditional Chinese exercise called Qigong twice a week for 10 weeks had lower scores of depression, anxiety, or stress than 16 control students interviewed with questionnaires DASS-21 and PHQ. This improvement was related with a decrease in salivary cortisol concentrations [46], which agrees with the beneficial effects of

Taken together these findings suggest that cortisol is not strongly correlated to the stress experienced by nurses or nursing students in different circumstances. Studies from other healthcare professionals point out the same findings. In physicians and paramedics, cortisol showed very little variation in response to the stress produced in high-fidelity patient simulation used for training, while salivary alpha-amylase appeared to be more sensitive than salivary cortisol

Mental illnesses are a health problem with high prevalence in the young adult population [59, 60]. Within this population, students are highly vulnerable, especially in the areas of health sciences.

students vary according to the kind of stressor and the schedule of exposition.

38 Health and Academic Achievement

There is plenty of evidence that nursing students are exposed to high levels of stress during their preparation. Among the most frequently stressors mentioned in literature are excessive workload, lack of time to accomplish academic assignments, test, interaction with patients, and negative interactions with peers and family. At the academic level, the stressors can be the result of a gap between the academic preparation and the practical training or the environments produced in universities and hospitals. In this sense, the educational models must contemplate simulations of the real life that the students will face at work. Such programs must also include the development of social, emotional, coping, and buffering skills. Levels of stress on nursing studies are strong enough to change secretion of cortisol with potential deleterious effects. Physical and psychosocial stress in nursing and healthcare students increased susceptibility to develop some mental disorder, and social support networks diminish the susceptibility to the development of such disorders. Thus, stress must be considered during the formation of nursing students to optimize their academic performances and avoid deleterious effects.

[8] Herrera-Covarrubias D, Coria-Avila GA, Muñoz-Zavaleta DA, Graillet-Mora O, Aranda-Abreu GE, Rojas-Durán F, Hernández ME, Ismail N. Impacto del estrés psicosocial en la

Stress in Nursing University Students and Mental Health http://dx.doi.org/10.5772/intechopen.72993 41

[10] Graham MM, Lindo J, Bryan VD, Weaver S. Factors associated with stress among second year student nurses during clinical training in Jamaica. Journal of Professional Nursing.

[11] Ahmadi Z, Sadeghi T. Application of the Betty Neuman systems model in the nursing care of patients/clients with multiple sclerosis. Multiple Sclerosis Journal—Experimental, Translational and Clinical. 2017;**3**(3): 2055217317726798. DOI: 10.1177/2055217317726798

[12] Davis J. Buffering the stress of programmatic accreditation. Teaching and Learning in

[13] Gunnar MR, Fisher PA, Early Experience, Stress, and Prevention Network. Bringing basic research on early experience and stress neurobiology to bear on preventive interventions for neglected and maltreated children. Development and Psychopathology.

[14] Heim C, Newport DJ, Mletzko T, Miller AH, Nemeroff CB. The link between childhood trauma and depression: Insights from HPA axis studies in humans. Psycho-

[15] Schneiderman N, Ironson G, Siegel SD. Stress and health: Psychological, behavioral, and

[16] Dinse HR, Kattenstroth JC, Lenz M, Tegenthoff M, Wolf OT. The stress hormone cortisol blocks perceptual learning in humans. Psychoneuroendocrinology. 2017;**77**:63-67

[17] Seligman MEP. Emotional development and education. In: Atkinson RC, Lindzey G, Thompson RF, editors. Helplessness on Depression, Development and Death. New York:

[18] Fröjd AS, Nissinen SE, Pelkonen MU, Marttunen MJ, Koivisto AM, Kaltiala-Heino R. Depression and school performance in middle adolescent boys and girls. Journal of

[19] Hjern A, Alfven G, Ostberg B. School stressors, psychological complaints and psychoso-

[20] La Greca AM, Harrison HM. Adolescent peer relations, friendships, and romantic relationships: Do they predict social anxiety and depression? Journal of Clinical Child and

[21] McElhaney KB, Antonishak J, Allen JP. They like me, they like me not: Popularity and adolescents´ perceptions of acceptance predicting social functioning over time. Child

biological. Annual Review of Clinical Psychology. 2005;**1**:607-628

salud. Eneurobiología. 2017;**8**(17):220617

neuroendocrinology. 2008;**33**(6):693-710

WH Freeman and Company; 1992. pp. 134-159

matic pain. Acta Paediatrica. 2008;**97**(1):112-117

Adolescent Psychology. 2005;**34**(1):49-61

Development. 2008;**79**(3):720-731

Adolescence. 2008;**31**(4):485-498

2016;**32**(5):383-391

2006;**18**(3):651-677

[9] Raile M. Modelos y teorías de la enfermería. España: Elsevier; 2015

Nursing. 2017;**13**(1):14-17. DOI: 10.1016/j.teln.2017.08.001
