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CHOW et al. BMC Medical Education (2018) 18:13
DOI 10.1186/s12909-018-1119-0




RESEARCH ARTICLE Open Access

Resilience and well-being of university
nursing students in Hong Kong: a cross-
sectional
Nursing
study school + veel artikels = betrouwbaar
1*
Ka Ming CHOW , Wing Ki Fiona TANG1, Wing Han Carmen CHAN1, Wing Hung Janet SIT1, Kai Chow CHOI1
and Sally CHAN2


Abstract samenvatting
korte


Background: University nursing students experience higher levels of academic stress than those of other
disciplines. Academic stress leads to psychological distress and has detrimental effects on well-being. The ability to
overcome such adversity and learn to be stronger from the experience is regarded as resilience. Resilience is found
to have an impact on learning experience, academic performance, course completion and, in the longer term,
professional practice. Resilience and positive coping strategies can resist stress and improve personal well-being.
However, the relationship between resilience and well-being remains unexplored in nursing students, which are
significant attributes to their academic success and future career persistence.
Methods: The study was a cross-sectional descriptive correlational design. Inclusion criteria for recruitment was
students studying pre-registration nursing programmes at both undergraduate and postgraduate levels. The 10-
item Connor-Davidson Resilience Scale (CD-RISC-10) and World Health Organisation-5 Well-Being Index (WHO-5)
were used to measure resilience and psychological well-being respectively.
Results: A convenience sample of 678 university nursing students was recruited from a university. The mean score
of CD-RISC-10 was 24.0. When comparing the resilience levels of undergraduate and postgraduate students, the
total scores were found to be 23.8 and 24.9 respectively. There was a statistically significant difference between the
groups (p = .020). With regard to perceived well-being, the mean score of WHO-5 was 15.5. There was no significant
difference between undergraduates and postgraduates (p = .131). Bivariate analysis showed that self-reported
resilience had a medium, positive correlation with perceived well-being (r = .378, p = .000), and senior students had
significantly higher level of perceived well-being than junior students (16.0 vs 15.1, p = .003). Multivariable regression
analysis on perceived well-being indicated that self-reported resilience emerged as a significant predictor of
perceived well-being (regression coefficient B = 0.259; p < .001).
Conclusions: The results demonstrate that nursing students with a high level of resilience have better perceived
well-being, and the level of resilience of postgraduates was significantly higher than that of undergraduates.
Therefore, educational strategies should be developed in the nursing curriculum and a supportive learning
environment should be created to foster resilience in the students.
Keywords: Resilience, Well-being, Nursing students, Nursing education
↳ artikel
opzoeken terugvinden




* Correspondence:
1
The Nethersole School of Nursing, The Chinese University of Hong Kong,
Hong Kong SAR, China
Full list of author information is available at the end of the article

© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

, CHOW et al. BMC Medical Education (2018) 18:13 Page 2 of 8
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Background that enables an individual to remain healthy or to re-
Nursing is becoming ever more demanding, and is cover quickly after adversity [15].
regarded as a stressful occupation because of manpower Well-being is a broad subjective concept with three
shortages and various other challenges associated with main components: life satisfaction, pleasant affect and
nursing practice [1]. While studying nursing at univer- unpleasant affect [16, 17]. It has been suggested that be-
sity, students experience higher levels of academic stress ing resilient is a necessary building block of well-being.
than those of other disciplines as they have to adapt to Resilience and positive coping strategies can resist stress
various clinical settings for practice, and are exposed to and improve personal well-being [18]. Resilient students
diverse patient conditions as well as dying and death are therefore taken to have better perceived well-being.
during placement [2–4]. Academic stress leads to As a result, the development of resilience and active
psychological distress and has detrimental effects on coping strategies has been highlighted as critical for suc-
well-being. In addition, nursing students have to apply cess and continuance in the nursing profession. Nursing
theoretical knowledge to practice in order to bridge the faculties therefore have a responsibility to help build stu-
theory-practice gap [5]. They have to cope with the emo- dent well-being through the development of resilience
tional and academic demands of patient care [3]. All and effective coping skills [3, 19].
these stressors may increase stress and psychological Despite the benefits of resilience to health, its relation-
morbidity, such as excessive anxiety, worry and depres- ship with the well-being of nursing students remains un-
sion. The ability to overcome such adversity and learn to explored. To our knowledge, no study on resilience and
be stronger from the experience is regarded as resilience, well-being among university nursing students has been
a concept that emerged in the 1970s [5, 6]. Resilience is conducted in Hong Kong. At the same time, nursing
imperative for nursing students to survive adversity and education in Hong Kong is more intense than in other
prepare them for undertaking professional role after countries, for example Australia and Singapore, in the
graduation [4, 7]. In a conceptual model of resilience in clinical hours required [20]. The clinical environment is
nursing students, resilience is conceptualised as a also stressful for health professionals and nursing stu-
process of cumulative success in overcoming adversity, dents in the local context, with a disproportionate nurse
which enhances personal well-being [4]. It is known that to patient ratio of 1:10 or 12 in the daytime and 1:16 up
chronic exposure to stressors contributes to poor well- to 20 on night duty [21]. Encountering such stressful
being, resulting in lower job satisfaction [8], which may working environments, health professionals tend to sup-
well affect nursing students’ aspirations to take up a clin- press their negative reactions, as Chinese culture empha-
ical post after graduation [9]. sises endurance and the suppression of emotions [22].
Wrm As a result, they may experience and perceive resilience
? Previous study has found that resilience has an impact
onderzoeken on learning experience, academic performance, course differently.
completion and, in the longer term, professional practice The present study aims to examine the relationship doel studie
[3]. Studies have also investigated whether resilience af- between resilience and well-being among university altijd laatste
fects the academic performance of undergraduates in nursing students in Hong Kong. We hypothesise that alinea
different disciplines. In the case of hospitality and tour- nursing students with higher levels of resilience will have background
ism students, resilience is a significant predictor of aca- higher levels of well-being. ↳
onafhankelijke
variabele
demic performance [10]. In the aspect of nursing, ↳
-



verband
positief ↳ afhankelijke variabele
resilience level of the students varies across countries. Methods
Nursing students in Nigeria showed a moderate level of Study design, participants and setting → antwoord formuleren
onderzoekt
resilience [11], while their counterparts in Australia and The study was a cross-sectional descriptive correlational vraag
Spain reported a high level of resilience [12, 13]. Resili- design. Students were recruited from pre-registration
ent nursing students showed better psychological health
and lower academic burnout [13]. There is a growing re-
search interest in exploring why some nursing students
nursing programmes at both undergraduate and post-
graduate levels at the Chinese University of Hong Kong.
Students in these programmes undertake the same cur-
] wie ?



can cope well but others cannot when they all face simi- riculum, which is required by the Nursing Council of
lar problems and challenges during their programme. Hong Kong for registration as registered nurses [20].
Resilient individual nurses would have a tendency to However, nursing undergraduates follow a five-year full-
look for positive meanings in negative circumstances, so time programme, to which they are admitted directly
that they can cope with distress effectively and adopt the from secondary schools to pursue their first degree.
knowledge they acquire from the setback as a form of Undergraduate students usually enter the university at
reference to help them cope with similar situations in age 18, while postgraduates follow a three-year full-time
the future [14]. It is important to note that resilience is programme which is designed for those with a first de-
not merely an indicator of well-being, but is a process gree in other disciplines but who want to pursue a

, CHOW et al. BMC Medical Education (2018) 18:13 Page 3 of 8




second career. Compared with undergraduate nursing widely used in research studies and tested in various
students, postgraduate ones are usually older and their populations with good psychometric properties [26].
study schedule is more packed. For both programmes,
clinical practice is integrated in the curriculum with the-
oretical inputs. Undergraduate students start their clin- Statistical data analyses
ical placement in year two of study and the duration Data analyses were performed by using IBM SPSS
gradually increases from four weeks to 18 weeks in the 24.0 (IBM Crop., Armonk, NY). Appropriate descrip-
final year. Students with adequate clinical exposure are tive statistics, including frequency (percentage) and
regarded as senior students. Therefore, year one to three mean (standard deviation, SD) were used to present
students in undergraduate programme are regarded as the background characteristics, including gender,
junior students, while those studying in year four and study programme and year of study, and self-report
five are identified as senior students. Clinical placement resilience and perceived well-being measures of the
of postgraduate students increases from eight weeks in sample. To compare any difference in resilience and
year one to 19 weeks in year three of study. Postgraduate well-being between students in the undergraduate
year one nursing students are regarded as junior stu- and postgraduate pre-registration programmes, as
dents, while those studying in the second and final year well as between junior and senior students, inde-
are senior ones. All eligible students were invited to par- pendent t-tests were conducted to examine the re-
ticipate, and data collection was conducted between sults. Bivariate analyses by means of Pearson
November 2016 and February 2017. wanneer correlation and independent t-test, as appropriate,
were performed to examine the associations between
Data collection procedure perceived well-being and self-report resilience as well
wie ? All eligible students were approached by trained re- as the background characteristics of university nurs-
search assistants at the end of their lectures. Information ing students, including sex, programme of study
sheets about the study and consent forms were distrib- (undergraduate or postgraduate) and whether in se-
uted. Students chose whether to take part or not on a nior year or not. Those factors showing significance
voluntary basis and were quite free to decline if unwill- (p < .05) in bivariate analyses were selected for multi-
ing to join for some reason. After written consent was variable regression analysis to delineate factors sig-
obtained, participants were asked to complete the ques- nificantly associated with perceived well-being. All
tionnaires, which took around 15–20 min. statistical tests were two-sided and the level of sig-
nificance was set at 0.05.
Outcome measures
Connor-Davidson resilience scale (CD-RISC) •
mogen




(
The 10-item CD-RISC (CD-RISC-10) was used to meas- Ethical considerations

IT
]
ure resilience in university nursing students. It captures Ethics approval was obtained from the Survey and Be-
ethische
core features of resilience over the preceding month. havioural Research Ethics Committee (SBREC) of the commissie



ÉTÉ
Each item is rated on a five-point Likert scale ranging Chinese University of Hong Kong. Participation was vol-
from 0 ‘never’ to 4 ‘almost always’, with higher scores in- untary and anonymous, and recruits were given an ex- pas na
dicating greater resilience [23]. The scale has been tested planation of the aims and nature of the study and their informed
consent
in undergraduate samples and student nurses with satis- right to withdraw at any times clarified. In view of the
qvootionnaire
factory reliability and validity [11, 23]. packed time table and data was collected after lectures,
moet niveau is ordinaal → sluit op elkaar aan de →
goed → . . ..



HKD20 cash was given to each participant on return of
continue
World Health Organisation-5 well-being index (WHO-5) the questionnaire to encourage their participation and
The WHO-5 is an instrument developed for assessing compensate for their time. The incentive for participa-
psychological well-being over a two-week period. The tion was approved by the SBREC. An information sheet
hoe
afgelopen
five items in the scale
2 weken
cover positivegevoeld
mood (feeling in with details of the study was given to all participants,
good spirits, feeling relaxed), vitality (being active and who were assured that personal information collected
waking up fresh and rested), and being interested in would be kept strictly confidential and used solely for
things. Each item is rated on a six-point Likert scale this study: electronic data would be stored in a
from 0 ‘at no time’ to 5 ‘all of the time’, with higher password-protected researcher’s computer, and only the
scores representing better self-perceived well-being. investigating team and their research staff would have
The total scores range from 0 to 25, with a score access to the data during and after the study. All hard
below 13 indicating poor well-being and the need to copies of questionnaires would be kept in a locked cabi-
test for depression [24, 25]. The WHO-5 has been net, with the researchers responsible for their
translated into more than 30 languages. It has been safekeeping.

, CHOW et al. BMC Medical Education (2018) 18:13 Page 4 of 8




Results Table 2 Self-report resilience (CD-RISC-10 total score) and
Participant characteristics perceived well-being (WHO-5 total score) of the university nurs-
A convenience sample of 678 university nursing students ing students standaarddeviatie
was recruited, 508 females and 170 males, of whom 474 /
CD-RISC-10 total score WHO-5 total score
were in the undergraduate (69.9%) and 204 in the post- Background characteristics Mean (SD) range Mean (SD) range
graduate programme (30.1%). Of these undergraduates, Sex Gemiddelde min Max
298 were junior students in years one to three (62.9%) Female gegooid 24.0 (5.5) 7–40 15.4 (3.8) 2–25


ook
'
and 176 in senior years four or five (37.1%). Of the post-
graduates, 75 were in year one (36.2%) and 129 in years
Male
p-value
÷
voor pet 24.2 (6.3)
0.717
7–40 15.7 (4.2)
0.547
0–25

two or three (63.8%). All participant characteristics are „



summarised in Table 1. Programme
↳ niet
isigniji want
verschil resultaten
geen en
vrouwen
mannen
Undergraduate minder 23.8 (5.9) 7–40 15.3 (3.9) 2–25
↳ weerbaar
Self-reported resilience Postgraduate dan 24.9 (5.3) 10–40 15.8 (4.0) 0–25
A summary of university nursing student outcome p-value
postgraduaten
0.020 0.131
verschil
measures is shown in Table 2. The total scores in
Senior year student
=
significant
CD-RISC-10 ranged from 7.0 to 40.0, with a mean of
No 24.1 (6.0) 7–40 15.1 (4.0) 0–25
24.0 (SD = 5.7). When comparing the resilience levels
of undergraduate and postgraduate students, the total Yes 24.1 (5.4) 8–40 16.0 (3.8) 4–25
scores were found to be 23.8 and 24.9 respectively. p-value 0.912 0.003
There was a statistically significant difference between p-values are computed by independent t-test
the groups (p = .020). However, no significant differ-
ence in resilience level was found between junior and university nursing students in Hong Kong are shown in
senior students (p = .912). Table 3. Only the year of study and self-reported resili-
positieve

Taiji
positieve ence showed significant bivariate associations with
Perceived well-being perceived well-being. Self-reported resilience had a
The total scores in WHO-5 ranged from 0.0 to 25.0, medium, positive correlation with perceived well-being
with a mean of 15.5 (SD = 3.9). Perceived well-being (r = .378, p < .001) and senior students had significantly
among undergraduates and postgraduates was not sig- higher level of perceived well-being than junior students
nificantly different (p = .131), but there was a statistically (16.0 vs 15.1, p = .003). Furthermore, the multivariable
significant difference between junior and senior students regression analysis revealed that both self-reported resili-
(p = .003). Seniors, in their 4th or 5th years as under- ence (regression coefficient B = 0.259; p < .001) and the
graduates and in their 2nd or 3rd years as postgraduates, year of study (senior vs junior, B = 0.875; p = .002) were
reported higher scores in WHO-5, reflecting a better significantly and independently associated with perceived
perceived level of well-being. well-being and collectively explained 15.5% of the
variance.
Predictors of perceived well-being
p > 0,050 dus significant
The results of the bivariate analyses and multivariable Discussion
regression analysis of perceived well-being among The results support the hypothesis that nursing students
with a high level of resilience have better perceived well-
beschrijving populatie being. The results also show that the level of resilience
Table 1 Background characteristics of the university nursing
students (N = 678)
of postgraduates was significantly higher than that of un-

|
dergraduates. The perceived well-being of senior stu-
Background characteristics n (%)
dents was significantly better than that of junior
Sex nominaal
students. in weerbaarheid
Female 508 (74.9%) je groeit resultaten kunnen niet
toegepast worden voor
→


U Nobel
post
Male 170 (25.1%) Resilience .




Programme The study found that the resilience level of Hong Kong
Undergraduate 474 (69.9%) university nursing students was generally lower than that
Postgraduate 204 (30.1%)
of their counterparts in other countries [11, 12], a result
that may be attributed to the stressful study and clinical
Senior year student
environment in Hong Kong. A survey of stress and
No 373 (55.0%) burnout among Hong Kong nursing students reported
Yes 305 (45.0%) an increased level of stress, burnout, and psychological
Data of the characteristics are presented as frequency (percentage) morbidity across semesters [27]. The perceived stress

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