Abstract
BACKGROUND:
Psychological factors, such as anxiety, depression, and self-esteem, can significantly impact nursing students’ clinical self-efficacy. Hypochondriasis emerges as a critical yet understudied factor in the clinical competence of nursing students, warranting further investigation. This study aimed to investigate the relationship between hypochondriasis and clinical self-efficacy among nursing students.
MATERIALS AND METHODS:
This cross-sectional study was conducted in nursing schools of West Mazandaran province in 2024. The sample size was 228 nursing students. Data were collected using a personal information form, the standard clinical self-efficacy questionnaire, and the hypochondriasis questionnaire during 2023–2024. Data were analyzed using univariable and multivariable logistic regression analyses performed in (Stata Corp LP, College Station, Texas, USA). Odds ratios (ORs) with 95% confidence intervals were calculated.
RESULTS:
The mean hypochondriasis score among students was 23.43 ± 10.81. The prevalence of hypochondriasis among nursing students was 54.3%. Univariable logistic regression analysis revealed a significant negative relationship between hypochondriasis and clinical self-efficacy (OR = 0.92, P < 0.001). Multivariable logistic regression analysis highlights a significant association between gender (<0.001), academic year (0.021), lower self-efficacy (<0.001), and increased levels of hypochondriasis.
CONCLUSIONS:
This study reveals a significant inverse link between hypochondriasis and clinical self-efficacy in nursing students, driven by gender, academic year, and GPA. These findings necessitate integrating mental health support and tailored academic strategies into nursing education to alleviate health-related anxieties, bolster clinical confidence, and ultimately improve patient care outcomes by fostering resilient, competent professionals.
Keywords: Cross-sectional studies, hypochondriasis, nursing student, self-efficacy
Introduction
Self-efficacy refers to an individual’s belief in their capability to successfully perform a specific task and to control the events that affect their lives.[1] Enhanced self-efficacy can boost an individual’s motivation and confidence in acquiring nursing skills. Students with higher levels of self-efficacy are more likely to engage in challenging learning activities that promote the development of nursing skills.[2] Psychological factors, such as anxiety, depression, and self-esteem, can significantly impact nursing students’ clinical self-efficacy.[3] The study conducted by Deprez et al.[4] showed a vicious cycle whereby individuals with hypochondriasis become preoccupied with their health, leading to increased anxiety and a decreased sense of control over their health outcomes and self-efficacy.[5]
Hypochondriasis is a psychological disorder characterized by excessive preoccupation with one’s health despite the absence of any significant physical illness. Individuals with hypochondriasis often distrust medical assessments and believe they have a serious illness, even when medical tests provide no evidence. The disorder is most prevalent among individuals aged 20–30 years.[4,6] Hypochondriasis is commonly reported during the first two years of medical school, although these complaints are often transient.[7] Talaee et al.[8] reported a prevalence of 16% for hypochondriasis among medical students in Mashhad. Salmani et al.[9] found that approximately 20% of medical students in northwestern Iran experienced mild to moderate hypochondriasis during the COVID-19 pandemic. Meng et al.[10] reported a prevalence of 28% for hypochondriasis among medical students in China. Anxiety has been identified as a significant psychological factor influencing hypochondriasis in previous studies.[11] Several studies have demonstrated a significant correlation between anxiety and clinical self-efficacy.[12,13,14] Given these findings, it can be inferred that hypochondriasis may negatively impact clinical self-efficacy.
Practically, clinical self-efficacy is a critical factor in the successful performance of bedside nurses. Nurses with high clinical self-efficacy are better equipped to provide safe and quality care. Historically, most studies examining factors influencing clinical self-efficacy have focused on simple linear relationships between variables. For instance, research has explored the relationship between anxiety and clinical self-efficacy,[15] self-concept and clinical performance,[16] and self-efficacy and clinical performance[17] among nursing students.[18] It seems that the relationship between common psychological factors and clinical self-efficacy has been investigated in these studies. Therefore, studies that explain the relationship between multiple factors and clinical self-efficacy in the form of more complex statistical models are necessary. Also, hypochondriasis is considered a very important variable in the adequacy of students’ clinical performance in different dimensions, which has received less attention in the clinical education of nursing students.[10] Therefore, hypochondriasis emerges as a critical yet understudied factor in the clinical competence of nursing students, warranting further investigation. Identifying some variables influencing clinical self-efficacy can inform the enhancement of nursing education programs and the development of effective interventions to increase clinical self-efficacy among nursing students. This study aimed to determine the relationship between hypochondriasis, demographic characteristics, and clinical self-efficacy among nursing students.
Material and Methods
Study design and setting
This multicenter, cross-sectional, descriptive-analytic study was conducted in nursing schools of west Mazandaran province, northern Iran, between February 2024 and June 2024. This study was reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines, with particular attention to the reporting of study design, participant characteristics, and data analysis.
Study participants and sampling
A total of 253 nursing students were included in this study using a census sampling method. Desire to participate in the research, nursing students higher than the 3rd term and having at least two academic terms of internship experience (clinical experience), not being a student on educational leave, transfer or vacation, and not having a history of physician-diagnosed psychiatric disorder or those currently taking psychotropic or sedative medications were among the inclusion criteria. Failure to complete more than 10% of the questionnaire questions was considered as an exclusion criterion. In this study, the sample size was calculated using the following formula: n = s2 (Z1–a2/ + Z1b)2/d2.
The sample size was calculated using the standard deviation (s = 7.71) from a pilot study, with a precision of d = 1.37, a 5% Type I error rate (Z = 1.96), and 80% test power (Z = 0.84), yielding 253 participants. Ultimately, 228 participants were included, with exclusions due to refusal (n = 11), anxiety/psychological history (n = 9), and incomplete questionnaires (n = 5).
The precision of the test (d) was set at 1.37, with a Type I error rate of 5% (Z (1-α/2) = 1.96) and a test power of 80% (Z (1-β) = 0.84). Consequently, the estimated sample size for this study was 253 participants. In this study, a total of 228 participants were evaluated, with 11 declining to participate, 9 refraining due to a history of anxiety and psychological disorders, and 3 not responding to more than 90% of the questionnaire items [Figure 1].
Figure 1.
The study flow diagram
Data collection tools and technique
After obtaining ethical approval from the deans of nursing faculties, data were collected from nursing students. Data were gathered using a demographic questionnaire, Hypochondriasis questionnaire, and the Clinical Self-Efficacy for Nursing Students scale. To enhance response rates, questionnaires were completed in a quiet room on campus and questionnaires were completed in the presence of the researcher. To ensure confidentiality, participation was voluntary and anonymous.
Demographic information
A demographic questionnaire was used to collect data on age, gender, marital status, residence, year of study, cumulative grade point average, type of educational setting, experience working as a part-time nursing student, and socioeconomic status.
The Self-Efficacy in Clinical Performance (SECP) instrument
The 37-item SECP was developed by Cheraghi et al.[19] for nursing students in Iran. It was used for assessing nursing students’ self-efficacy in clinical performance. The scale consists of five dimensions: patient assessment (12 items), nursing diagnosis (3 items), care planning (6 items), care implementation (10 items), and care evaluation (6 items). A 5-point Likert scale was used for responses. The total score ranges from 37 to 185, with scores between 37 and 74 indicating low self-efficacy, scores from 74 to 111 indicating moderate self-efficacy, and scores above 112 indicating high self-efficacy. In the study by Cheraghi et al.,[19] the scale demonstrated good content and face validity and a high internal consistency reliability with a Cronbach’s alpha of 0.96. The overall scale internal reliability had α = 0.96; the dimensions Cronbach’s α ranged from 0.90 to 0.92. The test–retest reliability with a 2-week time interval was r = 0.94. In addition, concurrent validity was obtained (r = 0.73).
The Evans Hypochondria standard questionnaire
The 36-item Evans’ Hypochondriasis scale was originally developed by Evans in 1980. The one-dimensional questionnaire employs a mixed scoring format, with some items using a 5-point Likert scale and others a dichotomous yes/no response. This questionnaire has 36 items and measures hypochondriasis based on a Likert scale, according to which individuals were classified into healthy groups (≤20) and severe hypochondriasis (60+). The Persian version of the questionnaire was translated and validated for nurses by Khani et al.[20] in Neyshabour. The reliability of questionnaire was demonstrated with a Cronbach’s alpha of 0.86. The Iranian version of hypocondriasis being validated led to a qualitative evaluation of the content validity of the 36-item Hypochondriasis questionnaire in the current study. Content validity of the questionnaire was confirmed by 10 nursing instructors at the nursing department of Babol University of Medical Sciences, and they verified the validity of the questionnaire’s contents. For test–retest reliability assessment, 20 nursing students completed the questionnaire twice with a 2 week interval (r = 0.81).
Data analysis
Data were entered into STATA version 17 (College Station, TX). All tests were two-sided and considered statistically significant at the 0.05 level. Pearson’s Chi-squared test was used to compare the distribution of categorical variables between groups. Independent samples t-tests were used to compare means between two independent groups. Prior to conducting parametric tests, normality of continuous variables was assessed using the Shapiro–Wilk test, Q-Q plots, and P-P plots.[21]
To evaluate the association between hypochondriasis and predictors of clinical self-efficacy, both univariable and multivariable logistic regression analyses were performed as the outcome variable (clinical self-efficacy) was binary. Univariable analysis identified individual predictors, while multivariable analysis adjusted for potential confounders, including gender, year of study, and GPA. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated to determine the direction and magnitude of associations. OR > 1 indicated a positive association between a predictor and clinical self-efficacy, whereas OR < 1 reflected a negative association.[22] A Mantel-Haenszel test was used to evaluate the heterogeneity of ORs across different subgroups.[23]
Ethics consideration
This study was approved by the Research Council of Babol University of Medical Sciences (approval code: IR.MUBABOL.HRI.REC.1402.179) on January 16, 2024.
All participants provided written informed consent.
Results
The majority of participants were between the ages of 21 and 23 years old, were female, were single, lived in private residences, and had a grade point average between 15 and 17.99. The overall GPA ranged from 12 to 18.94, with a mean of 15.59 (1.4). The mean GPA of students with high clinical self-efficacy was significantly higher than that of students with moderate clinical self-efficacy [Table 1].
Table 1.
Characteristics of study participants according to Clinical Self-Efficacy groups
| Variable Clinical Self-Efficacy | Moderate n=113 | Excellent n=115 | P | |||
|---|---|---|---|---|---|---|
| Age (years) | 21.8 (1.5) | 21.8 (1.4) | 0.87* | |||
| Gender | 0.49** | |||||
| Male | 45 (39.8) | 51 (44.3) | ||||
| Female | 68 (60.2) | 64 (55.7) | ||||
| College | 0.71** | |||||
| Medical university† | 43 (38.1) | 41 (35.7) | ||||
| Azad University | 70 (61.9) | 74 (64.3) | ||||
| Academic year | 0.31** | |||||
| Third year | 44 (47.3) | 49 (52.69) | ||||
| Fourth year | 69 (51.1) | 66 (48.89) | ||||
| Grade Point Average | 15.14 (1.34) | 16.03 (1.47) | <0.001* | |||
| C (10 – 13.99) | 19 (16.8) | 14 (12.2) | ||||
| B (14 – 16.99) | 74 (65.5) | 75 (65.2) | ||||
| A (17-20) | 20 (17.7) | 26 (22.6) | ||||
| Part time Work as a Nurse† | 0.74** | |||||
| No | 78 (69.0) | 77 (67.0) | ||||
| Yes | 35 (31.0) | 38 (33.0) | ||||
| Economy Level† | 0.18** | |||||
| Weak | 5 (4.7) | 5 (4.7) | ||||
| Medium | 79 (74.5) | 68 (63.6) | ||||
| Good | 22 (20.8) | 34 (31.8) | ||||
| Living Area† | 0.74** | |||||
| Native | 71 (62.8) | 70 (60.8) | ||||
| Student dormitory | 42 (37.2) | 45 (39.2) |
Data are presented as mean (SD) for continuous measures, and n (%) for categorical measures. Boldness: P<0.05. †Missing values within 1.5% to 13%. *Independent t-test. **Chi-square test
The mean hypochondriasis score among students was 23.43 ± 10.81. This finding suggests that students with lower confidence in their clinical abilities may be more prone to excessive health concerns. Scores ranged from 3 to 59, and no students were classified as having severe hypochondriasis. The prevalence of hypochondriasis among nursing students was 54.3%.
Results showed that 63.6% of women and 41.6% of men reported some degree of hypochondriasis. This finding suggests that the prevalence of hypochondriasis was significantly higher among women compared to men. Also, the mean clinical self-efficacy score of the study participants was 119.89 ± 16.38. Participants were categorized into two groups, moderate and excellent, as no students were classified with low self-efficacy [Figure 2].
Figure 2.
Hypochondriasis in Nursing Students by Clinical Self-Efficacy Levels
Logistic regression analysis revealed that female nursing students were 2.45 times more likely to experience hypochondriasis than male nursing students (OR = 2.45, P < 0.001). This finding suggests that gender-specific factors such as stress perception differences, socialization patterns, or clinical training-related health anxieties may disproportionately increase female students’ susceptibility to hypochondriasis. Additionally, fourth-year students had 87% increased odds of reporting higher levels of hypochondriasis compared to third-year students (OR = 1.87, P < 0.021). This finding suggests that advanced clinical responsibilities and licensure-related stressors during role transitions may heighten health-related anxieties in senior nursing students. Furthermore, students with a C GPA were 3.76 times more likely to experience higher levels of hypochondriasis than those with a B GPA (OR = 3.76, P < 0.006). This finding suggests that academic pressures and self-perceived skill gaps may intensify health-related anxieties, potentially establishing a reciprocal cycle where academic challenges reinforce somatic concerns and vice versa. Finally, students with a moderate level of self-efficacy were 2.46 times more likely to experience higher levels of hypochondriasis compared to those with high self-efficacy (OR = 2.46, P < 0.001) [Table 2]. This finding suggests that nursing students with lower clinical confidence may experience potentially creating a self-reinforcing cycle of health-related anxieties and self-doubt. These findings highlight significant associations between genders, academic year, lower GPA, lower self-efficacy, and increased levels of hypochondriasis.
Table 2.
Univariable analysis of Hypochondriasis categories in nursing students
| Variable | Levels | Healthy n (%) | Border Line n (%) | Mild n (%) | Moderate$ n (%) | OR* | CI** (95%) | P*** | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Gender | Male Female |
56 (53.8) 48 (46.2) |
30 (43.5) 39 (56.5) |
7 (17.5) 33 (82.5) |
3 (21.5) 12 (78.5) |
1 2.45 |
Reference (1.42 to 4.20) |
<0.001 | ||||||||
| Academic year | Third year Fourth year |
51 (49.0) 53 (51.0) |
24 (34.7) 45 (65.3) |
10 (25.0) 30 (75.0) |
8 (57.2) 7 (42.8) |
1 1.87 |
Reference (1.10 to 3.21) |
0.021 | ||||||||
| Grade Point Average | A (17 to 20) B (14 to 16.99) C (10 to 13.99) |
22 (21.1) 75 (72.1) 7 (6.8) |
14 (20.4) 44 (63.7) 11 (15.9) |
10 (25.0) 21 (52.5) 9 (22.5) |
0 (0) 9 (57.2) 6 (42.8) |
1.10 1 3.76 |
(0.57 to 2.14) Reference (1.53 to 9.21) |
0.006 | ||||||||
| Clinical Self-Efficacy |
Moderate group Excellent group |
39 (37.5) 65 (62.5) |
34 (49.3) 35 (51.7) |
26 (65) 14 (35) |
14 (92.8) 1 (7.2) |
2.46 1 |
(1.44 to 4.21) Reference |
<0.001 |
*Odds Ratio; **CI: 95% Confidence interval; ***P<0.05 obtained using univariable logistic regression
Logistic regression analysis revealed a significant inverse association between hypochondriasis and clinical self-efficacy (OR = 0.92, P < 0.001). This indicates that for every one-unit increase in hypochondriasis scores, there was a 7.4% decrease in the odds of having higher levels of clinical self-efficacy. Women had a 17% lower odds of reporting high levels of clinical self-efficacy compared to men; however, this difference did not reach statistical significance. (OR = 0.83, P < 0.48). Fourth-year students had a 44% higher odds of reporting high levels of clinical self-efficacy compared to third-year students. (OR = 1.44, P < 0.04). Each one-point increase in GPA was associated with a 56% increase in the odds of reporting high levels of clinical self-efficacy (OR = 1.56, P < 0.001). Students with an A GPA had 76% higher odds of reporting high clinical self-efficacy compared to those with a C GPA. Similarly, students with a B GPA had a 37% higher odds of reporting high clinical self-efficacy compared to those with a C GPA [Table 3]. These results suggest that demographic and academic factors alone do not adequately explain variations in clinical self-efficacy among the study participants.
Table 3.
Univariable analysis of Clinical Self-Efficacy categories in nursing students
| Variable | Levels | Moderate group n (%) | Excellent group n (%) | OR* | CI* (95%) | P* | ||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Gender | Male Female |
45 (39.8) 68 (60.2) |
51 (44.3) 64 (55.7) |
1 0.83 |
Reference (0.49 to 1.40) |
0.48 | ||||||
| Academic year | Third year Fourth year |
44 (38.9) 69 (61.1) |
49 (42.6) 66 (57.4) |
1 1.16 |
Reference (0.68 to 1.97) |
0.57 | ||||||
| Grade Point Average | C (10 – 13.99) B (14 – 16.99) A (17 – 20) |
19 (16.9) 74 (65.5) 20 (17.6) |
14 (12.1) 75 (65.2) 26 (22.7) |
1 1.37 1.76 |
Reference (0.65 to 2.94) (0.71 to 0.35) |
0.46 |
*Odds Ratio, CI 95% and P obtained using univariable Logistic regression. Boldness: P<0.05
Table 4 presents the results of a multiple logistic regression analysis examining the relationship between clinical self-efficacy and main variables after controlling for Part-time Work as a Nurse and Living Area [Table 4]. The loss of significance after adjustment likely occurs because part-time work and residential areas act as confounds that partially explain the apparent association between hypochondriasis and clinical self-efficacy in the unadjusted model.
Table 4.
Multivariable logistic regression associated between Clinical Self-Efficacy and main variables
| Variable | Level | COR* (95% CI) | AORa (95% CI) | AORb (95% CI) | ||||
|---|---|---|---|---|---|---|---|---|
| Hypochondriasis | _ | 0.92 (0.89 to 0.95) | 1.05 (058 to 1.90) | 1.11 (0.61 to 1.98) | ||||
| Gender | Female | Reference | _ | _ | ||||
| Male | 1.19 (0.71 to 2.01) | 1.18 (0.68 to 2.06) | 1.16 (0.68 to 1.98) | |||||
| Academic year | Third year | Reference | _ | _ | ||||
| Fourth year | 1.16 (0.68 to 1.97) | 2.31 (1.68 to 5.98) | 1.18 (0.68 to 1.99) | |||||
| Grade Point Average | C (10 – 13.99) | Reference | _ | _ | ||||
| B (14 – 16.99) | 1.37 (0.65 to 2.94) | 1.36 (0.63 to 2.93) | 1.38 (0.64 to 2.96) | |||||
| A (17 – 20) | 1.76 (0.71 to 4.35) | 1.74 (0.71 to 4.33) | 1.93 (1.08 to 4.78) |
*COR: Crude Odds Ratio, AOR: Adjusted Odds Ratio, AORa: Adjusted for Part-time Work as a Nurse, AORb: Adjusted for Living Area
The results showed that people with more hypochondriasis scores had a markedly lower chance of having high clinical self-efficacy (OR = 0.92). However, after adjusting for part-time nursing work and residential area, this association was no longer statistically significant. Although men exhibited an 18% higher mean level of clinical self-efficacy compared to women, this difference was not statistically significant. Fourth-year students were 2.31 times more likely to have high clinical self-efficacy compared to third-year students. Similarly, students with a higher overall GPA (grade A) were 1.93 times more likely to have high clinical self-efficacy compared to those with a lower overall GPA (grade C) [Table 4].
Discussion
This study aimed to investigate the relationship between hypochondriasis and clinical self-efficacy and to identify factors associated with hypochondriasis among nursing students.
The present study revealed a negative correlation between hypochondriasis and clinical self-efficacy. This finding aligns with previous research. The observed inverse relationship may be explained by a vicious cycle whereby individuals with hypochondriasis become preoccupied with their health, leading to increased anxiety and a decreased sense of control over their health outcomes.[5,24]
The current research revealed that over 50% of nursing students reported experiencing symptoms of hypochondriasis. Previous studies have reported varying prevalence rates of hypochondriasis among healthcare students. For instance, Talaei found a prevalence of 36.8% among dormitory students.[8] Khani et al.[20] reported a higher prevalence of 45.6% among nurses. While Meng et al.[10] found a prevalence of 28% among medical students in China. Our prevalence rate (58.3%) is higher than that reported by Talaei (36.8%) and Meng et al. (28%). This discrepancy may be due to differences in cultural perceptions of illness, variations in measurement tools, or heightened anxiety post-COVID-19.
Demographic factors significantly influenced the prevalence of hypochondriasis among students in this study. Notably, gender was a significant predictor, with females exhibiting a 2.5-fold higher prevalence than males, consistent with previous research.[8,10] This gender disparity may be attributed to various factors, including hormonal differences, societal expectations regarding gender roles, and heightened health anxiety among women. Because hormonal changes caused by the physiology of female students have a great impact on mood symptoms, depression, anxiety, fear and worry, and even different insight and attitudes toward the issues around them, this group is exposed to a greater risk of mental health disorders such as hypochondriasis.
The current study revealed a significant inverse relationship between academic performance and hypochondriasis. This finding aligns with previous research demonstrating a link between academic stress and psychological distress. Sajadi’s study further supports this notion, suggesting that academic pressure may lead students with lower GPAs to develop maladaptive coping strategies, such as somatization, in response to the inadequacy.[25] The current findings revealed a higher prevalence of hypochondriasis among fourth-year students compared to third-year students. This increasing trend in hypochondriasis as students’ progress through their academic journey may be attributed to several factors. The heightened academic pressures, significant life decisions, and changes in lifestyle associated with the final years of study may contribute to increased stress and anxiety, which can manifest as hypochondriasis.[26]
The findings of this study indicated that the nursing students demonstrated a generally moderate to high level of clinical self-efficacy, consistent with the results of Sahabi et al.,[27] study. However, the significant variability in clinical self-efficacy scores highlights substantial individual differences in this construct, which may be influenced by factors such as prior clinical experience, educational background, and personality traits.
While our findings suggest a trend toward lower clinical self-efficacy among women, this difference was not statistically significant. The nonsignificant result may be due to sample size limitations. Future studies with larger and more diverse samples could clarify whether gender plays a meaningful role in clinical confidence.
The positive correlation between academic performance and clinical self-efficacy observed in this study suggests the strong problem-solving skills, and a positive academic self-concept, which may generalize to the clinical setting. This finding is consistent with previous research suggesting that academic achievement is associated with higher levels of self-efficacy in various domains.[27,28] This suggests that external factors, such as real-world clinical exposure or social support from living conditions, may buffer the negative impact of hypochondriasis on self-efficacy. Future studies should further explore these mediating influences.
According to the findings, clinical self-efficacy among nursing students was not significantly influenced by gender, academic year, and GPA. However, women exhibited slightly lower levels of clinical self-efficacy compared to men. The results of this study demonstrated that academic year and overall GPA, after controlling for part-time nursing work and residential area, were significantly associated with clinical self-efficacy among nursing students.[30] These findings align with previous research emphasizing the importance of experience and academic achievement in enhancing self-efficacy.[19,29] This may be attributable to the complex interplay of factors influencing clinical self-efficacy or limitations inherent in the study design. However, this finding suggests that other factors, such as personality traits, prior clinical experiences, and social support, may play a more prominent role in shaping clinical self-efficacy. Future research should explore the complex interplay of these factors to develop targeted interventions aimed at enhancing clinical self-efficacy among nursing students.
Limitations and recommendations
Several limitations should be considered when interpreting the findings. First, the cross-sectional design precludes causal inferences about the observed relationships; longitudinal studies are needed to explore temporal dynamics between hypochondriasis and clinical self-efficacy. Second, reliance on self-reported data may introduce response bias, such as social desirability or recall bias, potentially inflating or underestimating true associations. Third, the study’s geographic restriction to nursing schools in West Mazandaran, Iran, limits generalizability to other cultural or educational contexts. Fourth, the absence of participants with severe hypochondriasis narrows insights into how extreme health anxiety impacts clinical confidence. Additionally, while validated tools were used, the Evans Hypochondriasis and SECP scales may not fully capture culturally specific manifestations of health anxiety or clinical self-efficacy. Finally, unmeasured confounders such as prior clinical exposure, personality traits, or institutional teaching methods could influence outcomes but were not accounted for.
Conclusion
The inverse relationship between hypochondriasis and clinical self-efficacy underscores the need to address health-related anxieties to bolster both student wellbeing and clinical competence. Nursing students demonstrated moderate levels of hypochondriasis and clinical self-efficacy, suggesting a critical window for intervention. Faculty and administrators should prioritize early identification of at-risk students and integrate counseling resources to mitigate health anxieties while fostering clinical confidence. Future research must adopt longitudinal, multimethod designs incorporating diverse populations, objective performance metrics, and individuals with severe hypochondriasis to clarify causal mechanisms and optimize tailored interventions.
Author’s contributions
ZF and AP: Conceptualization. ZF, AP and AZ: Study design. ZF and AP: Data analysis. ZF, AP and AZ: Interpretation of data. ZF, AP and AZ: Drafting and revising the manuscript. MTA, SL and AZ: Data collection.
Declaration of patient consent
The authors certify that all participants provided written informed consent. As this study involved nursing students and no patients were directly enrolled, separate patient consent was not applicable.
Conflicts of Interest
There are no conflicts of interest.
Acknowledgment
The authors would like to express their sincere gratitude to all those who contributed to this research.
Funding Statement
We did not receive any funding to carry out this study.
References
- 1.Oermann MH, Gaberson KB, De Gagne JC. New York: Springer Publishing Company; 2024. Evaluation and testing in nursing education. [Google Scholar]
- 2.Bhati K, Sethy T. Self-efficacy: Theory to educational practice. Int J Indian Psychol. 2022;10:1123–8. [Google Scholar]
- 3.Zia Z, Salehi A, Amini M, Vardanjani HM, Tavabe MS. Relationship between research self efficacy and evidence based practice in the medical students. J Educ Health Promot. 2022;11:221–8. doi: 10.4103/jehp.jehp_1233_21. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Deprez N, Triffaux JM. L’hypocondrie: la peur maladive des maladies. [Hypochondriasis: the morbid fear of diseases…] Rev Med Liege. 2023 May;78(5-6):335–341. French. [PubMed] [Google Scholar]
- 5.Taghinejad H, Mozafari M, Bazhdan A, Vasiee A. Investigating the effect of online gamification on electrocardiogram interpretation and self-directed learning in nursing students. J Adv Med Educ Prof. 2024;12:199–207. doi: 10.30476/JAMP.2024.101396.1925. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Hüsing P, Bassler M, Löwe B, Koch S, Toussaint A. Validity and sensitivity to change of the Somatic Symptom Disorder-B Criteria Scale (SSD-12) in a clinical population. Gen Hosp Psychiatry. 2018;55:20–6. doi: 10.1016/j.genhosppsych.2018.08.006. [DOI] [PubMed] [Google Scholar]
- 7.Muraru ID, Munteanu C, Iorga M, Petrariu FD. Investigating medical student‘s health concerns during their academic studies. Med-Surg J-Revista Medico-Chirurgicala. 2019;123:728–34. [Google Scholar]
- 8.Talaei A, Fayazi BM, Nasiraei A, Samari AA, Mirshojaeian M, Rezaei AA. Hypochondrias in resident students of Mashhad university of medical sciences. J Ilam Univ Med Sci. 2009;17:8–18. [Google Scholar]
- 9.Salmani R, Kazemi H, Sarbakhsh P, Mousazadeh Y. Hypochondriasis and self-medication among medical sciences students during the COVID-19 pandemic: A descriptive cross-sectional study in Northwestern Iran. Work. 2023;75:1139–51. doi: 10.3233/WOR-220368. [DOI] [PubMed] [Google Scholar]
- 10.Meng J, Gao C, Tang C, Wang H, Tao Z. Prevalence of hypochondriac symptoms among health science students in China: A systematic review and meta-analysis. PLoS One. 2019;14:e0222663. doi: 10.1371/journal.pone.0222663. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Hannah K, Marie K, Olaf H, Stephan B, Andreas D, Wilson Michael L, et al. The global economic burden of health anxiety/hypochondriasis-a systematic review. BMC Public Health. 2023;23:2237. doi: 10.1186/s12889-023-17159-5. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Karr JE, White AE. Academic self-efficacy and cognitive strategy use in college students with and without depression or anxiety. J Am Coll Health. 2024;72:1387–93. doi: 10.1080/07448481.2022.2076561. [DOI] [PubMed] [Google Scholar]
- 13.Rohilla J, Tak P, Jhanwar S, Hasan S, Gaykwad R, Yadav R, et al. Health anxiety among medical students: A comparison between preclinical and clinical years of training. J Educ Health Promot. 2020;9:356. doi: 10.4103/jehp.jehp_491_20. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Contreras JA, Edwards-Maddox S, Hall A, Lee MA. Effects of reflective practice on baccalaureate nursing students’ stress, anxiety and competency: An integrative review. Worldviews Evid Based Nurs. 2020;17:239–45. doi: 10.1111/wvn.12438. [DOI] [PubMed] [Google Scholar]
- 15.Ahmed FA, Alrashidi N, Mohamed RA, Asiri A, Al Ali A, Aly KH, et al. Satisfaction and anxiety level during clinical training among nursing students. BMC Nurs. 2023;22:187. doi: 10.1186/s12912-023-01352-3. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Harrell KM, Rawls M, Stringer JK, 4th, Edwards CD, Santen SA, Biskobing D. Understanding academic self-concept and performance in medical education. Acad Med. 2023;98:1032–5. doi: 10.1097/ACM.0000000000005224. [DOI] [PubMed] [Google Scholar]
- 17.Brocker A, Scafide KN. Systematic review: Self‐efficacy and skill performance. Int Nurs Rev. 2024;71:810–22. doi: 10.1111/inr.12915. [DOI] [PubMed] [Google Scholar]
- 18.Alavi A, Okhovat F. Effects of training nursing process using the concept map on caring self efficacy of nursing students in pediatric departments. J Educ Health Promot. 2024;13:149. doi: 10.4103/jehp.jehp_997_23. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Cheraghi F, Hassani P, Yaghmaei F, Alavi-Majed H. Developing a valid and reliable self-efficacy in clinical performance scale. Int Nurs Rev. 2009;56:214–21. doi: 10.1111/j.1466-7657.2008.00685.x. [DOI] [PubMed] [Google Scholar]
- 20.Khani H, Ghodsi H, Nezhadnik H, Teymori S, Ghodsi AR. Depression and its relationship with hypochondriasis in nurses in Neyshabur, Iran. Mil Caring Sci. 2016;3:34–40. [Google Scholar]
- 21.Yorlets RR, Lee Y, Gantenberg JR. Calculating risk and prevalence ratios and differences in R: Developing intuition with a hands-on tutorial and code. Ann Epidemiol. 2023;86:104–9. doi: 10.1016/j.annepidem.2023.08.001. [DOI] [PubMed] [Google Scholar]
- 22.Olivier J, May WL, Bell ML. Relative effect sizes for measures of risk. Commun Stat Theory Methods. 2017;46:6774–81. [Google Scholar]
- 23.Chen SY, Feng Z, Yi X. A general introduction to adjustment for multiple comparisons. J Thorac Dis. 2017;9:1725–9. doi: 10.21037/jtd.2017.05.34. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Lee SA, Crunk EA. Fear and psychopathology during the COVID-19 crisis: Neuroticism, hypochondriasis, reassurance-seeking, and coronaphobia as fear factors. Omega (Westport) 2022;85:483–96. doi: 10.1177/0030222820949350. [DOI] [PubMed] [Google Scholar]
- 25.Sajadi M, Mehrabi F. Relationship between clinical environment stressors and nursing students self-efficacy in clinical performance. J Nurs Educ. 2019;8:44–50. [Google Scholar]
- 26.Yusefi AR, Daneshi S, Davarani ER, Nikmanesh P, Mehralian G, Bastani P. Resilience level and its relationship with hypochondriasis in nurses working in COVID-19 reference hospitals. BMC Nurs. 2021;20:219. doi: 10.1186/s12912-021-00730-z. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Sahebi Z, Barkhordari-Sharifabad M. Spiritual care competency and its relationship with clinical self-efficacy in nursing students. BMC Med Educ. 2023;23:937. doi: 10.1186/s12909-023-04937-3. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28.Hayat AA, Shateri K, Amini M, Shokrpour N. Relationships between academic self-efficacy, learning-related emotions, and metacognitive learning strategies with academic performance in medical students: A structural equation model. BMC Med Educ. 2020;20:76. doi: 10.1186/s12909-020-01995-9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29.Zheng B, Chang C, Lin C, Zhang Y. Self-efficacy, academic motivation, and self-regulation: How do they predict academic achievement for medical students? Med Sci Educ. 2020;31:125–30. doi: 10.1007/s40670-020-01143-4. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 30.Abdal M, Masoudi Alavi N, Adib-Hajbaghery M. Clinical self-efficacy in senior nursing students: A mixed- methods study. Nurs Midwifery Stud. 2015;4:e29143. doi: 10.17795/nmsjournal29143. [DOI] [PMC free article] [PubMed] [Google Scholar]