Multidimensional Education Intervention for Improving Mental Well-Being Among Undergraduate Nursing Students

INTRODUCTION

Mental health issues of professional students are a global concern that needs to be addressed.^[1] One of the Sustainable Development Goals (SDGs) set by the United Nations (UN) is to ensure healthy lives and foster well-being for individuals of all ages. The concept of “well-being” is commonly understood as a person’s overall state of physical, mental, and social health. It relates to an individual’s mindset, mental stability, and overall quality of life.^[2,3]

Well-being is linked to success in various areas, including professional, personal, and social realms, as individuals with higher well-being generally exhibit improved productivity at work, better learning abilities, increased creativity, more supportive behaviours, and healthier relationships. The current shortage of nurses highlights the importance of addressing the psychological needs of nursing students and fostering an educational environment that promotes safe and effective learning. The mental wellness of nursing students and the surrounding educational context can greatly affect their academic performance. It is crucial to explore changes to the educational setting and to implement suitable interventions.^[4,5]

Well-being is an intricate concept that cannot be comprehensively assessed by looking at only personal factors, as there are multiple factors affecting mental well-being. Therefore, employing a single subjective measure to gauge well-being fails to offer a meaningful understanding of how individuals view the crucial aspects of their lives that are fundamental for significant results.^[5] Investigations focused on a comprehensive intervention strategy for improving mental well-being in nursing students are scarce. Therefore, the objective of this research was to apply a multidimensional education intervention tool to improve the mental well-being of undergraduate nursing students.

MATERIAL AND METHODS

Statistical analysis

Data were analysed using SPSS version 25.0. The level of significance for all analyses was set at 5%, and descriptive statistics, such as mean with standard deviation and percentages with a 95% confidence interval, were computed. The original continuous scores were available and were thereby used to compare the outcomes after the education intervention [Figure 1]. In collaboration with a group of statisticians, we conducted data analysis and interpretation using the Chi-square test.

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Figure 1:

Sequence of events in educational intervention and WEMWBS score. WEMWBS: Warwick-Edinburgh Mental Well-being Scale.

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The research team combined quantitative and qualitative data to create a comprehensive picture of the intervention’s early impacts and how they connected to the participants’ reflections. The qualitative data, which examined participants’ opinions of the intervention in terms of its acceptability and feasibility, provided context for the quantitative data’s assessment of changes in well-being. Content analysis was done to complete the qualitative study. Discussion meetings between the principal investigator, TBL instructors, mentors, co-investigators, and statistician were held on a regular basis to share the data analysis and interpretation. The experts from the department of physiology, medical education, community nursing, medical and surgical nursing, and psychiatric nursing were included in the meetings to complete the process. Second, transferability was addressed by providing descriptions of the research context.

RESULTS

52% of students had the mental well-being scores lower than the median scores in comparison to those from other specialities and developed nations. Even though there are no ceiling and floor values for WEMWBS, a correlation among students assessed by the scale developer and other developing countries will help in projecting the burden of this issue. Among the study participants in this study, the first and second-year students showed very low scores, with 56 students having scores of less than 40, 72 students had scores between 41-50, respectively, compared to the last two-year students, about 121 with scores more than 55-60 from the same institute reflecting better well-being status and on par with students from developed nations.

The Phase I students had lower M0 scores as they were subjected to stress and anxiety concerns, as mentioned in perceptions of the students due to a change in environment from school to university campus, and increased expectations from their parents, peers, and faculty.

After the implementation of the mental health course, mainly concentrating on aspects of self-care practices, there was improvement in the mental well-being scale with statistically significant change (p < 0.001) across the age groups and all the phases of nursing students [Table 2]. The students were found to perform better in formative assessment after TBL sessions in respective core competencies as compared to traditional lectures. These findings were concluded after quantitatively analysing the scores of the first internal assessment and the individual scores post TBL sessions, along with the second internal assessment scores. With a difference at a 10% level, the WEMWBS scores after the implementation of the multidimensional education approach at the end observed a statistically significant improvement across all the phases of nursing students [Table 3]. It was also found that there is an improvement in mental well-being at each phase of the nursing students, even though the proportionate change was seen more in year III and year IV nursing students. This was concluded as the baseline scores (M0) were relatively higher in year III and year IV students [Figure 2].

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Figure 2:

Percentage of progress in mental well-being scores after intervention at each phase among undergraduate nursing students. WEMWBS: Warwick- Edinburgh Mental Well-being Scale.

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There was a statistically significant improvement in scores from pre-test (M = 48.98) to post-test (M = 60.26). The large negative mean difference (Pre - Post = -11.28) indicates that participants performed substantially better after the intervention. The very high t-value and the p-value < 0.001 provide strong evidence that the intervention had a meaningful and reliable effect on improving test scores.

The strong and significant positive correlation suggests that while the intervention improved scores overall, individual differences were fairly consistent, students who performed well initially continued to do so after the intervention, and vice versa. The obtained t-value of 23.524 with 248 degrees of freedom indicates a very large difference between the groups (or conditions) being compared relative to the variability in the data. The corresponding p-value is reported as 0.000, which in practice means p < 0.001. This p-value is far below the conventional significance level of 0.05, providing strong statistical evidence against the null hypothesis. Therefore, we reject the null hypothesis and conclude that there is a statistically significant difference between the groups/conditions [Table 4].

The intervention/time produced a great and statistically significant improvement in participant scores [Table 5].

DISCUSSION

University students are considered a vulnerable group due to the developmental stage they are at in life, the nature of adaptation to the new environment at university, the academic or parental expectations, and the intensity of higher education programs.[11-14] Thereby, it becomes essential to evaluate the mental health of nursing students and execute mental health interventions to aid this at-risk group at an earlier stage, as maintaining the mental well-being of future healthcare providers is a crucial aspect of nursing education.[1]

In this study, we found that the median scores for mental well-being were relatively lower before intervention in students in comparison to other countries, with the students from the Scottish population, where the tool was developed, showing the median scores above 50.[10,15]

In this study, there is an improvement in mental well-being among the students after implementation of the mental health course, reflecting that self-care practices and handling the expectations from peers, parents, and society have an impact on the expected outcomes (Table 3). According to the General Health Questionnaire (GHQ), roughly 21% of the 145 nursing students in an Indian college who participated in the study experienced psychological distress. In another study, more than 70% nursing students in Italy reported having substantial psychological distress.[6,7,16] Thereby, it adds evidence to use the intervention to handle the psychological stress, improving their mental well-being and, in turn, their academic performance.

Adopting strong self-care habits is a key component of mental health and a way to reduce psychological suffering. It is often known that intentional self-care techniques can help nursing students feel less stressed.[17] According to another study, teaching nursing students 10-minute mindfulness exercises can reduce stress and improve present-moment awareness.[18]

In this study, the components of group mentoring followed by peer mentorship and one-on-one mentor role by the subject experts played one of the major roles in their overall development as a health care professional and found to have alleviated the apprehensions and hesitation in the learning process obtained from students’ perception of the educational intervention. These were also found to develop their communication skills and acquire the knowledge to work in a team. Similar findings were observed in studies conducted as standalone objectives among health care professionals.[19,20]

TBL is one active learning strategy that builds on individuals’ strengths by allowing them to collaborate and work as a team to achieve a common learning objective. In this study, the nursing students were able to perform better on the topics covered by TBL. The students’ reflections showed that the TBL sessions improved their engagement with course content, and they enhanced their understanding of course content, which made them believe that it would help them perform better in their exams. These findings were similar to other studies conducted among students in health specialties, which reflected higher student engagement, satisfaction, and long-term learning by TBL. These also raised concerns over the faculty workload, which will be alleviated in this approach.[21-24]

This study showed that, through a multidimensional approach of educational interventions, the mental well-being of the students across all the phases of nursing can be effectively improved [Figure 2]. Each of the intervention tools will have an additive impact on the other, helping in the overall improvement of mental well-being among nursing students. [Table 5] It is essential to create a nurturing atmosphere for students to enhance their learning experience. To reach this objective, clinical educators, students, and clinical personnel ought to collaborate effectively. Early screening of mental well-being and appropriate interventions will alleviate the burden of mental illness. Raised positive mental health in a society occupied with a larger younger population will improve the productivity of the nation.

Limitations of the study: The study was restricted to a single centre and lacked long-term follow-up, including a major part of the curriculum. Out of all the participants who enrolled in the programme and thereby in the study, 99% were female. This excluded us from seeing any sex-based differences in the study outcomes.

CONCLUSION

The inclusion of self-care and positive mental health as part of a strategy in the present study has promoted health and an opportunity for a reorganisation oriented towards community spaces and group interventions. The findings of this study indicated a notable enhancement in self-care abilities and a general improvement in mental health during all stages of the nursing program. TBL has served as a useful active learning strategy to supplement didactic lectures, adding to the accountability of students in their learning process, keeping them at the centre of learning. The study emphasises that there are multiple factors affecting the mental well-being of university students, and a multifactorial approach as an intervention, with consideration towards involved confounding factors, will alleviate the burden in society. Further research involving interventions across the health speciality students with long-term follow-up will add to the value for reliability of the interventions and reduce the burden of mental illness in this age group, creating productive and competent health care professionals. The addition of a control group in further studies between the disciplines may give further analysis of the outcomes of the study.