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. 2022 Dec 1;79(2):581–592. doi: 10.1111/jan.15478

The mental health impact of COVID‐19 on pre‐registration nursing students in Australia: Findings from a national cross‐sectional study

Kim Usher AM 1,✉, Debra Jackson 2, Debbie Massey 3, Dianne Wynaden 4, Julian Grant 5, Caryn West 6, Shirley McGough 4, Martin Hopkins 7, Amanda Muller 8, Carey Mather 9, Zac Byfield 1, Zaneta Smith 1, Irene Ngune 10, Rochelle Wynne 11
PMCID: PMC9877832  PMID: 36453452

Abstract

Aim

The study aimed to measure and describe the mental health impact of COVID‐19 on Australian pre‐registration nursing students.

Background

The COVID ‐19 pandemic has had a swift and significant impact on nursing students across the globe. The pandemic was the catalyst for the closure of schools and universities across many countries. This necessary measure caused additional stressors for many students, including nursing students, leading to uncertainty and anxiety. There is limited evidence available to identify the mental health impact of COVID‐19 on Australian pre‐registration nursing students currently.

Design

A cross‐sectional study was conducted across 12 Australian universities.

Methods

Using an anonymous, online survey students provided demographic data and self‐reported their stress, anxiety, resilience, coping strategies, mental health and exposure to COVID‐19. Students' stress, anxiety, resilience, coping strategies and mental health were assessed using the Impact of Event Scale‐Revised, the Coronavirus Anxiety Scale, the Brief Resilience Scale, the Brief Cope and the DASS‐21. Descriptive and regression analyses were conducted to investigate whether stress, anxiety, resilience and coping strategies explained variance in mental health impact. Ethical Approval was obtained from the University of New England Human Research Ethics Committee (No: HE20‐188). All participating universities obtained reciprocal approval.

Results

Of the 516 students who completed the survey over half (n = 300, 58.1%) reported mental health concerns and most students (n = 469, 90.9%) reported being impacted by COVID‐19. Close to half of students (n = 255, 49.4%) reported signs of post‐traumatic stress disorder. Mental health impact was influenced by students' year level and history of mental health issues, where a history of mental health and a higher year level were both associated with greater mental health impacts. Students experienced considerable disruption to their learning due to COVID‐19 restrictions which exacerbated students' distress and anxiety. Students coped with COVID‐19 through focusing on their problems and using strategies to regulate their emotions and adapt to stressors.

Conclusion

The COVID‐19 pandemic has considerably impacted pre‐registration nursing students' mental health. Strategies to support nursing students manage their mental health are vital to assist them through the ongoing pandemic and safeguard the recruitment and retention of the future nursing workforce.

Impact statement

This study adds an Australian understanding to the international evidence that indicates student nurses experienced a range of negative psychosocial outcomes during COVID‐19. In this study, we found that students with a pre‐existing mental health issue and final‐year students were most affected. The changes to education in Australian universities related to COVID‐19 has caused distress for many nursing students. Australian nursing academics/educators and health service staff need to take heed of these results as these students prepare for entry into the nursing workforce.

Patient or public involvement

The study was designed to explore the impact of COVID‐19 on the mental health of undergraduate nursing students in Australia. Educators from several universities were involved in the design and conduct of the study. However, the study did not include input from the public or the intended participants.

Keywords: clinical placement, COVID‐19, mental health, nurse education, nursing, students

What is already known about the topic?

  • The COVID‐19 pandemic has impacted the healthcare sector on a global scale

  • Healthcare professionals, in particular nurses, have been at the forefront of the healthcare response to the pandemic

  • Nursing students have been impacted two‐fold: as members of society where imposed quarantine has resulted in isolation and as students learning in educational and clinical settings affected by the pandemic

What this paper adds

  • Most students reported being impacted by the COVID‐19 pandemic, and more than half of students reported mental health concerns.

  • Despite students reporting these mental health concerns, students displayed levels of resilience and utilized coping strategies to adapt to their situation.

1. INTRODUCTION

In March 2020, the World Health Organization formally labelled the global spread of the SARS‐CoV‐2 strain of coronavirus as a pandemic (hereafter known as COVID‐19) (WHO, 2020). Since this time, the COVID‐19 pandemic has gone on to have impact on almost every aspect of modern living. The healthcare sector has seen significant upheaval during this time, with impact on all areas of health delivery, from policy development, research, clinical practice and education. As the largest professional group in the global healthcare workforce, nurses have been at the forefront of the healthcare response and consequently, the COVID‐19 pandemic has had a major influence on nursing education, with the actions taken to ‘flatten the curve’ of transmission having impact on nursing students across the globe (Fowler & Wholeben, 2020).

In response to the first case of COVID‐19 in Australia in January 2020, the government introduced the Australian Health Management Plan for Pandemic Influenza (Australian Government, 2020) to limit the spread of the virus resulting in the implementation of social distancing policies and imposed limitations on social gatherings. At certain time of the pandemic, lockdown on movements of people within and between States and territories were enforced (Australian Government Department of Health, 2020) and the national borders were closed from March 2020. The effect of the pandemic varied across Australia with the most severe lockdowns occurring in Victoria. The prevention strategies led to closure of schools and universities, and cancellation of non‐urgent surgeries and health services (Wahlquist, 2020). The closure of universities led to the rapid transformation of nursing education into online delivery modes (Cao et al., 2020), and clinical placements were cancelled or offered as online simulations (Carolan et al., 2020). Given previous research indicates that nursing students experience high levels of distress related to clinical placements during pandemics (Dewart et al., 2020), the cancellation of placements or transfer to simulated learning may have also caused distress to nursing students in Australia.

In this study, we sought to examine the background variables (e.g. year of study, previous mental health issues) in relation to the impact of COVID‐19 and related educational changes on undergraduate nursing students in Australia. A deeper understanding of these impacts may help identify the need for system level changes to improve nurse education delivery and foster a smoother transition to the nursing workforce.

2. BACKGROUND

The pandemic has resulted in many changes to nursing education programs across the globe (Carolan et al., 2020). The states and territories of Australia adopted a containment strategy attained through various systems of tracing, social restrictions, lockdowns and other measures from March 2020 and only relaxing these measures from late 2021 once sufficient vaccination was attained and appropriate treatments were established. These measures included the closure of schools and universities across Australia and globally (Viner et al., 2020). For many nursing students, the isolation resulted in the cancellation of classes and clinical placement activities, the introduction of virtual or hybrid learning approaches (Haslam, 2021; Suliman et al., 2010), replacement of clinical placements with other models of clinical learning (Canet‐Vélez et al., 2021; Casafont et al., 2021; de Almeida Peres et al., 2020), or working or attending clinical placements in hospitals where they may be required to care for infectious people, and/or risk exposure to infected patients and staff (Cao et al., 2020; Usher, Wynaden, Bhullar, et al., 2020).

As a result of the quarantine strategies, nurse educators altered modes of delivery of education and clinical practice activities; many of which were continued for some time (Ion et al., 2021) and in some instances continue today (Ramos‐Morcillo et al., 2020). The need to rapidly alter the way in which curricula and courses were delivered has caused disruption to the education of thousands of nursing students, with evidence suggesting that many students will be delayed in their progression and graduation (Jackson & Usher, 2022). Delays in progression for nursing students have been linked to negative mental health outcomes (Palese et al., 2020) with potential to impact the student as an individual, nursing as a profession, as well as the healthcare system. Indeed, uncertainty over the pandemic, and the ongoing interruptions to study and clinical placement have resulted in some nursing students deciding the leave the profession (Eweida et al., 2020, González et al., 2021), though conversely some students have reported that participating in pandemic‐related duties reinforced a desire to enter the nursing profession (Michel et al., 2021).

Little is known about the potential short‐ and longer‐term impacts of the COVID‐19 pandemic on nursing students (Jackson & Usher, 2022). Previous studies have identified an impact of the COVID‐19‐related changes to nursing education on student mental well‐being (Aslan & Pekince, 2021; Patelarou et al., 2021; Reverté‐Villarroya et al., 2021; Savitsky et al., 2020). International students have been identified as a particularly vulnerable group of nursing students who may be more isolated and hence more at risk to the negative effects of imposed quarantine strategies (Andrew, 2020). In the Australian state of Victoria, which unquestionably experienced the most stringent and most prolonged restrictions, it is known that nursing students experienced significant stress, anxiety, isolation and loss of motivation as a result of the pandemic (Rasmussen et al., 2022). However, moving beyond the state of Victoria, looking nationally to the whole of Australia, the picture of psycho‐social and mental health impacts on nursing students is less clear.

Similar to other countries, Australia is facing a significant shortage of skilled graduate nurses and this shortage is predicted to become more acute as COVID‐19 places increasing burden on nurses and midwives and the healthcare system (Adelson et al., 2021). Thus, a national understanding of the mental health impacts of COVID‐19 on Australian pre‐registration nursing students will provide important information that can inform health and education providers to better support students in the future. The objectives of the study were to measure the mental health impact of COVID‐19 on Australian pre‐registration nursing students, and to determine if effects are linked to factors such as location/university, experience, degree or years completed.

3. THE STUDY

3.1. Aim

The study aimed to measure and describe the mental health impact of COVID‐19 on Australian pre‐registration nursing students. In addition, we explore related variables (for example year of study and previous history of mental health issues) and level of distress. The objectives of the study were to:

  • Measure the mental health impact of COVID‐19 on Australian pre‐registration nursing students.

  • Determine if the mental health impact of COVID‐19 on Australian pre‐registration nursing students is linked to location or university, experience, degree, years completed or level of resilience.

3.2. Design

A national multi‐centre, cross‐sectional survey was administered via Qualtrics® between the 27 February and 3 November 2021. The G*Power 3.1 program was used to calculate sample size requirements to determine whether PTSD (IES‐R), COVID‐19 anxiety (CAS), resilience (BRS) and coping strategies (Brief COPE Inventory) predict mental health impact (DASS‐21), and which predictors explain variance in this outcome. A total of 261 participants were required to detect a small effect size of 0.10, with a power (1‐β) of .90 for 17 predictors (IES‐R x 3 sub‐scales, CAS x 5 items, BRS x 6 items, 3 COPE sub‐scales) in a linear multiple regression model.

Several valid and reliable instruments were used to measure the effect of independent (location or university, experience, degree, years completed and level of resilience) on the dependent variable (mental health impact of COVID‐19). Demographic variables included age, sex, postcode, indigenous status, relationship status, local or international student status, year of enrolment in the degree, living arrangements and employment status, in addition to whether students had a history of mental health problems or COVID‐19 exposure. There were three open‐ended questions to ascertain students' perceptions of challenges linked to COVID‐19‐related clinical placement delays, attendance at clinical placement during COVID‐19, issues related to isolation and the inability to attend face‐to‐face classes, and laboratory learning sessions during periods of COVID‐19 restrictions (this information will be presented in a later paper). This cross‐sectional study has been reported using the STROBE guidelines (Vandenbroucke et al., 2007).

3.3. Participants

A convenience sample of pre‐registration nursing students from 12 Australian universities was invited to participate via email or their university‐specific online learning platform. Several university schools of nursing were invited to participate in the study; those that responded were included. The final sample included representative universities from New South Wales, Tasmania, South Australia, Victoria, Western Australia and Queensland. The Australian Capital Territory and the Northern Territory were not included in the sample and not all universities in included States participated in the study. The total potential sample was approximately 11,500 students. We did not record numbers from individual universities as the ethics committee was not prepared to endorse that request.

3.4. Data collection

Invitations were sent by student administration services with a reminder sent 2–4 weeks after the initial invitation. The online survey was comprised of three key sections to ascertain sample demographics (Section 1), independent variables (Section 2) to assess effect on mental health impact including post‐traumatic stress, COVID‐19 distress and anxiety, level of resilience and coping strategies and the dependent variable mental health impact (Section 3). Section 3 was comprised of three open‐ended questions to ascertain students' perceptions of challenges linked to COVID‐19‐related clinical placement delays, attendance at clinical placement during COVID‐19, issues related to isolation and the inability to attend face‐to‐face classes and laboratory learning sessions during periods of COVID‐19 restrictions. The survey took an estimated 50 min to complete.

3.5. Ethical considerations

Permission to conduct the study was initially received from the University of New England Human Research Ethics Committee (HREC) (#HE20‐188). Other participating higher education schools of nursing submitted an ethics application at their relevant university after the initial ethical clearance was received from the lead university. The invitation was not linked to any course materials and academic teaching staff were not involved in recruitment to mitigate potential perceptions of coercion. The participant information sheet was embedded within the survey. Consent was implied by survey completion. As the survey had potential to cause emotional distress, participants were provided with numbers for mental health support services and were provided with the access details to a local support person should they become distressed. As surveys were anonymous, there was no way to follow‐up students who did indicate distress directly. However, the Participant Information sheet did provide the details for the lead researcher. As the outcomes of this survey have important results for the participants, dissemination of results will include the development of a one‐page handout of the results will be developed and shared with universities schools of nursing and health service providers.

3.6. Data analysis

Survey data were extracted from Qualtrics® into an IBM SPSS® (Statistical Package for the Social Sciences Version 27.0: IBM Corp.) file for analysis. Data were screened and cleaned. Continuous data were analysed using descriptive statistics presented as mean (M) with standard deviation (SD), or median (Med) and inter‐quartile range when abnormally distributed (IQR). Frequency (n) and proportion (%) were calculated for categorical variables. Likert scale item responses that did not meet assumptions of normality were treated as ordinal categorical data and described using frequency and proportion for each response. DASS‐21 scores are reported as mean (M) with standard deviation (SD) and proportion of responses in each category. To enable categorization according to developers' recommendations and comparisons with population norms, scores were doubled. Mental health impact is reported as extremely severe (≥82), severe (62–79), moderate (43–59), mild (33–40) or normal (0–30).

The characteristics of participants who did and did not complete Section 3 of the survey were compared to determine whether there were factors that might have influenced the decision to complete survey items. Apart from two factors, demographics did not differ. Those who did not complete were younger (M 24.1, SD 7.8 vs. M 26.7, SD 8.6 years; t [735] = −3.9, p < .001) and more likely to have had professional treatment for mental health problems (n = 204, 70.1% vs. n = 87, 29.9%; χ 2 [1, 291] 4.08, p = .04). Incomplete responses for independent and dependent variables were subsequently excluded from further analyses. Univariate comparisons were completed to determine whether there were any differences in the demographic characteristics of responders according to the primary endpoint of mental health impact as indicated by total DASS‐21 score. Independent samples t‐tests or one‐way analysis of variance (ANOVA) for more than two group comparisons, were used to explore group differences in mental health impact (DASS‐21). Hierarchical multiple regression analyses were completed to examine whether PTSD (IES‐R), COVID‐19 anxiety (CAS), resilience (BRS) and coping strategies (Brief COPE Inventory) as a set of predictors explained variance in mental health impact (DASS‐21) in a model adjusted for univariate group differences. The study has been reported according to the STROBE guidelines.

3.7. Validity and reliability

Quantitative assessment of mental health involved the use of validated reliable instruments that captured responses on a 4‐ or 5‐point Likert scale.

3.7.1. Impact of Event Scale‐Revised

This 22‐item scale (Weiss & Marmar, 1997) assesses general negative affectivity related to a traumatic experience. The tool is not intended as a diagnostic tool but rather offers a way to measure the subjective response to a specific traumatic event. There is no true cut‐off score but scores higher than 24 are considered worrisome with scores higher than 33 indicate the presence of post‐traumatic stress disorder (PTSD) and associated mental health consequences (McCabe, 2019; Weiss, 2007). The scale has good psychometric scores; the three subscales were found to be very high, with intrusion alphas ranging from .87 to .92, avoidance alphas ranging from .84 to .86 and hyperarousal alphas ranging from .79 to .90 (Briere & Elliott, 1998). The IES‐R has been used to evaluate the impact of COVID‐19 with good fit, reliability and convergent validity (Nia et al., 2021; Vanaken et al., 2020).

3.7.2. Coronavirus Anxiety Scale

This 5‐item scale (Lee, 2020a, 2020b) is brief mental health screener for the COVID‐19 pandemic‐related anxiety. Principal component and factor analyses for the CAS were shown to be highly reliable (α = .93), thematically consistent (i.e. distressing physical symptoms associated with coronavirus fear and anxiety) and stable (i.e. CFA confirmed PCA results). In addition, the CAS was shown to measure anxiety symptoms in similar ways across demographic groups and was recommended as a useful screening tool (Lee, 2020a, 2020b).

3.7.3. Brief Resilience Scale

This 6‐item scale (Smith et al., 2008) measures resilience or how well one is equipped to bounce back after hard times or stressful life events and an ability to recover from stress. The BRS reliability was tested across four samples with a Cronbach's alpha ranging from .80 to .91 (Smith et al., 2008). The BRS has further been validated and recommended as a reliable tool (coefficient alpha of .71) to examine resilience among undergraduate students (Fung, 2020).

3.7.4. Brief COPE Inventory

This 28‐item scale assesses problem‐focused, emotion‐focused coping and avoidant coping styles using responses (Carver et al., 1989). Response categories for Likert scale items were assigned the lowest value at the negative end of the scale (e.g. Strongly Disagree), the highest value at the positive end (e.g. Strongly Agree) and a zero for ‘no’ or ‘not at all’, with the exception of three items in the BRS that had reverse scoring.

3.7.5. Depression Anxiety Stress Scale

This 21‐item scale (Lovibond & Lovibond, 1995) measures symptoms of depression, anxiety and stress. The severity of mental health impact as the primary endpoint measure was assessed using the Depression Anxiety Stress Scale (DASS‐21). This 21‐item survey (Lovibond & Lovibond, 1995) provides a continuous estimate of level of distress that can be further scrutinized according to the separate sub‐scales of depression, anxiety and stress. The depression sub‐scale was categorized as extremely severe (≥28), severe (21–27), moderate (14–20), mild (10–13) or normal (0–9); Anxiety as extremely severe (≥20), severe (15–19), moderate (10–14), mild (8–9) or normal (0–7) and Stress as extremely severe (≥34), severe (26–30), moderate (19–25), mild (15–18) or normal (0–14). Internal consistency (Cronbach's alpha coefficient) of the sub‐scales in this sample was assessed and a value of 0.75 or higher indicative of good reliability.

3.7.6. The Brief COPE Inventory

(Carver, 1997) has recently been validated among nurses with a reliable second‐order exploratory factor analysis of 0.81 and 0.86 (Abdul Rahman et al., 2021).

4. RESULTS

Of the 858 students that accessed the survey 516 (60.1%) completed all survey items. Sample characteristics are listed in Table 1. There were similar proportions of students in years one, two or three of their degree with 35 (6.8%) enrolled beyond 3 years because they had progress issues secondary to COVID‐19 (n = 7, 1.4%), changed degrees (n = 8, 1.6%), were enrolled part time (n = 10, 1.9%) or were in enrolled a double degree (n = 10, 1.9%). Most students lived in metropolitan locations (n = 326, 63.2%). Students (n = 293, 56.8%) in Australian States largely unaffected by ongoing lockdowns (WA n = 127, 24.6%; QLD n = 42, 8.1%; NT n = 1, 0.2%; Tasmania n = 38, 7.4%; SA n = 85, 16.5%) were surveyed in March or April. The remaining students from Victoria (n = 74, 14.3%) and NSW (n = 124, 24.0%) completed the survey in July or August when Victoria was in lockdown for the sixth time and Sydney had a 5 km travel restriction in place.

TABLE 1.

Participant characteristics

Characteristic n, M %, SD
Age 26.7 8.5
Female 453 87.8
Aboriginal or Torres Strait Islander 10 2.0
Geographical location
Metropolitan 326 63.2
Regional 126 24.4
Rural 47 9.1
Remote 4 0.8
Lockdown Affected (NSW, VIC) 198 38.3
Year of enrolment
First year 144 27.9
Second year 166 32.2
Third year 171 33.1
International student 105 20.3
Not in a relationship 247 47.9
Partnered 252 48.8
Lives with others 474 91.9
Lives alone 42 8.1
Full‐time employment 27 5.2
Part‐time/casual employment 290 56.2
Unemployed looking for work 77 14.9
Unemployed not looking 46 8.9
Mental health history 300 58.1
Professional mental health treatment 205 39.7
Impacted by COVID‐19 469 90.9
COVID‐19 Positive 20 3.9
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Note: Figures may not equal 100% due to missing data.

Mental health problems had been experienced by just over half (n = 300, 58.1%) of the participants and most (n = 469, 90.9%) claimed they had been impacted by COVID‐19. Students' experience of COVID‐19 at the time of the survey influenced their responses a lot or a great deal (n = 228, 44.2%), moderately (n = 159, 30.8%) or had little to no influence (n = 122, 23.6%). CAS scores indicative of dysfunctional anxiety (≥9) secondary to COVID‐19 were evident in only a small proportion of respondents (n = 41, 7.9%) but most participants agreed COVID‐19 was distressing (Table 2).

TABLE 2.

Covid‐19 distress

Item Response
Disagree Neutral Agree M SD
N % n % n %
Anxious about negative consequences of COVID‐19 53 10.3 66 12.8 397 76.9 3.9 0.9
Distressed that COVID‐19 might affect me, family or friends 53 10.3 57 11.0 406 78.7 3.9 0.9
Plan to carry out actions to protect myself or others from COVID‐19 impacts 16 3.1 38 7.4 462 89.5 4.2 0.8
Find it hard to get on with things because am thinking about COVID‐19 212 41.1 121 23.4 183 35.5 2.9 1.2
Watching news stories about the pandemic makes me nervous or anxious 114 22.1 107 20.7 295 57.2 3.5 1.1
Stressed around other people in case I catch COVID‐19 219 42.4 123 23.8 174 33.7 2.9 1.2
Thinking about COVID‐19 makes me feel threatened 199 38.6 130 25.2 187 36.2 2.9 1.2
COVID‐19 has negatively impacted me financially 136 26.4 87 16.9 293 56.8 3.5 1.3
Has been difficult to get essential resources I need because of COVID‐19 232 45.0 128 24.8 156 30.2 2.8 1.2
COVID‐19 has impacted my psychological health negatively 97 18.8 93 18.0 326 63.2 3.6 1.1
I spend a lot of time trying to find updates about COVID‐19 272 52.7 107 20.7 137 26.6 2.6 1.2
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According to IES‐R scores, 49.4% of students (n = 255) had at a minimum, signs of clinically concerning PTSD. Of these students, 10.9% (n = 28) had probable PTSD and 56.4% (n = 144) had levels of stress consistent with immune system suppression and severe PTSD. Notably, level of resilience was within normal limits (BRS M 3.1, SD 0.5, IQR 4.0) at the time of the survey. Coping strategies to deal with stressors were explored using the Brief COPE inventory that revealed students' approach to coping was generally underpinned by being problem focused (M 18.8, SD 5.5, IQR 24.0) using strategies to regulate their emotions (M 26.5, SD 6.6, IQR 34) and to adapt to stressors (M 14.8, SD 4.4, IQR 23.0).

In this cohort, the DASS‐21 had excellent internal consistency with a Cronbach alpha coefficient of .91. Cronbach alpha coefficients for the stress (.86), anxiety (.79) and depression (.82) subscales were also indicative of good reliability. Mean scores for the DASS‐21 sub‐scales for students for stress (M 8.4, SD 5.3), anxiety (M 5.7, SD 4.9) and depression (M 7.6, SD 5.8) were much higher than pre‐pandemic Australian population means of 3.99, 1.74 and 2.57 respectively. In this sample, the impact of COVID‐19 on mental health was not problematic (n = 202, 39.1%), mild (n = 65, 12.6%), moderate (n = 110, 21.3%), severe (n = 75, 14.5%) or extremely severe (n = 64, 12.4%). The proportion of students for each category of the stress, anxiety and depression sub‐scales is shown in Table 3.

TABLE 3.

Categories of stress, anxiety and depression as indicated by DASS‐21 sub‐scale scores

Dass‐21 sub‐scales Normal Mild Mod Severe Extreme
n % n % n % n % n %
Stress 244 47.3 71 13.8 84 16.3 56 10.9 61 11.8
Anxiety 199 38.6 52 10.1 111 21.5 43 8.3 111 21.5
Depression 186 36.0 60 11.6 121 23.4 63 12.2 86 16.7
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Mental health impact differed according to two demographic characteristics. The higher the year of study the greater the DASS‐21 score for students; F (3, 512) = 3.0, p = 0.03. Post hoc comparisons using the Tukey test indicated the mean score for first‐year students (M 18.6, SD 13.8) was significantly different from that of third‐year students (M 23.2, SD 14.7) whose scores were not unlike those in second (M 22.1, SD 15.0) and fourth year (M 24.1, SD 16.9). Those students who had a previous history of mental health issues (n = 300, 58.1%) were also more likely to have higher DASS‐21 scores (M 26.4, SD 14.2 versus M 15.1, SD 13.0 years; t [514] = −9.4, p < 0.001). Hierarchical multiple regression was used to identify predictors of mental health impact, after controlling for the influence of year of study and previous mental health issues. Preliminary analyses confirmed no violation of required assumptions. Year of study and previous mental health issues were entered at Step 1 explaining 15.9% of the variance in mental health impact. After entry of variables used to assess PTSD (IES‐R), COVID‐19 anxiety (CAS), resilience (BRS) and coping strategies (Brief COPE Inventory) in Step 2 the total variance explained by the model was 64.1%, F (19, 496) = 46.6, p < .001. In the final model factors associated with increased mental health impact were previous mental health issues (β = .14, p < .001), feeling nauseous as a symptom of anxiety when exposed to information about COVID‐19 (β = .99, p = .02), hyperarousal as a symptom of PTSD (β = .36, p < .001), finding it hard to make it through stressful events (β = .08, p = .03), not being able to regulate emotions to cope (β = .18, p < .001), and having to use physical or cognitive efforts to disengage from stress to cope (β = .20, p < .001).

5. DISCUSSION

This study aimed to explore whether the changes related to the COVID‐19 pandemic affected the mental health of Australian pre‐registration nursing students. The study found that mental health problems had been experienced by just over half (n = 446, 56.6%) of the participants, and 65% (n = 290) had sought professional help or treatment for their mental health problem. Most participants (n = 717, 91%) claimed they had been impacted by COVID‐19 and 33 (4.2%) had tested positive, 49.4% of students (n = 255) had at a minimum, signs of clinically concerning post‐traumatic stress disorder (PTSD). Issues ranged from disconnection or breakdown of social support of the family and friends; disconnection with industry professional networks; making poor decisions around their health and well‐being; to the deeper psychological impacts of hyperarousal, physical symptoms of anxiety and being unable to regulate emotions to disengage from stress or cope. The deeper psychological impacts on the participants in this study were more pronounced among students in their final year of study and those with a pre‐existing mental disorder. The combined impact of these two variables explained 15.9% of the variance, with the pre‐existing mental health conditions showing statistically significant findings (β = .14, p < .001). These results echo similar studies undertaken with nursing students during the COVID‐19 pandemic (Aqeel et al., 2021, Cao et al., 2020, Reverté‐Villarroya et al., 2021).

The fact that final‐year students reported higher levels of distress in this study is worrying. These students are close to completion and will soon enter the workforce. Previous researchers have also reported similar findings (Aqeel et al., 2021, Cao et al., 2020, Reverté‐Villarroya et al., 2021). Reverté‐Villarroya et al. (2021) found that final‐year nursing students who experienced COVID‐19 experienced a two‐times greater risk of experiencing mental health issues than previous final‐year students who did not experience COVID‐19. In addition, also found that final‐year students reported more symptoms of mental health distress. These final‐year students will soon transition to the workforce and will be charged with providing caring for unwell people. Given the current shortage of registered nurses in Australia and across the globe, it is paramount that educators recognize the risk of mental distress in nursing students and develop appropriate interventions to assist students to manage their symptoms (Li et al., 2021). Furthermore, as these students transition to the practice environment, they must be supported to manage their distress and must be provided with adequate support and counselling as needed.

The finding that 49.4% of the participants in this study reported severe signs of PTSD are concerning. Previous studies have, however, presented similar results. For example, reported 44.5% of nursing students with signs of PTSD. The greater levels of psychosocial distress and PTSD reported by final‐year students in this study is concerning as these students are close to entering the workforce as registered nurse professionals. It is important for the health services to recognize that many new registered nurses will still be experiencing symptoms of PTSD and may require professional support such as mentoring during the transition period.

The findings of this study revealed that students with a pre‐existing mental health condition were more likely to experience greater levels of mental distress related to the pandemic and the changes to their course than other students. Pre‐existing mental health conditions are becoming more evident in students enrolling in nursing courses (Ramluggun et al., 2018, Yang & Yoon, 2015). It is also known that students in nursing experience high levels of stress (Reeve et al., 2013) which makes them more vulnerable in times of great change and distress such as the recent pandemic. These students need greater levels of support from universities and educators must be careful that course demands are addressed to ensure they do not cause students' undue distress. It is also necessary for universities to include inclusive teaching and learning approaches to ensure the needs of all students are better accommodated (Ramluggun et al., 2021).

The introduction of virtual or hybrid learning approaches (Haslam, 2021; Suliman et al., 2010), introduced to ensure nurse education could continue during the pandemic. Poor psychosocial outcomes, as identified in this study, affect active learning (Rasmussen et al., 2022), reduce motivation to learn, decrease concentration and impact the learning process (Alici & Copur, 2021), which may be even worse when a totally new learning strategy is introduced. While only 105 international nursing students from across Australia participated in the study, we know that they are more likely to live in isolation from family and friends if they remained in Australia which left them with little active support; hence they may have been more at risk of developing distress. In addition, most international students were sent home during the pandemic but when they returned, the education experience they returned to had differed greatly. Outcomes of increased mental distress are likely to lead to poorer academic achievements, which may have impacted student completion and progression. To overcome this potential problem, students need to be offered mental health support and counselling during their education to avoid worsening mental health.

The prevalence of PTSD in a community has been linked to how well a particular community is managing COVID‐19 and the impact it is having on community members. The unprecedented coverage of the pandemic on social and other media sources may also account for high levels of PTSD (Horesh & Brown, 2020). Researchers have reported that the prevalence of PTSD during COVID‐19 in the community ranges from 8 to 50% (Cenat et al., 2021). For many nursing students, the experience of living through COVID‐19 while trying to complete their nursing program has been a significant traumatic event with almost half of the students surveyed in this study describing clinically concerning signs of PTSD.

Some research has identified that younger females experience higher levels of PTSD than other groups in the population (Rodriguez‐Rey et al., 2020). As nursing is a predominantly female profession, this is an important factor to identify in managing support programs both in the university and health settings. In this study, younger students.

Additionally, there is a risk to participant confidence and negative mental health outcomes (Palese et al., 2020) including their registration status and future career if they unknowingly or through lack of experience do not have strong clinical decision‐making skills and near‐miss or clinical errors occur. Furthermore, due to other factors compounded by the pandemic including staff attrition, burn‐out or increased acuity recipients of care, staffing skill mix may not be optimum (Galanis et al., 2021; Peters et al., 2021). Mandated numbers of staff may not reflect a deeper issue of lack of high‐level knowledge, skills and capability of the complexity of nursing within healthcare environments that may further exacerbate feelings of under preparedness or inadequacy. These new graduates may lack mentoring or opportunities to access knowledge, skills and capability of advanced practitioners due to changes in workforce within healthcare environments created by the burden of the pandemic (Galanis et al., 2021).

Participants reported negative financial impacts of delayed preparation or inadequate preparation through a change in mode of delivery to be more heavily weighted to online learning and inability to practise nursing skills in a simulation environment (Ion et al., 2021).

The acute psychosocial distress and rates of post‐traumatic stress disorder identified in this population will undoubtedly have lasting impact on this cohort and the emerging nursing workforce. While many may have been able to adapt to psychological distress in the early stages of the pandemic, additional and long‐term stressors can potentially trigger mental health conditions (Sampaio et al., 2021). Changes to health and well‐being can affect the entry and transition into the nursing workforce. The disruption to learning/education and the resulting elevated distress experienced by participants is yet to be actualized in the emerging new nurse workforce (Haslam, 2021). However, these factors in combination with emerging global workforce concerns, such as population health trends and an ageing workforce, are likely to impact sustainability, recruitment and retention of the global nursing workforce and undoubtedly exacerbate predicted future nursing shortages in Australia and across the globe. If unprecedented and unexpected challenges to the transition from nursing student to graduate nurse because of the pandemic continue, nurses may leave the profession, increasing the impact on future workforce numbers (Udod et al., 2021). Delays in graduation have been predicted to affect the support and development of the nursing workforce in the short term (Kennedy, 2021), with the disruption to the supply of newly graduating nurses hindering efforts to re‐establish nursing skill mix and ratios in the wake of the pandemic (Kennedy, 2021).

While there is much discussion on the negative impacts of the pandemic on nursing students, some suggest that the multiple challenges have equipped this group with enhanced information and technological skills (Wallace et al., 2021). In this study, the finding that students' coping scores were quite unaffected even though high levels of distress were reported, indicated that the participants were coping quite well despite the challenges faced because of the pandemic. Furthermore, these participants have adapted to unprecedented challenges potentially strengthening personal resilience and adapted coping styles as reported elsewhere (Drach‐Zahavy et al., 2022). Regardless, the COVID‐19 pandemic highlighted existing challenges within the existing nursing workforce, and although the effect will continue to be felt soon (Dow et al., 2020; Weston, 2022), the impact of the COVID pandemic on the emergent and future workforce is yet to be fully realized.

5.1. Implications for education, practice and research

Nursing students have clearly been negatively impacted by COVID‐19 and have experienced a range of mental health issues that may have long‐reaching effects including causative triggers for PTSD as future registered nurses. It is recommended that in the aftermath of the COVID‐19 pandemic, nursing students are supported by their university for the remainder of their educational preparation through the provision of counselling and mental health support services. Furthermore, nursing students need to be cognisant of the potential for post‐pandemic PTSD both short term as a nursing student, but also in the coming years as a registered nurse, where other significant healthcare events and pressures may trigger negative feelings and emotions related to the impact of COVID‐19. Further studies of the longer‐term impact of the COVID‐19 pandemic on nursing students should be undertaken. The research should focus on ongoing mental health problems, transition to practice by students affected by the pandemic and the competence and confidence of new graduates.

5.2. Limitations

Inherent limitations of cross‐sectional studies are that they capture one moment in time and are inherently prone to certain biases thus accurately interpreting the outcome and association must be undertaken with some caution. The COVID‐19 outbreaks occurred at different times across the States and territories of Australia; hence timing of our data collection may have impacted the results. The 8‐month data collection period potentially was a multiplying effect of COVID‐19 that potentially had a greater impact for the student nurses who completed the survey later in the study administration period. The use of self‐reported scales is also an issue as reporting may have been influenced by individual emotional state and/or insight into the issue causing a biased sample. It also has an impact on whether participants decide to participate in the study or complete the survey in its entirety. As the survey used in this study was quite lengthy, the high number of students who did not complete the entire survey may be because of this fact. The recruitment of students from 12 universities in Australia and the sample size may modify the limitations to some degree.

6. CONCLUSIONS

Today's nursing students are tomorrow's nursing workforce; society will depend on this labour force in the event of future public health crises such as a pandemic. The findings of this study provide crucial information about the effects of the COVID‐19 pandemic on student nurse's mental health and exposes their vulnerability during the pandemic. As educators, understanding underlying mental health conditions that may impact students are fundamental to our duty of care. It is therefore vital that information about any negative sequelae associated with the pandemic is recognized and quantified, and that strategies are put into place to support nursing students and mitigate any residual distress in the future. As the COVID‐19 epidemic continues information gained through this study provides evidence to inform the provision of health and educational services to support students in the event of further pandemic‐associated restrictions to social participation and disruptions to education. Importantly, further research is needed to determine if these findings reveal longer‐term impacts of this cohort.

AUTHOR CONTRIBUTIONS

Kim Usher AM and Debra Jackson were involved in conceptualizing the study and designing the protocol. Kim Usher AM led the project. Rochelle Wynne conducted the statistical analysis. All authors contributed to the interpretation of results. All authors contributed to the writing of the manuscript, and all authors read and approved the final manuscript.

FUNDING INFORMATION

The authors received no funding for the project.

CONFLICT OF INTEREST

The authors declare no conflicts of interest.

PEER REVIEW

The peer review history for this article is available at https://publons.com/publon/10.1111/jan.15478.

ETHICS STATEMENT

(HREC) (#HE20‐188).

Supporting information

Appendix S1

Click here for additional data file. (32.3KB, docx)

Usher AM, K. , Jackson, D. , Massey, D. , Wynaden, D. , Grant, J. , West, C. , McGough, S. , Hopkins, M. , Muller, A. , Mather, C. , Byfield, Z. , Smith, Z. , Ngune, I. , & Wynne, R. (2023). The mental health impact of COVID‐19 on pre‐registration nursing students in Australia: Findings from a national cross‐sectional study. Journal of Advanced Nursing, 79, 581–592. 10.1111/jan.15478

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available from the corresponding author upon reasonable request.

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Associated Data

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Supplementary Materials

Appendix S1

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Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.

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