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. 2026 Aug 21;13(8):e70761. doi: 10.1002/nop2.70761

The Mediating Role of Cognitive Flexibility in the Relationship Between Self‐Transcendence and Depression Symptom Level: A Sample of Health Department Students

Şevval Yeyit Bozdemir 1,✉, Havva Kaçan 1
PMCID: PMC13494672  PMID: 42625518

ABSTRACT

Aim

To examine the cross‐sectional indirect association between self‐transcendence and depressive symptoms through cognitive flexibility and to determine whether the Alternatives and Control dimensions show different indirect associations.

Design

The study had a descriptive, correlational, cross‐sectional design.

Methods

The study population consisted of students studying in the nursing and midwifery department of a state university's Faculty of Health Sciences, and the sample consisted of 451 students (245 nursing and 206 midwifery). The data were collected using a Students' Personal Information Form (SPIF), the Self‐Transcendence Scale (STS), the Cognitive Flexibility Inventory (CFI) and the Beck Depression Inventory (BDI). The self‐report questionnaires were administered in classroom settings. Item scoring was audited against the published Cognitive Flexibility Inventory scoring key. A one‐factor model and a correlated two‐factor model were compared using diagonally weighted least squares. Regression‐based indirect associations were estimated with HC3 heteroskedasticity‐consistent standard errors and 5000 bias‐corrected and accelerated bootstrap samples. The parallel dimension model and covariate‐adjusted models were treated as exploratory sensitivity analyses.

Results

The mean Cognitive Flexibility Inventory total score was 59.44 ± 7.70, and 164 students (36.4%) scored at or above the Beck Depression Inventory screening cutoff of 17, indicating elevated depressive symptoms rather than a clinical diagnosis. The correlated two‐factor model fit substantially better than the one‐factor model (CFI = 0.939, TLI = 0.931, RMSEA = 0.069, SRMR = 0.094). In the prespecified total‐score model, the indirect association between self‐transcendence and depressive symptoms through cognitive flexibility was statistically significant (B = −0.174, BootSE = 0.051, BCa 95% CI [−0.278, −0.077]). In the exploratory parallel model, the indirect association through the Control dimension was statistically significant (B = −0.123, BootSE = 0.040, BCa 95% CI [−0.212, −0.057]), whereas the indirect association through the Alternatives dimension was not (B = 0.042, BootSE = 0.060, BCa 95% CI [−0.073, 0.160]).

Conclusion

The findings support a cross‐sectional indirect association between self‐transcendence and depressive symptoms through cognitive flexibility. The dimension‐specific findings suggest that the total cognitive flexibility score may conceal different patterns across the Alternatives and Control dimensions. Temporal or causal mediation cannot be inferred from this cross‐sectional study. Longitudinal and experimental studies are needed to further clarify these relationships.

Patient or Public Contribution

Health department students contributed by providing anonymous self‐reports.

Impact

The findings identify the Control dimension as a potentially important focus for future longitudinal and intervention research on student mental health.

Keywords: cognitive flexibility, health department students, self‐transcendence

1. Introduction

Cognitive flexibility refers to the capacity to recognise alternatives, adapt cognitive strategies to situational demands and perceive difficult situations as manageable (Dennis and Vander Wal 2010; Uddin 2021). These capacities may be particularly relevant to nursing and midwifery students, who encounter changing clinical situations, uncertainty and emotionally demanding experiences during professional education (Abbasszade et al. 2025; Panda et al. 2021; Tayhan et al. 2023). Such experiences may contribute to broader perspectives and more adaptive responses to challenging situations, both of which have been associated with cognitive flexibility (Tayhan et al. 2023). Previous studies have generally linked cognitive flexibility with more adaptive psychological functioning and fewer depressive symptoms, but the construct is multidimensional and its Alternatives and Control dimensions may not relate to other variables in the same way (Sapmaz and Doğan 2013; Yu et al. 2020; Novak et al. 2022).

Self‐transcendence is a characteristic of developmental maturity and is characterised by an orientation towards developing a broader perspective on life with enhanced awareness of the environment (Reed 2023). Self‐transcendence is also a cognitive maturity that enables an enhanced awareness of adaptation to the environment and a broader perspective on life (Reed 2014). Within Reed's theory, self‐transcendence is considered relevant to adaptation and well‐being in situations involving vulnerability (Reed 2023). Health students are secondarily exposed to patients' challenging experiences during the care process, which often involve vulnerability, a fundamental concept in Reed's theory of self‐transcendence (Aryuwat et al. 2024; Reed 2023). Exposure to diverse experiences has also been associated with greater cognitive flexibility (Ritter et al. 2012). Studies have reported inverse associations between self‐transcendence and depressive symptoms and positive associations between self‐transcendence and adaptive psychological resources (Er and Buzlu 2022a; Ge and Yang 2023; Liu et al. 2021).

A statistical sequence in which self‐transcendence is associated with cognitive flexibility and cognitive flexibility is associated with depressive symptoms is theoretically plausible. Nevertheless, this ordering should not be interpreted as an established temporal process because cross‐sectional data cannot determine temporal precedence (Maxwell and Cole 2007). Cognitive flexibility may develop alongside self‐transcendence; the association may be reciprocal, and depressive symptoms may also influence both constructs (Bozdemir and Tatu 2026; Er and Buzlu 2022a; Babaei et al. 2023). Thus, an indirect effect observed in cross‐sectional data indicates that the covariance among the variables is compatible with the proposed statistical model, but it cannot establish that self‐transcendence precedes cognitive flexibility or causes subsequent changes in depressive symptoms (Hayes 2013; Maxwell and Cole 2007).

According to the World Health Organization (2023), approximately 5% of adults in the world experience depression (WHO 2023). While providing care to individuals, healthcare students face factors that negatively affect mental health, such as emotional stress, secondary exposure to challenging experiences, workload, perceived fear, lack of belonging and role ambiguity (Panda et al. 2021; Oates et al. 2019; Horgan et al. 2016). According to one study, healthcare students exhibit symptoms of depression such as self‐blame for negative events, indecisiveness, anger and sleep problems (Bresolin et al. 2020). Previous studies have reported that greater cognitive flexibility is associated with fewer depressive symptoms (Sapmaz and Doğan 2013).

Accordingly, cognitive flexibility may represent one possible explanatory mechanism for the association between self‐transcendence and depressive symptoms. A previous study conducted with nurses reported that self‐transcendence and cognitive flexibility were negatively related to depressive symptoms, and that higher levels of self‐transcendence and cognitive flexibility were associated with lower levels of depressive symptoms (Bozdemir and Tatu 2026). When these results are evaluated together, it is predicted that the relationships between self‐transcendence, cognitive flexibility and depressive symptoms may be complementary and that it may be important to consider these variables together within a process.

Therefore, examining the relationships among self‐transcendence, cognitive flexibility and depressive symptoms in health department students may contribute to a better understanding of the psychological processes associated with depressive symptoms. Accordingly, cognitive flexibility may statistically account for part of the association between self‐transcendence and depressive symptoms. Based on this theoretical framework, this study aimed to examine the cross‐sectional indirect association between self‐transcendence and depressive symptoms through cognitive flexibility among health sciences students. To this end, the following hypotheses were formulated.

There is a significant and positive relationship between the levels of self‐transcendence and cognitive flexibility among health students.

There is a significant and negative relationship between cognitive flexibility levels and depressive symptoms levels among health students.

There is a significant and negative relationship between the levels of self‐transcendence and depressive symptoms among health students.

The indirect association between self‐transcendence and depressive symptoms through cognitive flexibility is statistically significant.

2. Method

2.1. Study Design, Sample Size and Recruitment

The study had a descriptive, correlational and cross‐sectional design and was conducted at the Faculty of Health Sciences of a state university between December 2024 and January 2025. The study population consisted of 912 students enrolled in the nursing or midwifery programmes at the Faculty of Health Sciences. A non‐probability sampling method, specifically convenience sampling based on voluntary participation, was used. Participation criteria included being enrolled in nursing or midwifery education at the faculty, being aged over 18 years and voluntary participation in the study.

Appointments were scheduled with the instructors responsible for the course before each class, and data collection tools were distributed to students in classroom settings. The questionnaires were administered by the researcher during the scheduled class sessions, and the course instructors were not present in the classroom during data collection. Students present during the scheduled data‐collection sessions who met the inclusion criteria were invited to participate. The students were informed that participation was voluntary and that declining or withdrawing from the study would not result in any academic or personal disadvantage. Data were collected only from students who agreed to participate. Participants were included in the study on a voluntary basis from the first, second, third and fourth years of the nursing and midwifery departments. The sample consisted of 451 health sciences students, and complete data were obtained from each. All participants were included in the analyses because there were no incomplete data collection forms. Counts of students present, individually invited, absent or declining were not retained in the analytic records; therefore, a conventional response rate could not be calculated. The participants were informed that the study was conducted solely for scientific purposes, that the surveys were anonymous, that no identifying information would be collected, that their responses would be kept confidential and that there were no right or wrong answers. They were also told that it was important to answer the questions honestly. Because the questionnaires were completed anonymously, individual participants could not be identified or contacted on the basis of their responses, including responses indicating potential self‐harm or suicidal ideation. Therefore, all participants were provided with information about the university's psychological counselling services should they wish to seek professional support. This study was reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement. The completed STROBE checklist is provided as Supporting Information S1.

2.2. Sample Population

The population‐based minimum sample size was calculated using the finite‐population formula (Salant and Dillman 1994), with N = 912, z = 1.96, p = 0.50 and d = 0.05, yielding a minimum of 271 participants. An a priori power analysis specifically targeting the indirect effect was not conducted before data collection. Consequently, the final sample of 451 participants was not described as prospectively powered for mediation. Precision of the estimated indirect effects was evaluated using 5000 bootstrap confidence intervals.

2.3. Data Collection Tools

2.3.1. Students' Personal Information Form (SPIF)

SPIF consisted of 12 questions prepared by the researchers in line with the literature data on the students' age, sex, department, whether they chose their department willingly and how they coped with problems.

2.3.2. Self‐Transcendence Scale (STS)

The Turkish validity and reliability study of the scale developed by Reed (1991) was conducted by Sarıçam (2015). The STS aims to measure individuals' levels of transcendence, which is expressed through the concepts of transcending their own boundaries and making sense of experiences by changing their perspective. The scale consists of a single dimension. The scale consists of 15 items and is a 4‐point Likert‐type scale. Participants are expected to mark the appropriate option from (1) = Not at all, (2) = A little, (3) = A fair amount and (4) = A lot. The lowest score that can be obtained from the scale is 15, and the highest is 60. A high score obtained from the scale indicates a high level of self‐transcendence. The Cronbach's alpha internal reliability coefficient of the scale was found as 0.87 (Sarıçam 2015). In our study, the Cronbach's alpha internal reliability coefficient of the scale was 0.812.

2.3.3. Cognitive Flexibility Inventory (CFI)

The validity and reliability study of the scale, which was developed by Dennis and Vander Wal (2010), was conducted by Sapmaz and Doğan (2013). The CFI consists of two subdimensions (alternatives and control). The ‘alternatives’ dimension contains 13 items (items 1, 3, 5, 6, 8, 10, 12, 13, 14, 16, 18, 19 and 20) and includes items that indicate that an individual can find alternative solutions to difficult situations or that there may be alternative explanations for life situations and human behaviour. The ‘control’ subdimension contains seven items (items 2, 4, 7, 9, 11, 15 and 17) and includes statements that difficult situations can be controlled. The scale is a 5‐point Likert‐type scale with the following dimensions: ‘Not at all suitable’ (1), ‘Not Suitable’ (2), ‘Somewhat Suitable’ (3), ‘Suitable’ (4), ‘Completely Suitable’ (5). Items 2, 4, 7, 9, 11 and 17 of the scale are reverse‐coded. Three different scores can be obtained from the scale: total, alternatives sub‐dimension and control sub‐dimension. The lowest score from the scale is 20, and the highest is 100. A high score obtained from the scale indicates high cognitive flexibility. The Cronbach alpha internal reliability coefficients of the scale were found to be 0.90 for the entire scale, 0.90 for the alternatives sub‐dimension and 0.84 for the control sub‐dimension (Sapmaz and Doğan 2013). In our study, the Cronbach alpha internal reliability coefficient was found to be 0.877 for the entire scale, 0.905 for the alternatives sub‐dimension and 0.820 for the control sub‐dimension.

Cognitive flexibility was assessed in our study using the total score of the CFI. The scale's developers and the Turkish adaptation study also considered cognitive flexibility as a holistic construct encompassing alternatives and control dimensions and stated that a total cognitive flexibility score could be obtained from the scale. It was shown that the total score of the scale was highly correlated with both sub‐dimensions and had a high internal consistency coefficient for the entire scale. The total score was used in the analyses, rather than its sub‐dimensions, because the aim of the study was to examine the role of general cognitive flexibility level in the relationship between self‐transcendence and depression (Sapmaz and Doğan 2013). The total score was retained as the prespecified primary operationalisation based on the established scoring framework of the original instrument and the Turkish adaptation. In addition, an exploratory parallel analysis of the Alternatives and Control dimensions was conducted to examine potential dimension‐specific indirect associations.

2.3.4. Beck Depression Inventory (BDI)

The Beck Depression Inventory (BDI), developed by Beck et al. (1961), was used to determine the depression symptom levels of health department students. The Turkish validity and reliability study of the scale was conducted by Hisli (1989). The scale is a 21‐item self‐report scale intended to measure depression symptom levels. The participant is asked to select ‘the sentence that best describes how they have felt over the last week’. The scale is a 4‐point Likert‐type scale, and items are scored on a scale of 0–3. A score of ‘0’ indicates the absence of depressive symptoms, and a score of 1, 2 or 3 indicates increased symptoms. The total score on the scale ranges from 0 to 63. The cut‐off point is 17. Scores of 17 or higher indicate elevated depressive symptoms. High depression scores indicate higher levels of symptoms. The Cronbach alpha internal reliability coefficient of the scale was determined as 0.74 (Hisli 1989). In our study, the Cronbach alpha internal reliability coefficient of the scale was found to be 0.92.

2.4. Data Analysis

The data of the study were analysed using the Statistical Package for the Social Sciences (SPSS) for Windows 22.0 programme. Descriptive statistics, including frequencies, percentages, means and standard deviations, were calculated to summarise the characteristics of the sample and study variables. Kurtosis and skewness values were examined to determine whether the research variables showed a normal distribution (Table 2). In the relevant literature, a normal distribution is accepted when the results regarding the kurtosis and skewness values of the variables are between +1.5 and −1.5 (Tabachnick and Fidell 2013), +2.0 and −2.0 (George and Mallery 2010). The variables showed a normal distribution. Parametric methods were used in the analysis of the data. To evaluate the CFI measurement structure, one‐factor and correlated two‐factor models were fitted to the 20 item scores using diagonally weighted least squares. Model fit was evaluated using chi‐square, the comparative fit index (CFI), Tucker‐Lewis index (TLI), root mean square error of approximation (RMSEA) and standardised root mean square residual (SRMR). The two‐factor model was not interpreted as evidence for a higher‐order factor because only two first‐order dimensions were present. Pearson correlation analysis and regression analyses for the indirect association among the continuous variables of the study were conducted using the Process Model 4 developed by Hayes' PROCESS macro for SPSS (Model 4; Hayes 2013). In the model, the effect of the mediator variable on the relationship between the independent and dependent variables was examined by obtaining total effect, indirect effect and direct effect scores. Unstandardised regression coefficients (B), standardised regression coefficients (β), HC3 heteroskedasticity‐consistent standard errors, z values and p values are reported separately for each path of the model (a, b, c and c′), and indirect effects are reported with bootstrap standard errors (BootSE) and bias‐corrected and accelerated (BCa) bootstrap confidence intervals, consistent with recommended reporting practice (Hayes 2013). An indirect association was considered statistically significant when its bootstrap confidence interval excluded zero. The terms indirect association and statistical mediation model were used descriptively; causal mediation was not inferred.

TABLE 2.

Descriptive statistics and internal consistency of study variables.

Variable N M SD Min Max Skewness Kurtosis Cronbach's α
Cognitive flexibility total 451 59.44 7.70 34 84 0.227 0.234 0.877
Alternatives 451 37.70 5.20 19 50 −0.332 0.680 0.905
Control 451 21.75 4.58 8 35 −0.036 0.133 0.820
Depressive symptoms 451 14.06 10.54 0 58 0.767 0.393 0.922
Self‐transcendence 451 43.95 5.29 20 60 −0.316 1.405 0.812
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Note: CFI total and Control scores were recomputed after restoring Item 15 to its intended direction. Higher BDI scores indicate more severe depressive symptoms.

The demographic variables collected in the study were employed to define the participant group; however, because the primary aim of the study was to examine the theoretical relationships between the variables, no demographic variable was included as a covariate in the mediation model. The analysis results were generated using bias‐corrected and accelerated (BCa) 95% bootstrap confidence intervals based on 5000 resamples for the indirect effect, consistent with the regression‐based logic of Hayes' PROCESS Model 4. Because the two‐factor model fit better than the one‐factor model, Alternatives and Control were additionally entered as simultaneous parallel indirect variables. This analysis was designated exploratory. Sensitivity analyses adjusted for age, sex, department and class year.

The assumptions underlying the regression‐based mediation model were evaluated using the following criteria. Linearity was assessed by inspecting scatterplots of standardised residuals against predicted values, which did not indicate any systematic departure from linearity. The Breusch‐Pagan test indicated heteroskedasticity in the total‐score outcome equation (LM = 15.02, p < 0.001); therefore, HC3 standard errors were used throughout the regression analyses. Multicollinearity was evaluated using tolerance and variance inflation factor (VIF) values; both predictors showed acceptable values (VIF = 1.35; tolerance = 0.74), indicating no multicollinearity concern. Influential observations were examined using Cook's distance. The maximum Cook's distance was 0.057; 18 observations exceeded the conservative 4/n threshold, although none approached the conventional threshold of 1.0. Exclusion of these observations was examined as an influence sensitivity analysis.

2.5. Ethical Considerations

Before starting the study, the researchers obtained ethical approval from the Kastamonu University Social and Human Sciences Ethics Committee. Ethical approval was obtained from the Board (decision number 2024/25) and institutional permission (E‐26616204‐044‐24400156633) from the faculty where the study was conducted. Permission for the data collection tools used in the study was obtained via e‐mail from the authors who conducted the validity and reliability studies. The health students were informed about the purpose, method and process of the study. Participants completed the questionnaires anonymously, and verbal and written informed consent was obtained in accordance with the principle of voluntary participation. Every stage of the study was conducted in line with the principles of the Declaration of Helsinki. The ethics committee decision number, approval date and institutional permission number should be inserted by the authors before journal submission.

3. Results

Results regarding the descriptive characteristics of the students are given below.

The descriptive information about the students participating in the study is given in Table 1. The average age of the students participating in the study was 20.550 ± 1.529 (min = 18; max = 29). The majority of participants were female (85.8%); male participants comprised 14.2% of the sample. With respect to marital status, 98.7% of the students were single, only 1.3% were married. Regarding department, 54.3% of the students were enrolled in the nursing programme and 45.7% in the midwifery programme. By class year, 28.4% of students were in their second year, 28.2% in their fourth year, 24.2% in their first year and 19.3% in their third year. With respect to of sibling numbers, the highest proportion (51.4%) had two siblings, followed by those with three siblings (28.6%), four or more siblings (15.3%) and only children (4.7%). Regarding income status, the majority of the students (75.8%) reported that their income was equal to their expenses, 15.7% reported income lower than their expenses and 8.4% reported income higher than their expenses. With respect to health insurance, 92.7% of students had health insurance, 7.3% did not. Regarding employment status, the majority of students (97.3%) were not employed, only 2.7% were working. With respect to living arrangement, 60.1% of students were renting with friends, while 39.9% lived with their families. A total of 76.1% of students reported that they had chosen their department voluntarily, 23.9% had not. Regarding the ability to cope with clinical problems, 76.1% of students reported that they were able to cope with clinical problems, but 23.9% reported difficulty in this regard.

TABLE 1.

Distribution of participants by descriptive characteristics (N = 451).

Characteristic n %
Gender: Male 64 14.2
Gender: Female 387 85.8
Marital status: Married 6 1.3
Marital status: Single 445 98.7
Department: Midwifery 206 45.7
Department: Nursing 245 54.3
Class year: First 109 24.2
Class year: Second 128 28.4
Class year: Third 87 19.3
Class year: Fourth 127 28.2
Number of siblings: One 21 4.7
Number of siblings: Two 232 51.4
Number of siblings: Three 129 28.6
Number of siblings: Four or more 69 15.3
Income: Lower than expenses 71 15.7
Income: Equal to expenses 342 75.8
Income: Higher than expenses 38 8.4
Health insurance: Yes 418 92.7
Health insurance: No 33 7.3
Employment: Working 12 2.7
Employment: Not working 439 97.3
Living arrangement: With family 180 39.9
Living arrangement: Renting with friends 271 60.1
Chose department voluntarily: Yes 343 76.1
Chose department voluntarily: No 108 23.9
Able to cope with clinical problems: Yes 343 76.1
Able to cope with clinical problems: No 108 23.9
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Note: Age was 20.55 ± 1.53 years (range 18–29). Percentages are calculated within each characteristic.

The students who participated in the study had a total mean cognitive flexibility score of 59.44 ± 7.70. The mean alternatives score, one of the sub‐dimensions of cognitive flexibility, was 37.70 ± 5.20 and the mean control score, another sub‐dimension of cognitive flexibility, was 21.75 ± 4.58. The students' mean depression score was 14.06 ± 10.54, and their mean Self‐Transcendence score was 43.95 ± 5.29 (Table 2). A total of 164 participants (36.4%) scored at or above the BDI screening threshold of 17; this finding indicates elevated depressive symptoms on a self‐report screening instrument and does not establish a diagnosis (Table 2). The one‐factor CFI model showed poor fit, χ 2(170) = 1105.20, CFI = 0.840, TLI = 0.822, RMSEA = 0.111 and SRMR = 0.134. The correlated two‐factor model fit substantially better, χ 2(169) =526.00, CFI = 0.939, TLI = 0.931, RMSEA = 0.069 and SRMR = 0.094. Standardised loadings in the two‐factor model ranged from 0.503 to 0.750 for Alternatives and 0.480 to 0.743 for Control. The latent factor correlation was 0.312 (p < 0.001). Although the two‐factor results supported related dimensions, SRMR remained slightly above commonly used thresholds; therefore, the model was interpreted as supportive rather than definitive evidence (Table 3).

TABLE 3.

Comparison of Cognitive Flexibility Inventory measurement models.

Model χ 2 df χ 2/df CFI TLI RMSEA SRMR
One factor 1105.20 170 6.50 0.840 0.822 0.111 0.134
Correlated two factors 526.00 169 3.11 0.939 0.931 0.069 0.094
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Note: Models were estimated using diagonally weighted least squares. In the two‐factor model, standardised loadings were 0.503–0.750 for Alternatives and 0.480–0.743 for Control; the standardised latent factor correlation was 0.312 (p < 0.001).

According to the relationship analysis results, there was a positive and significant relationship between the total score of cognitive flexibility and self‐transcendence (r = 0.520; p < 0.001). Similarly, a strong positive relationship was determined between self‐transcendence and alternatives (r = 0.538; p < 0.001). A lower level but significant positive relationship was found between the control dimension and self‐transcendence (r = 0.264; p < 0.001). A negative and significant relationship was found between the total score of cognitive flexibility and depression (r = −0.367; p < 0.001). A negative and statistically significant relationship was found between cognitive flexibility scores and depression scores. A similar negative and significant relationship was determined between the alternatives dimension and depression (r = −0.246; p < 0.001). The negative relationship between control and depression was slightly more pronounced (r = −0.337; p < 0.001). The relationship between self‐transcendence and depression was negative and significant (r = −0.469; p < 0.001) (Table 4). Alternatives and Control were positively correlated (r = 0.238, p < 0.001), but the association was modest, supporting examination of dimension‐specific patterns (Table 4).

TABLE 4.

Pearson correlations among study variables.

Variable 1 2 3 4 5
1. Cognitive flexibility total —
2. Alternatives 0.816*** —
3. Control 0.755*** 0.238*** —
4. Depressive symptoms −0.367*** −0.246*** −0.337*** —
5. Self‐transcendence 0.520*** 0.538*** 0.264*** −0.469*** —
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Note: The alternatives‐control correlation was r = 0.238, p < 0.001.

***

p < 0.001.

According to the indirect association analysis results, a statistically significant indirect association of cognitive flexibility (CFI) was found in the relationship between self‐transcendence (STS) and depressive symptoms (BDI). First, the association of the self‐transcendence variable on cognitive flexibility (path a) was found to be significant (B = 0.756, HC3 SE = 0.066, z = 11.382, p < 0.001, 95% CI: [0.626, 0.887]; β = 0.520). The R 2 value, which represents the explanatory power of the model, was 0.271, and it was observed that this variable explained 27.1% of the variance in cognitive flexibility. The total association of self‐transcendence on depressive symptoms (path c) was also significant (B = −0.933, HC3 SE = 0.081, z = −11.515, p < 0.001, 95% CI: [−1.092, −0.774]; β = −0.469). However, when cognitive flexibility was entered into the model, the direct association (c′) of Self‐Transcendence on depressive symptoms remained significant (B = −0.759, HC3 SE = 0.100, z = −7.590, p < 0.001, 95% CI: [−0.955, −0.563]; β = −0.381) and the association of cognitive flexibility on depressive symptoms (path b), controlling for self‐transcendence, was negative and significant (B = −0.231, HC3 SE = 0.066, z = −3.506, p < 0.001, 95% CI: [−0.359, −0.102]; β = −0.168).

The indirect association analysis showed that both the total association (B = −0.933, HC3 SE = 0.081, p < 0.001, 95% CI: [−1.092, −0.774]; β = −0.469) and the direct association (B = −0.759, HC3 SE = 0.100, p < 0.001, 95% CI: [−0.955, −0.563]; β = −0.381) between self‐transcendence and depressive symptoms were statistically significant. The indirect association of self‐transcendence on depressive symptoms through cognitive flexibility was also significant, both in its unstandardised form (B = −0.174, BootSE = 0.051, BCa bootstrap 95% CI: [−0.278, −0.077]) and completely standardised form (β = −0.088, BCa bootstrap 95% CI: [−0.138, −0.039]). This was supported by the bootstrap confidence intervals because neither bootstrap confidence interval contained zero. This pattern indicates a statistically significant indirect association of cognitive flexibility in the relationship between self‐transcendence and depressive symptoms (Table 5). This result is interpreted primarily in terms of the size and precision of the indirect association itself, together with the cross‐sectional limitations of the design, rather than as a categorical classification, because current methodologic guidance cautions against assigning strong theoretical meaning to the traditional ‘full versus partial mediation’ distinction once the direct association remains significant.

TABLE 5.

Prespecified total‐score indirect association model with HC3 robust inference.

Path B HC3 SE z p LLCI ULCI Standardised β
a: Self‐transcendence ‐> CFI total 0.756 0.066 11.382 < 0.001 0.626 0.887 0.520
c: Self‐transcendence ‐> Depressive symptoms −0.933 0.081 −11.515 < 0.001 −1.092 −0.774 −0.469
c′: Self‐Transcendence ‐> Depressive symptoms −0.759 0.100 −7.590 < 0.001 −0.955 −0.563 −0.381
b: CFI total ‐> Depressive symptoms −0.231 0.066 −3.506 < 0.001 −0.359 −0.102 −0.168
Indirect effect (STS → CFI → Depressive symptoms) −0.174 BootSE 0.051 — — BootLLCI −0.278 BootULCI −0.077 −0.088
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Note: N = 451. The a‐path model R 2 = 0.271; total‐effect model R 2 = 0.220; outcome model R 2 = 0.240. Regression coefficients (paths a, b, c and c′) are reported with HC3 heteroskedasticity‐consistent standard errors and corresponding HC3 confidence intervals. The indirect effect is reported with bootstrap standard errors (BootSE) and bias‐corrected and accelerated (BCa) 95% bootstrap confidence intervals based on 5000 bootstrap resamples. Bold values indicate statistically significant effects (p < 0.05).

In the parallel model, self‐transcendence was positively associated with Alternatives (B = 0.528, HC3 SE = 0.046, β = 0.538, p < 0.001) and Control (B = 0.228, HC3 SE = 0.054, β = 0.264, p < 0.001). When both dimensions and self‐transcendence were entered simultaneously, Control was negatively associated with depressive symptoms (B = −0.537, HC3 SE = 0.103, β = −0.233, p < 0.001), whereas Alternatives was not independently associated with depressive symptoms (B = 0.080, HC3 SE = 0.116, β = 0.039, p = 0.492). The indirect association through Control was significant (B = −0.123, BootSE = 0.040, BCa 95% CI [−0.212, −0.057]); the indirect association through Alternatives was not (B = 0.042, BootSE = 0.060, BCa 95% CI [−0.073, 0.160]). The contrast between the two indirect effects excluded zero (B = 0.165, BCa 95% CI [0.016, 0.330]), indicating different dimension‐specific patterns in this sample (Table 6).

TABLE 6.

Exploratory parallel alternatives‐control indirect association model.

Path B HC3 SE z p LLCI ULCI Standardised β
a1: Self‐transcendence ‐> Alternatives 0.528 0.046 11.511 < 0.001 0.438 0.618 0.538
a2: Self‐transcendence ‐> Control 0.228 0.054 4.266 < 0.001 0.123 0.333 0.264
c′: Self‐transcendence ‐> Depressive symptoms −0.853 0.107 −7.953 < 0.001 −1.063 −0.643 −0.428
b1: Alternatives ‐> Depressive symptoms 0.080 0.116 0.687 0.492 −0.148 0.308 0.039
b2: Control ‐> Depressive symptoms −0.537 0.103 −5.219 < 0.001 −0.739 −0.335 −0.233
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Note: Outcome‐model R 2 = 0.270. Alternatives indirect effect: B = 0.042, BootSE = 0.060, BCa 95% CI [−0.073, 0.160]. Control indirect effect: B = −0.123, BootSE = 0.040, BCa 95% CI [−0.212, −0.057]. Difference between indirect effects: B = 0.165, BCa 95% CI [0.016, 0.330]. Bootstrap estimates used 5000 resamples. Indirect effects are reported with bootstrap standard errors (BootSE) and BCa 95% bootstrap confidence intervals based on 5000 bootstrap resamples. Bold values indicate statistically significant effects (p < 0.05).

Adjustment for age, sex, department and class year did not change the substantive pattern: the total‐score indirect association remained significant (B = −0.189, bootstrap 95% CI [−0.296, −0.090]), the Control indirect association remained significant (B = −0.119, bootstrap 95% CI [−0.205, −0.054]) and the Alternatives indirect association remained nonsignificant (B = 0.023, bootstrap 95% CI [−0.101, 0.141]). After excluding the 18 observations exceeding Cook's 4/n threshold, the total indirect association was B = −0.211 (bootstrap 95% CI [−0.296, −0.129]), the Control indirect association was B = −0.108 (bootstrap 95% CI [−0.188, −0.046]) and the Alternatives indirect association remained nonsignificant (B = −0.015, bootstrap 95% CI [−0.120, 0.091]). Overall, individuals with higher levels of self‐transcendence had lower depressive symptom scores and cognitive flexibility showed a statistically significant indirect association in this relationship. The cross‐sectional indirect association model is presented in Figure 1. For this reason, cognitive flexibility may contribute to understanding the relationship between self‐transcendence and depressive symptoms.

FIGURE 1.

FIGURE 1

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Cross‐sectional indirect association model.

4. Discussion

In the present study, the mediating role of cognitive flexibility in the relationship between self‐transcendence and depressive symptom levels of health department students was examined.

4.1. Cognitive Flexibility, Self‐Transcendence and Depression Symptom Levels of Health Department Students

The mean scores for cognitive flexibility of the health department students' (59.44 ± 7.70, range 34–84) and self‐transcendence (43.949 ± 5.293, range 20–60) are reported descriptively. These scores are not classified as ‘high’ or ‘above average’ because no validated normative cut‐off values exist for either instrument. Other studies conducted with health department students have reported comparable score ranges for cognitive flexibility (Abbasszade et al. 2025; Yurt and Hayli 2025; Karakuş 2024) and self‐transcendence (Wang et al. 2024; Zhao et al. 2020).

The students' mean depressive symptoms score was 14.064 ± 10.538, with scores ranging from 0 to 58. Based on the validated screening cut‐off score of 17 (Hisli 1989), 164 students (36.4%) scored at or above this threshold, indicating clinically elevated depressive symptoms in more than one‐third of the sample; this finding should not be interpreted as a formal clinical diagnosis. Although some students reported no depressive symptoms, others exhibited relatively high levels of depressive symptoms. Unlike our study, some studies have reported elevated depressive symptoms among health sciences students. (Agyapong‐Opoku et al. 2023; Fauzi et al. 2021; Hamasha et al. 2019). In general, the students' scores on cognitive flexibility, self‐transcendence and depressive symptoms showed a heterogeneous distribution across the sample, with depressive symptom scores varying considerably between individuals.

4.2. The Mediating Role of Cognitive Flexibility in the Relationship Between Self‐Transcendence and Depression Symptom Levels of Health Department Students

The present study examined the mediating role of cognitive flexibility in the relationship between self‐transcendence and depression symptom level among health department students. The results showed a significant positive association between self‐transcendence and cognitive flexibility. The direct relationship between self‐transcendence and depressive symptoms was negative and significant. The results, based on the relationship between self‐transcendence and depression, are similar to other research results (Er and Buzlu 2022b; Seemab et al. 2024; Liu et al. 2021). Vulnerability, one of the basic concepts of self‐transcendence theory, may be a risk factor for depression (Reed 2023). Studies have reported that health students have relatively high levels of depressive symptoms (Horgan et al. 2016; Hamasha et al. 2019). A study examining the prevalence of depression in the literature found that the prevalence of depression was lower in nursing and midwifery students compared with students in other health departments (Hadavi and Rostami 2017; Tung et al. 2018). This result is broadly consistent with our finding that higher self‐transcendence scores were associated with lower depression scores in the present sample. However, findings indicating that self‐transcendence is related to meaning in life and experiences of suffering also provide theoretical support for this relationship (Ge and Yang 2023).

The direct relationship between cognitive flexibility and depressive symptoms was also negative and significant. These results, based on the relationship between cognitive flexibility and depression, are similar to other research results (Yu et al. 2020; Novak et al. 2022). Cognitive flexibility reflects the ability to be flexible and possess functional beliefs, rather than dysfunctional, rigid and unchanging beliefs (Sapmaz and Doğan 2013). Individuals with depressive symptoms exhibit the opposite of these characteristics; they struggle to demonstrate cognitive flexibility due to their rigid, unchanging and negative thinking patterns (Sapmaz and Doğan 2013). However, individuals who develop self‐transcendence tend to think and act more flexibly in their lives (Reed 2014). In this sense, self‐transcendence and supporting cognitive flexibility can be important factors in thinking and acting flexibly. Generally speaking, cognitive flexibility and self‐transcendence are inversely correlated with depression symptoms and are important factors in individuals' mental health.

Consistent with the present results, prior studies also reported negative associations between self‐transcendence, cognitive flexibility and depressive symptoms. The literature suggests that self‐transcendence and cognitive flexibility may share underlying characteristics, such as exposure to challenging life experiences (Kalia et al. 2021; Reed 2014; Tayhan et al. 2023; Teixeira 2008); related constructs such as mindfulness and creativity have also been discussed within this broader theoretical framework (Acikgoz and Karaca 2025; Hanley et al. 2023), although they were not measured in the present study. Future longitudinal and experimental research may examine whether strategies aimed at developing students' mindfulness or creativity are associated with self‐transcendence, cognitive flexibility or depressive symptom levels (Bozdemir and Tatu 2026).

Individuals who have high levels of self‐transcendence are reported to have lower levels of depressive symptoms (Er and Buzlu 2022b). The statistically significant indirect association through cognitive flexibility identified in our study can be explained within the framework of theoretical approaches suggesting that self‐transcendence is related to viewing life events from a broader perspective, while cognitive flexibility is related to the ability to adapt to different situations and evaluate alternative viewpoints (Reed 2014; Kucukkelepce et al. 2026). In this context, self‐transcendence and cognitive flexibility are considered complementary structures in explaining the negative relationship with depressive symptoms. For this reason, cognitive flexibility can be considered an important variable for understanding the indirect association between self‐transcendence and depressive symptoms. However, the exploratory parallel mediation analysis suggested that the two dimensions of cognitive flexibility may not contribute equally to this relationship. Although the total cognitive flexibility score showed a statistically significant indirect association, only the Control dimension demonstrated a statistically significant dimension‐specific indirect association, whereas the Alternatives dimension did not. These findings suggest that the total score may combine components with different relationships to depressive symptoms. This interpretation is also consistent with the measurement model findings; the CFI was better represented by related Alternatives and Control dimensions than by a single‐factor structure in the present sample (Dennis and Vander Wal 2010). From a practical perspective, the finding that a significant indirect association was observed for the Control dimension may have implications for nursing educational practices and student support strategies. The Control dimension reflects individuals' perceptions that challenging situations are manageable and that they are capable of responding to them in adaptive ways (Dennis and Vander Wal 2010). Given that nursing students frequently encounter emotionally demanding clinical situations, uncertainty and academic stress throughout their education, the literature has discussed nursing‐specific educational approaches that may support cognitive flexibility, including simulation‐based education supported by structured debriefing, reflective learning activities and mindfulness‐based educational approaches (Acikgoz and Karaca 2025; Hanley et al. 2023; Cheng et al. 2025; Zou et al. 2026). These approaches may contribute to ongoing discussions regarding nursing educational practices and student support strategies.

Nevertheless, these dimension‐specific findings should be considered exploratory and require confirmation in future studies. Although this finding is consistent with the mediation analysis results obtained in the present study, the study's methodologic limitations should also be considered when interpreting it because of the cross‐sectional design of this study; self‐transcendence, cognitive flexibility and depressive symptoms were all assessed at the same point in time. Therefore, temporal precedence among the variables could not be established and the direction of the relationship between self‐transcendence and cognitive flexibility could not be determined with certainty. These two variables may also be simultaneously or reciprocally related rather than sequentially ordered. In addition, reverse‐direction or alternative models cannot be ruled out. Accordingly, the indirect association obtained in this study should be interpreted as a finding consistent with the statistical relationships among the variables, rather than as evidence of a causal mediating mechanism. Longitudinal and experimental research is needed to clarify the direction of these relationships and the possible causal mechanisms involved.

5. Conclusion

The results of our study indicate a statistically significant indirect association between self‐transcendence and depressive symptoms through cognitive flexibility. In addition, higher self‐transcendence and cognitive flexibility scores were found to be associated with lower depressive symptom levels among health department students. In this context, cognitive flexibility may be an important variable for understanding the relationship between self‐transcendence and depressive symptoms. Exploratory dimension‐specific analyses suggested that this indirect association was evident for the Control dimension but not for the Alternatives dimension of cognitive flexibility. From a practical perspective, the finding that the indirect association was significant for the Control dimension may have implications for nursing educational practices and student support strategies. However, owing to the cross‐sectional design of the study, these findings should not be interpreted as evidence of a causal mediating mechanism. Longitudinal and experimental studies are recommended in the future to clarify the direction of the relationships among the variables and the possible causal mechanisms involved.

6. Implications for Nursing Practice

Health students care for individuals exposed to challenging life experiences in clinical practice, which makes them vulnerable. For this reason, identifying factors related to students' mental health may be important. The study found a statistically significant indirect association between self‐transcendence and depressive symptoms through cognitive flexibility. Also, self‐transcendence and cognitive flexibility were found to be associated with lower levels of depressive symptoms. In this respect, these findings highlight the potential relevance of health students' ability to adapt to different situations, develop alternative perspectives and evaluate problems flexibly. Practices discussed in the literature in relation to cognitive flexibility include mindfulness‐based cognitive therapy programmes (Acikgoz and Karaca 2025), mindfulness training (Hanley et al. 2023) and transactional analysis training programmes (Abbasszade et al. 2025). Furthermore, reflective journaling, case‐based learning, problem‐based learning, simulation‐based training supported by structured debriefing and peer discussion groups have been reported to foster students' adaptive thinking and flexible problem‐solving skills (Cheng et al. 2025; Esteron and Dizon 2025; Zou et al. 2026; Yun and Kang 2024). Additionally, providing regular mental health screening and easily accessible psychological counselling and mental health support services may be important for facilitating the early identification of depressive symptoms (Cerolini et al. 2023; O'Connor et al. 2023). However, none of these interventions were evaluated in the present study; therefore, future longitudinal and experimental studies are needed to directly evaluate their potential effects on self‐transcendence, cognitive flexibility and depressive symptoms in health students.

6.1. Strengths and Limitations

The study had several limitations that must be considered. First, the majority of participants were female, which may limit the generalisability of the findings. Although sensitivity analyses adjusted for age, sex, department and class year, residual confounding cannot be ruled out because other potentially important variables were not measured. Participants were recruited using convenience sampling, which may have introduced selection bias. Also, the data were collected only from a specific faculty at a single university, so the results have limited generalisability. Because information regarding the number of students invited, absent or declining participation was unavailable, the response rate could not be calculated. The relationships between variables cannot be interpreted causally because of the cross‐sectional design of the study. Temporal precedence cannot be established, and alternative or reverse relationships between the variables cannot be excluded. Also, there is a risk of common method bias, social acceptability and respondent bias because data were collected using a self‐report method. Although measures were taken to protect participants' anonymity and confidentiality, these procedures cannot completely eliminate common method bias. In addition, because data were collected in the classroom setting, participants' perceptions of privacy and their tendency to provide socially desirable responses may have been influenced. Depression symptoms were assessed using the BDI, which is not a clinical diagnostic tool and only provides information on the level of depressive symptoms. However, cognitive flexibility was assessed in the study based on the total score of the scale. Although this approach is consistent with the theoretical structure of the scale, the Alternatives and Control dimensions may demonstrate different patterns of association with self‐transcendence and depressive symptoms and the use of the total cognitive flexibility score may have concealed subscale‐specific relationships. Therefore, it may be beneficial to examine the sub‐dimensions of cognitive flexibility separately in future studies. Since no studies exist in the literature on the indirect role of cognitive flexibility in the relationship between self‐transcendence and depression, this lack of comparison also limits the generalisability of the study. A strength of the study is that the concept of self‐transcendence has primarily been studied in older individuals, patients with cancer and caregivers; studies with student samples are limited. The fact that the study was conducted with health students, who will likely work in different areas of healthcare in the future, adds to its strength, scientific value and originality.

Author Contributions

Şevval Yeyit Bozdemir: conceptualization, methodology, data curation, validation, supervision, resources, writing – original draft, visualization, formal analysis, investigation. Havva Kaçan: methodology, conceptualization, writing – review and editing, data curation, supervision, resources, visualization, formal analysis, investigation, writing – original draft, validation.

Funding

The authors have nothing to report.

Disclosure

Statistics: The authors affirm that the methods used in the data analyses are suitably applied to their data within their study design and context, and the statistical findings have been implemented and interpreted correctly.

Ethics Statement

Before starting the study, the researchers obtained ethical approval from the Kastamonu University Social and Human Sciences Ethics Committee. Ethical approval was obtained from the Board (decision number 2024/25) and institutional permission (E‐26616204‐044‐24400156633) from the faculty where the study was conducted. Permission for the data collection tools used in the study was obtained via e‐mail from the authors who conducted the validity and reliability studies. The health students were informed about the purpose, method and process of the study. They were asked to use pseudonyms instead of their real names in the data collection forms, and verbal and written consent was obtained, observing the principle of voluntariness in participation in the study. Every stage of the study was conducted in line with the principles of the Declaration of Helsinki. The ethics committee decision number, approval date and institutional permission number should be inserted by the authors before journal submission.

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information

Supporting Information: S1. STROBE checklist for reporting this cross‐sectional study in accordance with the STROBE statement.

NOP2-13-e70761-s001.docx (116.5KB, docx)

Acknowledgements

No support from any organisation was received for the submitted work.

Data Availability Statement

The data that support the results of the study are available on request from the corresponding author. The data are not publicly available because of privacy or ethical restrictions.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supporting Information: S1. STROBE checklist for reporting this cross‐sectional study in accordance with the STROBE statement.

NOP2-13-e70761-s001.docx (116.5KB, docx)

Data Availability Statement

The data that support the results of the study are available on request from the corresponding author. The data are not publicly available because of privacy or ethical restrictions.

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