Depression, anxiety, and stress among the nursing students during clinical placement in Sylhet, Bangladesh

Abstract

Introduction

Clinical placements are a required component of nursing education. However, the high-demanding nature of these settings may heighten students’ risk for adverse mental health outcomes. This study aimed to investigate the prevalence and factors associated with depression, anxiety, and stress among nursing students during clinical placements.

Methods

We conducted a cross-sectional study between June 20 and July 12, 2025, among nursing students at a selected nursing college in Sylhet, Bangladesh. Eligible participants must have at least 6 months of clinical placement experience. The study included socio-demographic, academic, and clinical placement-related variables. The Depression, Anxiety, and Stress (DASS-21) scale was used to assess depression, anxiety, and stress symptoms. The DASS-21 scale is a screening tool that assesses symptom severity rather than a diagnostic tool. Data were analyzed using descriptive statistics, t-tests, one-way ANOVA, Pearson's correlation, and multiple linear regression.

Results

A total of 382 nursing students participated, with a mean age of 21.69 years. The prevalence of depression, anxiety, and stress symptoms (mild to extremely severe) was 74.6%, 77.8%, and 53.1%, respectively. Being female, having poor peer relationships, lacking rest opportunities, and being dissatisfied with the behaviour of nurses were significantly associated with depression. Female students, those who had no rest opportunities, and those who spent 100% of their clinical hours standing, were significantly associated with anxiety. Female students, those with poor peer relationships, and those dissatisfied with the behaviour of nurses were significantly associated with stress. Depression, anxiety, and stress scores were strongly correlated.

Conclusion

Although clinical placements are fundamental to nursing education, students often face mental health challenges during these training periods. Our findings reveal a high prevalence of depression, anxiety, and stress and several factors associated with these outcomes. Therefore, strengthening support systems and improving clinical placement conditions may be crucial for both student well-being and the sustainability of a resilient nursing workforce in Bangladesh.

Supplementary Information

The online version contains supplementary material available at 10.1007/s44192-026-00508-2.

Introduction

Poor mental health outcomes have become increasingly prevalent across communities, with university students, especially those in healthcare programs, facing higher vulnerability. In particular, nursing students must navigate the dual pressures of balancing academic coursework with the demanding clinical placement [1]. Clinical placements are not only time-intensive but also essential for fulfilling graduation and licensure requirements. Within these clinical placements, a range of factors, including heavy workload, inadequate rest, limited institutional support, and challenging interpersonal dynamics, impact students’ mental health outcomes [2–4]. Nursing students are reported as one of the most at-risk groups, as the emotionally demanding nature of their training [5] and the expectation to provide compassionate and high-quality care in diverse and often stressful clinical settings [6]. As such, clinical placements serve not only as essential learning experiences that bridge theoretical knowledge with practical application, but also as critical periods that may influence students’ mental health [7].

During clinical training, nursing students rotate through morning, evening, and night shifts. According to institutional schedules, rotation provides them with hands-on experience, strengthens critical thinking, and develops essential clinical skills [8]. Despite these learning benefits, clinical placements often expose students to emotionally demanding situations, heavy workloads, and the significant responsibility of patient care [9]. These circumstances are intensified in high-stress clinical environments, where students must apply theoretical knowledge in real-world healthcare settings, often under pressure and with limited support [10].

Nursing students are uniquely positioned within the healthcare education system. They balance academic pressures with the challenges of clinical placement [11]. These placements require a high level of competence, empathy, and emotional resilience. The placement often exposes students to heavy workloads and stressors related to staff behaviour, which can impact mental health outcomes [12, 13]. Anxiety is commonly reported in previous studies, particularly during the early stages of placement when approximately 30% of students experience anxiety symptoms, while 41% report moderate to severe stress [14–16]. Depression in clinical placement is less frequently studied in previous studies. A study reported that depression was found among 34% of students, which was correlated with the intensity and duration of clinical exposure [17].

In Bangladesh, a densely populated country with a historically challenged healthcare system, nursing students may face significant mental health burdens. Limited research suggests that stress is widespread, with one study reporting mild stress in 41% and moderate stress in 22.2% of students [18]. Despite these findings, to our knowledge, no prior study has examined the mental health outcomes of clinical placements among nursing students in Bangladesh. Keeping these gaps in mind, the present study aimed to investigate the prevalence and associated factors of depression, anxiety, and stress during clinical placements in Bangladesh. The findings may inform strategies for supporting nursing students’ well-being during this critical stage of their professional development.

Methods

Study design, participants, and settings

We conducted a cross-sectional study from June 20 to July 12, 2025, among nursing students at Begum Rabeya Khatun Chowdhury Nursing College (BRKCNC), Sylhet, Bangladesh. BRKCNC is a college with approximately 700 students. We invited 550 students and 382 students to participate in the study. The response rate was around 70%. Students were completing required clinical placement at Jalalabad Ragib Rabeya Medical College and Hospital (JRRMCH), Sylhet. The inclusion criteria of the study were: (i) enrolled full-time (first year to fourth year), (ii) having a minimum of 6 months’ clinical placement experience, (iii) willing to participate, and (iv) given written informed consent to participate. The exclusion criteria of the study were: (i) requested to withdraw, and (ii) provided incomplete responses.

Study variables

The outcome variables were depression, anxiety, and stress experienced by students during clinical placement. We selected and validated variables based on literature reviews, discussions with students, and opinions from experienced clinical nurses. Demographic variables included age, sex, permanent residence, and total monthly family income. Academic variables included the course name, academic year, any study gaps (e.g., breaks during studentship), overall relationship with peers (e.g., bonding with friends or classmates), and faculty support during coursework (e.g., nursing faculty members' support).

We included several clinical placement-related variables in this study. The variable “feeling of doing more clinical placement than required” refers to spending additional time in clinical practice beyond the officially required hours. “Receiving leave approval when sick” indicates whether students are able to obtain leave easily during periods of illness. “On average the total night shift duties per month” represents the number of night shifts assigned to students. “Getting opportunities for rest” reflects the availability of breaks during extended duty hours, while “standing duty hours” denotes the amount of time students spend standing during clinical duties. “Overall support from staff at the hospital” refers to the extent of assistance provided by hospital personnel. “Overall support from hospital authorities” captures the level of institutional support students receive when they encounter problems. “Overall support from clinical instructors” measures the services and assistance that clinical instructors provide. “Receiving guidance from the instructor or supervisor” indicates whether students receive procedural support during clinical activities. Finally, “overall behaviour of nurses (staff nurses)” and “overall behaviour of physicians”, describe how nursing staff and physicians interact with students during clinical placements. These clinical related variables were separate and independent variables not as a single constructed item.

Depression, anxiety, and stress measurement

We used the Depression, Anxiety, and Stress (DASS-21) scale to measure the outcome variables. This is a screening tool to assess symptom severity, but not a confirmation of diagnosis. The scale was validated by Ahmed et al. (2024) among Bangladeshi healthcare workers (physicians and nurses) and reported a reliability coefficient (Cronbach’s alpha) of 0.93 [19, 20]. The scale contains 21 items divided into three subscales: depression, anxiety, and stress. Each subscales have seven items and items are rated on a 4-point Likert scale ranging from 0 to 3, where 0 indicates “did not apply to me at all/never” and 3 indicates “applied to me very much or most of the time/almost always.” Participants were instructed to recall their experiences over the past 7 days and respond accordingly. The scores for each subscale were summed and then multiplied by two. The higher score indicates a higher level of depression, anxiety and stress. Based on the total scores, severity levels were categorized as follows: for depression, normal (0–9), mild (10–13), moderate (14–20), severe (21–27), and extremely severe (≥ 28); for anxiety, normal (0–7), mild (8–9), moderate (10–14), severe (15–19), and extremely severe (≥ 20); and for stress, normal (0–14), mild (15–18), moderate (19–25), severe (26–33), and extremely severe (≥ 34). These categories helped us to calculate the prevalence of the outcomes. To investigate the associated factors, our primary analysis used a continuous score from the scale.

Questionnaire development

We developed a semi-structured questionnaire based on a review of literature and informal consultations with nursing students, hospital authorities, and clinical supervisors. The initial draft was sent for multiple rounds of revision in collaboration with the nurse researchers and public health experts. The feedback was incorporated in the final version to improve clarity and content validity. The purpose of the study was outlined on the first page, which also included a section for obtaining written informed consent. The second page of the questionnaire captured socio-demographic information, followed by academic variables on the third page. Subsequent sections included clinical placement-related variables, and the final section contained DASS-21 items. A sample questionnaire is provided in Supplementary file 1. Prior to data collection, the questionnaire was pilot tested among 10 nursing students engaged in clinical placements at JRRMCH. Based on the pilot survey, further modifications were made. The participants from the pilot survey were excluded from the final analysis.

Sample size

We found that no prior studies have reported the prevalence of depression, anxiety, and stress among Bangladeshi undergraduate nursing students. Using the finite population size of (N = 700) students at BRKCNC, the minimum required sample size for this study was 249. We used the following sample size calculation formula [21].

We manually calculated the sample size based on a 95% confidence level (Z = 1.96), a 5% margin of error (d = 0.05), and an assumed prevalence of 50% (P = 0.50, [1−P] = 0.50). Finally, we enrolled 382 students, which provided additional statistical power for this study.

Sample recruitment

A convenience sampling technique was used for sample selection. For data collection, we recruited 20 trained volunteer nursing students. The final questionnaire was converted into “Google Forms” and distributed via an online link. Data were collected in classroom settings rather than during clinical placement to avoid interfering with direct patient care. Students attended clinical placement 3 days per week and theoretical classes on the remaining 3 days. We invited students to participate in the study upon returning to the classroom following clinical placement. Trained volunteers visited classrooms, introduced the study, and shared the online link with interested students. After accessing the link, participants provided written informed consent before completing the questionnaire. Volunteers remained available to offer clarification or technical support throughout the data collection process. To prevent duplicate responses, the one-response-per-user setting in Google Forms was enabled.

Statistical analysis

Data collected via a “Google Forms” was automatically entered into a “Google Sheets”. The “Google Sheets” was downloaded in Microsoft Excel and then imported into statistical software. All statistical analyses were conducted using STATA version 14. All visualizations were generated using STATA version 14 and R version 4.4.0. Descriptive statistics were computed, including frequencies and percentages for categorical variables, and means with standard deviations for continuous variables. To examine group differences in depression, anxiety, and stress scores across independent variables, two-sample t-tests and one-way ANOVA were performed. Pearson’s correlation coefficient was used to assess the relationships among depression, anxiety, and stress scores. Multiple linear regression models were fitted to identify factors associated with depression, anxiety, and stress. Normality assumptions were tested using density plots and the Shapiro–Wilk tests. The data were found to be approximately normally distributed. Only variables that were statistically significant in the bivariate analyses (t-tests and ANOVA) were included in the multivariable models. Multicollinearity among the independent variables was examined prior to model fitting. After fitting the model, we calculated the variance inflation factors (VIF). A p value of < 0.05 was considered statistically significant.

Results

Background characteristics of participants

The background characteristics of the participants (n = 382) are presented in Table 1. Most of the participants were female (81.41%), with a mean age of 21.69 years. More than half of the respondents (58%) were from rural areas, 40.84% reported a monthly family income of ≥ 30,000 BDT, 59.69% were enrolled in a B.Sc. in Nursing program, and the majority (81.94%) had no study gaps.

Table 1.

Background characteristics of participants (n = 382)

Variables	Number (n)	Percentage (%)/mean (SD)
Demographic variables
Mean age		21.69 (1.30)
Age
< 21 years	70	18.32
21–22 years	211	55.24
> 22 years	101	26.44
Sex
Male	71	18.59
Female	311	81.41
Permanent residence
Urban	160	41.88
Rural	222	58.12
Total family income per month
< 15,000 BDT	74	19.37
15,000 to 29,999 BDT	152	39.79
≥ 30,000 BDT	156	40.84
Academic variables
Course name
BSc in Nursing	288	59.69
Diploma in Nursing	154	40.31
Academic year
First year	81	21.20
Second year	108	28.27
Third year	126	32.98
Fourth year	67	17.54
Having any study gaps
Yes	69	18.06
No	311	81.94
Overall relationship with peers
Poor	48	12.57
Good	334	87.43
Faculty support during the course works
Adequate	294	76.96
Inadequate	88	23.04
Clinical placement related variables
Feeling of doing more clinical placement than required
Agree	230	60.21
Disagree	152	39.79
Receiving leave approval when sick
Always	214	56.02
Never	168	43.98
On average the total night shift duties per month
< 1 night shift	131	34.29
≥ 1 night shift	251	65.71
Getting opportunities for rest
Always	166	43.46
Never	216	56.54
Standing duty hours
100% of the duty hours	62	16.23
75% of the duty hours	270	70.68
50% of the duty hours	38	9.95
25% of the duty hours	12	3.14
Overall support from staff at hospital
Adequate	187	48.95
Inadequate	195	51.05
Overall support from hospital authorities
Adequate	156	40.84
Inadequate	226	59.16
Overall support from clinical instructors
Adequate	151	39.53
Inadequate	231	60.47
Receiving guidance from the instructor or the supervisor
Frequently	155	40.58
Never	227	59.42
Overall behaviour of nurses
Satisfied	184	48.17
Dissatisfied	198	51.83
Overall behaviour of physicians
Satisfied	242	63.35
Dissatisfied	140	36.65

Descriptive statistics of depression, anxiety, and stress scores

Descriptive statistics for depression, anxiety, and stress scores are presented in Table 2. The mean scores for depression, anxiety, and stress were 16.96 (SD = 10.49), 14.52 (SD = 9.61), and 17.11 (SD = 9.17), respectively. The Cronbach’s alpha for depression, anxiety, and stress subscales was 0.84, 0.84, and 0.82, respectively, indicating good internal consistency.

Table 2.

Descriptive statistics of depression, anxiety, and stress scores (n = 382)

Scales	Mean	Median	SD	IQR	Cronbach alpha
Depression	16.96	16	10.49	8	0.84
Anxiety	14.52	12	9.61	8	0.84
Stress	17.12	16	9.18	8	0.82

Prevalences of depression, anxiety, and stress

The prevalence of depression, anxiety, and stress is illustrated in Figs. 1, 2, 3. Figure 1 shows that the overall prevalence of depression was 74.61%, with 15.97% classified as mild, 24.87% as moderate, 13.09% as severe, and 20.68% as extremely severe. The overall prevalence of anxiety was 77.75%, including 11.26% mild, 24.61% moderate, 13.87% severe, and 28.01% extremely severe, as presented in Fig. 2. Figure 3 shows that the overall prevalence of stress was 53.14%, with 16.23% classified as mild, 15.71% as moderate, 14.66% as severe, and 6.54% as extremely severe.

Fig. 1.

Shows the severity level of depression

Fig. 2.

Shows the severity level of anxiety

Fig. 3.

Shows the severity level of stress

Distribution of depression, anxiety, and stress scores across study variables

The distribution of depression, anxiety, and stress scores across study variables is presented in Table 3. Age was found to be significantly associated with depression (p < 0.05) and anxiety (p < 0.05). Sex and academic year were significantly associated with all three outcomes (p < 0.05–p < 0.001). The overall relationship with peers was significantly associated with depression and stress (p < 0.01–p < 0.001). Faculty support during study was significantly associated with depression (p < 0.001). The total number of night duties per month was significantly associated with depression (p < 0.01) and anxiety (p < 0.05). Students who felt they were doing more clinical placement than required, leave approval when sick, and getting opportunities for rest during clinical placement were significantly associated with all three outcomes (p < 0.001). The total standing hours during clinical placement were significantly associated with anxiety (p < 0.001) and stress (p < 0.05). Support from hospital staff, overall support from hospital authorities, the overall behaviour of nurses, and the overall behaviour of physicians during clinical placement were found to be significantly associated with all three outcomes (p < 0.01–p < 0.001).

Table 3.

Distribution of depression, anxiety, and stress scores across study variables

Variables	Depression	Anxiety	Stress
	M ± SD	M ± SD	M ± SD
Demographic variables
Age
< 21 years	14.6 ± 9.73	15.02 ± 9.76	16.77 ± 9.07
21–22 years	16.91 ± 10.74	13.43 ± 9.21	16.79 ± 9.08
> 22 years	18.71 ± 10.25	16.45 ± 10.07	18.01 ± 9.47
F/t	3.22*	3.55*	0.67
Sex
Male	14.02 ± 10.02	9.69 ± 8.27	13.21 ± 8.48
Female	17.63 ± 10.50	15.62 ± 9.56	18.01 ± 9.11
F/t	− 2.63**	− 4.83***	− 4.05***
Permanent residence
Urban	17.38 ± 10.73	14.81 ± 9.44	17.62 ± 9.53
Rural	16.66 ± 10.34	14.31 ± 9.74	16.74 ± 8.91
F/t	0.67	0.49	0.92
Total family income per month
< 15,000 BDT	15.21 ± 10.29	14.43 ± 9.35	16.81 ± 9.83
15,000 to 29,999 BDT	17.64 ± 10.48	15.11 ± 9.34	17.56 ± 8.92
≥ 30,000 BDT	17.12 ± 10.59	13.98 ± 9.99	16.82 ± 9.14
F/t	1.37	0.54	0.30
Academic variables
Course name
B.Sc. in nursing	17.64 ± 10.68	14.92 ± 9.99	17.84 ± 9.45
Diploma in nursing	15.96 ± 10.17	13.92 ± 9.00	16.03 ± 8.67
F/t	1.54	1.01	1.88
Academic year
First year	11.53 ± 8.38	11.60 ± 8.91	13.67 ± 7.97
Second year	18.16 ± 10.29	14.98 ± 9.16	18.01 ± 9.38
Third year	18.19 ± 10.92	14.85 ± 9.63	17.69 ± 9.34
Fourth year	19.28 ± 10.32	16.68 ± 10.43	18.71 ± 9.05
F/t	10.03***	3.84*	5.14**
Having any study gaps
Yes	18.75 ± 11.20	16.23 ± 10.14	18.34 ± 9.51
No	16.56 ± 10.31	14.14 ± 9.46	16.84 ± 9.09
F/t	1.57	1.63	1.23
Overall relationship with peers
Poor	23.25 ± 10.42	16.70 ± 11.25	20.37 ± 10.75
Good	16.06 ± 10.21	14.20 ± 9.32	16.64 ± 8.84
F/t	4.55***	1.69	2.65**
Faculty support during the course works
Adequate	16.12 ± 10.50	14.31 ± 9.59	16.70 ± 9.23
Inadequate	19.77 ± 10.02	15.20 ± 9.67	18.47 ± 8.88
F/t	− 2.89**	− 0.76	− 1.59
Clinical placement related variables
Feeling of doing more clinical duty than required
Agree	19.33 ± 10.29	19.33 ± 10.29	18.49 ± 9.28
Disagree	13.36 ± 9.78	13.36 ± 9.78	15.02 ± 8.63
F/t	5.66***	5.66***	3.67***
Receiving leave approval when sick
Always	14.97 ± 10.03	12.76 ± 8.87	15.34 ± 8.85
Never	19.5 ± 10.57	16.76 ± 10.07	19.36 ± 9.11
F/t	− 4.28***	− 4.12***	− 4.35***
On average the total night shift duties per month
< 1 night shift	14.80 ± 10.16	12.99 ± 9.31	16.01 ± 9.22
>  = 1 night shift	18.08 ± 10.51	15.32 ± 9.68	17.68 ± 9.12
F/t	− 2.93**	− 2.26*	− 1.69
Getting opportunities for rest
Always	13.48 ± 9.44	12.01 ± 8.12	14.78 ± 8.20
Never	19.63 ± 10.50	16.45 ± 10.21	18.90 ± 9.49
F/t	− 5.93***	− 4.59***	− 4.46***
Standing duty hours
100% of the duty hours	20.09 ± 11.59	17.83 ± 11.30	19.80 ± 10.59
75% of the duty hours	16.40 ± 10.61	14.19 ± 9.42	16.94 ± 9.16
50% of the duty hours	16.10 ± 7.09	12.57 ± 6.39	14.68 ± 5.73
25% of the duty hours	16 ± 9.10	11 ± 9.43	14.83 ± 7.92
F/t	2.23	3.70*	2.99*
Overall support from staff at hospital
Adequate	13.79 ± 9.85	12.70 ± 9.25	14.65 ± 8.57
Inadequate	20 ± 10.23	16.26 ± 9.64	19.47 ± 9.13
F/t	− 6.04***	− 3.68***	− 5.31***
Overall support from hospital authorities
Adequate	12.93 ± 8.95	12.08 ± 8.38	13.91 ± 8.06
Inadequate	19.74 ± 10.60	16.20 ± 10.05	19.32 ± 9.26
F/t	− 6.56***	− 4.20***	− 5.91***
Overall support from clinical instructors
Adequate	13.56 ± 9.84	13.37 ± 8.90	14.94 ± 8.74
Inadequate	19.18 ± 10.33	15.27 ± 9.99	18.53 ± 9.19
F/t	− 5.30***	− 1.89	− 3.81***
Receiving guidance from clinical instructors
Always	12.75 ± 9.41	12.17 ± 8.19	14.46 ± 8.02
Never	19.84 ± 10.24	16.13 ± 10.17	18.92 ± 9.49
F/t	− 6.87***	− 4.04***	− 4.79***
Overall behaviour of nurses
Satisfied	12.75 ± 8.65	12.03 ± 7.85	13.66 ± 7.33
Dissatisfied	20.88 ± 10.57	16.84 ± 10.50	20.32 ± 9.56
F/t	− 8.19***	− 5.04***	− 7.59***
Overall behaviour of physicians
Satisfied	14.96 ± 9.92	13.36 ± 8.95	15.41 ± 8.48
Dissatisfied	20.43 ± 10.60	16.52 ± 10.37	20.05 ± 9.60
F/t	− 5.06***	− 3.14**	− 4.90***

*p < 0.05, **p < 0.01, ***p < 0.001

Factors associated with depression

Table 4 presents the factors associated with depression based on the multivariable linear regression model. Depression scores were approximately normally distributed, and the VIF value ranged from 1.07 to 4.23, indicating no evidence of serious multicollinearity. The adjusted R-squared value was 0.29, suggesting that the model explained 29% of the variance in depression scores. Model assumptions and diagnostic tests results are presented in Supplementary file 2. Female students reported significantly higher depression scores compared to male students (β = 2.89, 95% CI 0.52 to 5.27, p = 0.017). Students with poor peer relationships had significantly higher depression scores (β = 5.64, 95% CI 2.84 to 8.43, p < 0.001) compared to those with good peer relationships. Students who never had the opportunity to take rest during clinical placement had significantly higher depression scores (β = 3.37, 95% CI 1.36 to 5.38, p < 0.01) than those who always had the opportunity. Students who were dissatisfied with the behaviour of nurses had significantly higher depression scores (β = 4.04, 95% CI 1.74 to 6.35, p = 0.001) compared to those who were satisfied.

Table 4.

Multivariable linear regression model to identify factors associated with depression

Variables	95% confidence interval			p value
	β	Lower level	Upper level
Age
< 21 years	Reference
21–22 years	− 0.90	-3.74	1.93	0.531
> 22 years	0.11	-3.62	3.84	0.954
Sex
Male	Reference
Female	2.89	0.52	5.27	0.017
Academic year
First year	− 4.28	− 8.77	0.21	0.062
Second year	0.12	− 3.33	3.57	0.946
Third year	− 1.69	− 4.64	1.24	0.258
Fourth year	Reference
Overall relationship with peers
Good	Reference
Poor	5.64	2.84	8.43	< 0.001
Faculty support during course works
Adequate	Reference
Inadequate	1.76	− 0.48	4.01	0.124
Feeling of doing more clinical placement than required
Disagree	Reference
Agree	2.00	− 0.05	4.06	0.056
Receiving leave approval when sick
Always	Reference
Never	− 0.22	− 2.25	1.79	0.823
On average the total night shift duties per month
< 1 night shift	Reference
>  = 1 night shift	0.19	− 2.75	3.12	0.899
Getting opportunities for rest
Always	Reference
Never	3.37	1.36	5.38	0.001
Overall support from staff at hospital
Adequate	Reference
Inadequate	0.55	− 1.87	2.96	0.657
Overall support from hospital authorities
Adequate	Reference
Inadequate	1.88	− 0.86	4.62	0.178
Overall support from clinical instructors
Adequate	Reference
Inadequate	− 0.69	− 3.33	1.94	0.604
Receiving guidance from instructor or supervisor
Always	Reference
Never	1.80	− 0.42	4.03	0.111
Overall behaviour of nurses
Satisfied	Reference
Dissatisfied	4.04	1.74	6.35	0.001
Overall behaviour of physicians
Satisfied	Reference
Dissatisfied	1.02	− 1.17	3.21	0.362

Model details: F (18, 363) = 9.42, P value < 0.001, R-squared = 0.32, Adjusted R-squared = 0.29, Root MSE = 8.88. Bold p-values indicate statistical significance

Factors associated with anxiety

Table 5 presents the factors associated with anxiety based on the multivariable linear regression model. Anxiety scores were approximately normally distributed, and the VIF value ranged from 1.08 to 4.26, indicating no evidence of serious multicollinearity. The adjusted R-squared value was 0.17, suggesting that the model explained 17% of the variance in anxiety scores. Model assumptions and diagnostic test results are presented in Supplementary file 3. Students aged 21–22 years had significantly lower anxiety scores compared to those under 21 (β = −3.18, 95% CI −5.97 to −0.40, p = 0.025). Female students reported significantly higher anxiety scores than male students (β = 5.77, 95% CI 3.42 to 8.11, p < 0.001). Students who never had the opportunity to take rest during clinical placement had significantly higher anxiety scores compared to those who did (β = 2.46, 95% CI 0.43 to 4.49, p = 0.018). Students who stood for 75% of their duty hours experienced significantly lower anxiety scores compared to those who stood for 100% of the time (β = −2.72, 95% CI −5.26 to −0.18, p = 0.036).

Table 5.

Multivariable linear regression model to identify factors associated with anxiety

Variables	95% confidence interval			P value
	β	Lower level	Upper Level
Age
< 21	Reference
21–22	− 3.18	− 5.97	− 0.40	0.025
> 22	0.36	− 3.34	4.06	0.847
Sex
Male	Reference
Female	5.77	3.42	8.11	< 0.001
Academic year
1st year	-0.90	-5.34	3.53	0.690
2nd year	1.40	-1.98	4.79	0.415
3rd year	− 0.41	− 3.30	2.48	0.782
4th year	Reference
Feeling of doing more clinical placement than required
Disagree	Reference
Agree	0.99	− 1.03	3.02	0.338
Receiving leave approval when sick
Always	Reference
Never	0.73	− 1.27	2.73	0.474
On average the total night shift duties per month
< 1 night shift	Reference
>  = 1 night shift	1.06	− 1.90	4.04	0.480
Getting opportunities for rest
Always	Reference
Never	2.46	0.43	4.49	0.018
Standing duty hours
100% of the hours	Reference
75% of the hours	− 2.72	− 5.26	− 0.18	0.036
50% of the hours	− 3.22	− 7.07	0.64	0.102
25% of the hours	− 4.97	− 10.62	0.67	0.084
Overall support from staff at hospital
Adequate	Reference
Inadequate	− 0.19	− 2.54	2.14	0.869
Overall support from hospital authorities
Adequate	Reference
Inadequate	1.22	− 1.17	3.61	0.317
Receiving guidance from the instructor or supervisor
Always	Reference
Never	0.69	− 1.42	2.79	0.522
Overall behaviour of nurses
Satisfied	Reference
Dissatisfied	1.91	− 0.37	4.19	0.100
Overall behaviour of physicians
Satisfied	Reference
Dissatisfied	1.31	− 0.86	3.49	0.236

Model details: F (18, 363) = 5.42, P value < 0.001, R-squared = 0.21, Adjusted R-squared = 0.17, Root MSE = 8.74. Bold p-values indicate statistical significance

Factors associated with stress

Table 6 presents the factors associated with stress based on the multivariable linear regression model. Stress scores were approximately normally distributed, and the VIF value ranged from 1.08 to 4.26, indicating no evidence of serious multicollinearity. The adjusted R-squared value was 0.21, suggesting that the model explained 21% of the variance in stress scores. Model assumptions and diagnostic test results are presented in Supplementary File 4. Female students reported significantly higher stress scores compared to male students during clinical placement (β = 4.11, 95% CI 1.92 to 6.31, p < 0.001). Students who reported poor peer relationships had significantly higher stress scores than those with good peer relationships (β = 2.86, 95% CI 0.30 to 5.42, p = 0.029). Students who were dissatisfied with the behaviour of nursing staff during clinical placement experienced significantly higher stress scores (β = 3.72, 95% CI 1.59 to 5.85, p = 0.001) compared to those who were satisfied.

Table 6.

Multivariable linear regression model to identify factors associated with stress

Variables	95% confidence interval			P value
	β	Lower level	Upper Level
Age
< 21	Reference
21–22	− 1.77	− 4.37	0.82	0.180
> 22	− 0.74	− 4.15	2.66	0.668
Sex
Male	Reference
Female	4.11	1.92	6.31	< 0.001
Academic year
1st year	− 3.01	− 6.60	0.57	0.100
2nd year	0.38	− 2.70	3.47	0.806
3rd year	− 1.27	− 3.96	1.41	0.351
4th year	Reference
Overall relationship with peers
Good	Reference
Poor	2.86	0.30	5.42	0.029
Feeling of doing more clinical placement than required
Disagree	Reference
Agree	0.32	− 1.55	2.21	0.732
Receiving leave approval when sick
Always	Reference
Never	0.43	− 1.43	2.28	0.653
Getting opportunities for rest
Always	Reference
Never	1.66	− 0.23	3.55	0.085
Standing duty hours
100% of the hours	Reference
75% of the hours	− 1.98	− 4.35	0.38	0.101
50% of the hours	− 2.87	− 6.40	0.65	0.110
25% of the hours	− 2.97	− 8.25	2.29	0.267
Overall support from staff at hospital
Adequate	Reference
Inadequate	0.55	− 1.65	2.76	0.620
Overall support from hospital authorities
Adequate	Reference
Inadequate	2.48	− 0.01	4.98	0.051
Overall support from clinical instructors
Adequate	Reference
Inadequate	− 1.45	− 3.88	0.96	0.238
Receiving guidance from clinical instructor or supervisor
Always	Reference
Never	0.54	− 1.48	2.58	0.596
Overall behaviour of nurses
Satisfied	Reference
Dissatisfied	3.72	1.59	5.85	0.001
Overall behaviour of physicians
Satisfied	Reference
Dissatisfied	1.65	− 0.37	3.67	0.109

Model details: F (18, 363) = 6.40, P value < 0.001, R-squared = 0.25, Adjusted R-squared = 0.21, Root MSE = 8.15. Bold p-values indicate statistical significance

Correlation among depression, anxiety, and stress

Figures 4, 5, 6 illustrate the correlations among depression, anxiety, and stress scores. Figure 4 shows a strong positive correlation between depression and anxiety scores (r = 0.726). Figure 5 depicts a strong correlation between depression and stress scores (r = 0.793). Figure 6 also presents a strong correlation between anxiety and stress scores (r = 0.836).

Fig. 4.

Shows the correlation between depression and anxiety scores

Fig. 5.

Shows correlation between depression and stress scores

Fig. 6.

Shows correlation between anxiety and stress scores

Discussion

In our study, the prevalence of depression, anxiety, and stress during clinical placement was 74.61%, 77.75%, and 53.14%, respectively. Various demographic, academic, and clinical placement-related factors were significantly associated with these mental health outcomes. Sex, peer relationships, getting opportunities to rest, and the overall behaviour of nurses were significantly associated with depression. Age, sex, getting opportunities to rest, and the standing duty hours showed significant associations with anxiety. Sex, peer relationships, and the behaviour of nurses were significantly associated with stress.

Several studies from various countries investigated the prevalence of depression, anxiety, and stress among nursing students during clinical placements. A study conducted in Pakistan found that the prevalence of depression, anxiety, and stress among nursing students was 44.2%, 64.2%, and 42.3%, respectively [22]. In India, Tapariya (2020) reported that 1.7% of nursing students had very low stress, 4.2% had low stress, 10% had average stress, 38.8% had high stress, and 53.3% had very high or above-average stress [23]. Regarding anxiety levels, 26.2% of students experienced mild anxiety, 66.7% moderate anxiety, and 4.2% severe anxiety [23]. In terms of depression, 43.3% reported minimal depression, 23.3% had mild depression, 24.2% moderate depression, and 9.2% very severe depression [23]. In Canada, Chernomas and Shapiro (2013) reported that 10% of undergraduate nursing students experienced severe to extremely severe depression, where 16% had severe to extremely severe anxiety, and 10% reported severe to extremely severe stress [24].

In this study, the prevalence of depression, anxiety, and stress among Bangladeshi nursing students was higher compared to international studies. We believe that the high prevalence of these mental health issues among nursing students in Bangladesh during clinical placement may be due to several factors that were also discussed in the literature. For example, in Bangladesh, working in clinical settings is reportedly less welcoming, which may make clinical placement less attractive to the students. Chowdhury et al. (2022) found that nurses in Bangladesh face a high prevalence of violence in the workplace, which may also impact nursing students as the students have to share the same workplace [25]. Another study conducted in Bangladesh found that the workload is a contributing factor of mental health challenges among both nurses and nursing students [26]. Nurses in Bangladesh were reportedly dissatisfied with their jobs, which may also negatively impact both the nurses and nursing students due to shared workplace [25].

In the present study, age was found to be a significant factor associated with anxiety. Students under the age of 21 years experienced higher levels of anxiety compared to those aged 21–22 years. Wang et al. (2019) found that nursing students, in Canada, aged 18–24 years, reported significantly higher levels of anxiety compared to older age groups, which supports the finding of our study [27]. We did not find any association between age and depression. In contrast to our study, Altaweel et al. (2023) reported that depression levels varied significantly by age in Saudi Arabia, with younger nursing interns during clinical placement exhibiting higher levels of depression than their older counterparts [28]. In Bangladesh, younger students may have higher clinical placement fear and a lack of coping skills, which could explain their poor mental health outcomes.

Female nursing students experienced significantly higher levels of depression, anxiety, and stress compared to their male counterparts in this study. This finding aligns with previous research conducted in various countries. For example, Albikawi (2022) reported similar results in Saudi Arabia, where female nursing students reported higher levels of all three mental health outcomes [29]. In Bahrain, Sanad (2019) found that female students had significantly higher anxiety levels during clinical placements [30]. Similarly, a study conducted in Spain by García-Velasco et al. (2025) reported that female nursing students experienced significantly higher levels of both anxiety and stress [2]. A study conducted in Pakistan reported that female students were more likely to experience high levels of stress compared to their male peers [22]. In Bangladesh, this may be influenced by gender-based social expectations, such as the expectation for women to manage both academic and household responsibilities, along with limited emotional support and increased safety concerns during clinical placements.

The poor peer relationships were significantly associated with higher levels of depression and stress among nursing students in this study. This finding is supported by a study conducted in Hong Kong by Cheung et al. (2016), which reported that students experiencing peer conflict or weak social connections exhibited significantly higher levels of depression during their academic program [12]. Similarly, García-Velasco et al. (2025) conducted a study in Spain and found that poor peer relationships were significantly associated with high levels of anxiety and stress among nursing students during clinical placements [2]. In Bangladesh, this may be attributed to a limited teamwork culture during clinical environments that hinders peer cooperation.

Nursing students who did not have the opportunity to rest during clinical placements experienced higher levels of depression and anxiety in this study. This finding is consistent with a study conducted at King Khalid University by Mohamed Bayoumi et al. (2012), which reported that students who faced a lack of rest during clinical placements reported significantly higher levels of anxiety [31]. Similarly, a study was conducted in the United States and noted that long-term clinical duty without any break increases the risk of depression and anxiety among healthcare workers [32]. However, not only in healthcare settings, but Maria Boström et al. (2016) also reported that, among various professionals in Sweden, having opportunities for rest or break time during work influences productivity and job satisfaction [33].

Negative behaviour from nurses during clinical placements was significantly associated with higher levels of depression and stress among nursing students in this study. Similarly, a study conducted in China by Zhang et al. (2024) reported that poor treatment by nurses related to increased levels of depression and stress among nursing students during clinical practice [34]. Supporting this, a scoping review by Yosep et al. (2024) revealed that nursing students often faced bullying and violence from nursing staff, which had a significant impact on their mental health [35]. Furthermore, Watson and Patti (2025) also identified negative interactions with nurses as a significant contributing factor to high stress levels among students during their clinical training [36].

Nursing students who spent approximately 75% of their clinical placement time standing experienced significantly lower levels of anxiety compared to those who spent 100% of their clinical time on their feet in this study. This finding is supported by a study conducted in China by Zhao et al. (2015), which identified workload burden and prolonged standing hours as significant contributors to anxiety among nursing students during clinical placements [37]. In the context of Bangladesh, this finding may be related to the fact that nursing students commonly encounter high patient loads and inadequate rest, which may contribute to an increased likelihood of anxiety during clinical placements.

Limitations and strengths

This study has several limitations. Firstly, the design was cross-sectional, which limits the ability to infer a causal association between the factors and mental health outcomes. Secondly, the study used convenience sampling from a single institute. Therefore, selection bias, volunteer bias, non-response bias, and sample representativeness might not be ignored. As a result, the generalizability of the findings to the broader population is limited. Thirdly, the reliance on self-reported data may be subject to social desirability and recall biases, leading to under- or overestimation of mental health symptoms. Future research should use longitudinal designs to assess mental health outcomes over time and a qualitative design to explore students’ lived experiences during clinical placements. Future research should also focus on conducting studies in multi-center settings, using random sampling techniques to maximize response rates and enhance generalizability. Fourthly, we performed multiple tests, which is another limitation of our study. There might be a high risk of a Type I error due to multiple tests. Furthermore, we included only the significant variables in the model. Therefore, the other confounder variables may have been omitted. This is also a limitation of our study. Moreover, we used the DASS-21 scale, which was validated among healthcare workers but not among nursing students in Bangladesh. Future research should validate the tool among nursing students. Finally, we measured various variables related to the mental health outcomes; however, we did not measure other potentially important variables, such as living arrangements, financial stress, social support outside the academic environment, and academic workload.

However, our study has several strengths. This is the first study in Bangladesh that investigated the prevalence and associated factors of depression, anxiety, and stress among nursing students during their clinical placements. We used the DASS-21 scale, which is a validated and widely used tool for measuring severity. We also included a relatively large sample size, which could be acceptable and comparable for the nursing students and nursing colleges for the other regions of Bangladesh. The internal consistency of the DASS-21 subscales was also high, as reflected by Cronbach’s alpha values ranging from 0.82 to 0.84. These strengths could provide methodological support for the potential policy impact of this study.

Conclusions and recommendations

Mental health outcomes such as depression, anxiety, and stress were found to be highly prevalent among students during clinical placement in this study. Our study has several limitations, including a cross-sectional design, convenience sampling, numerous biases, a one-centred study design, reliance on symptom severity rather than diagnostic tools, and missing measurements of several clinically relevant variables. However, we found that numerous factors were associated with the outcomes, including sex, peer relationships, rest opportunities, standing duty hours, and nursing staff behaviour.

Based on the findings, evidence-based interventions are needed to support the mental well-being of nursing students during clinical placements. For example, institutions should implement structured mental health support initiatives, such as counselling services, peer support groups, and stress management workshops. It could be more beneficial to take particular attention to female students who may feel less empowered to voice concerns in clinical settings. Taking initiatives, such as creating a positive and inclusive peer environment through mentorship programs, team-building activities, and regular check-ins, may improve mental health outcomes. Our results also showed that negative behaviour from nurses was associated with poorer mental health outcomes. This suggests that professional training and student-centred communication could be more convenient for helping clinical staff build a positive attitude towards students. Clinical placement settings should ensure students are not overburdened by excessive standing or unrealistic workloads. Students should be provided with designated rest areas and scheduled breaks. Thus, implementing these strategies may improve the clinical placement settings, reduce mental health burdens, enhance the overall quality of nursing education, strengthen the healthcare system, and ensure high-quality patient care in Bangladesh.

Supplementary Information

Below is the link to the electronic supplementary material.

Author contributions

Md. Ikbal Hossain drafted the manuscript. Md. Ikbal Hossain, Humayun Kabir, Azaz Bin Sharif, and Dipak Kumar Mitra conceived and designed the study. Md. Ikbal Hossain, Anika Nawar, Amir Hamza, Masuda Akter, Humayun Kabir, Azaz Bin Sharif, and Dipak Kumar Mitra developed the questionnaire. Md. Ikbal Hossain and Anika Nawar collected data. Md. Ikbal Hossain, Anika Nawar, Amir Hamza, Masuda Akter, Sopon Akter, Anar Koly, Shimpi Akter, Anjan Kumar Roy, and S. M. Shubho Ahmed perform data cleaning and verification. Md. Ikbal Hossain and Humayun Kabir conducted the statistical analysis and prepared visualizations. Md. Ikbal Hossain, Humayun Kabir, Sheila Boamah, and Ashikur Rahman completed the revision of intellectual content. Humayun Kabir, Azaz Bin Sharif, and Dipak Kumar Mitra supervised the study. All authors edited, read, and approved the final manuscript.

Funding

The authors received no funding for this research.

Data availability

Data of the study is publicly available at Zenodo: https://zenodo.org/records/17544118

Declarations

Ethics approval and consent to participate

The study protocol was approved by the Institutional Review Board/Ethical Review Committee of North South University, Bangladesh (approval ID: 2025/OR-NSU/IRB/0504) in accordance with the Declaration of Helsinki [38]. The purpose of the study was clearly described on the first page of the questionnaire. Participation was entirely voluntary, and participants retained the right to withdraw at any stage of the study. Written informed consent to participate in the study and to publish research articles based on the anonymous data was obtained from all participants.

Consent for publication

No personal data was collected, and consent to publish is not applicable for this study.

Clinical trial number

Not applicable for this research.

Competing interests

The authors declare no competing interests.