Insights from Nursing Students about Factors Affecting and Strategies Supporting their Mental Health

descriptive qualitative design to achieve the objective. Purposive sampling was used to recruit nursing students from a university representing undergraduate and graduate nursing programs. Data were collected using four focus group discussions. All discussions were audio recorded and transcribed. Coding was generated by the research team to drive key themes and sub themes. Results: The 28 participants identified teachers’ attitude, university environment and family responsibilities as key factors influencing their mental health. They also recommended several strategies for nursing institutions to promote students’ mental health during training. Conclusion: Nursing students are the future of healthcare systems. It is important that their mental health is given priority during nursing training. Promoting mental health would help nursing institutions create environments that foster health and well-being of students. These findings may also be useful for promoting mental health of students in other healthcare disciplines. ABSTRACT


INTRODUCTION
Mental health is an essential part of overall health that is often overlooked due to priorities given to other aspects of health.This is also true for healthcare professionals, who often neglect their own mental health concerns.Mental health of nurses is of utmost importance due to its direct association with patient care [1].Nursing students are the future of the healthcare workforce and a vital part of healthcare systems, especially in resource-limited contexts where there are not enough nurses to handle the surge of healthcare burden [2].Research suggests that nursing students are vulnerable to stress and mental health issues such as anxiety and depression due to various individual, cultural, social, and environmental reasons [3][4].In countries like Pakistan, stigma towards mental health issues can contribute to mental health problems.This risk can be compounded by demanding, competitive and stressful environments at nursing institutions that often lead to poor mental health of future nurses.Therefore, it is essential for nursing institutions to hear students' voices and implement measures for their mental health promotion.
In recent years, the burden of mental health issues has been increasing among post-secondary students [5][6].This situation is exacerbated when these individuals feel reluctant to seek help for addressing their mental health concerns [7].Research shows that nursing students are at a considerable risk of high stress because of a variety of factors related to academic and clinical environments [8][9][10][11].A systematic review of 23 studies reported workload and fear of clinical situations as some of the most common stress causing factors among nursing students [12].
A study conducted at 11 nursing schools in Karachi, Pakistan revealed high stress scores among the final year students of the undergraduate nursing program [13].In addition to these academic stressors, financial issues and living away from home are also known sources of stress for nursing students [14].
Stress and maladaptive ways of dealing with stressors are considered risk factors for developing serious mental health issues among nursing students [15].Evidence from Pakistan also supports the association of stress related to academic activities with nursing students' academic performance [9,13,16].Studies report that 34% to 67% of nursing students suffer mild to severe depressive and anxiety symptoms [4,17] leading to poor academic performance, low quality of life, suicidal ideations [18] and feelings of rejection and inadequacy [19].Adding to the burden of mental health issues, there is also a high stigma related to mental illness among this group [20][21][22].Nursing students perceive difficulty managing mental health issues and feel uncomfortable seeking help [23].
Academic institutions play a key role in promoting students' mental health.So far, counseling is one of the common interventions available at universities for students who experience psychological challenges [24][25][26].A systematic review of mental health interventions showed effectiveness of psychotherapy on nursing students' depression, anxiety, and stress; however, these interventions did not improve self-efficacy [10].It is important for nurse educators and nursing institutions to recognize that the notion of mental health promotion is more than the absence of mental illness.
The existing evidence suggests many factors impacting nursing students' mental health; however, in our search, there is very limited literature available that reports institutional level assessment of nursing students' perspectives.The aim of this study is to explore nursing students' perceptions about factors affecting their mental health and gain insight on measures that student nurses find helpful for supporting their mental health during nursing training.

Study Design
An exploratory descriptive qualitative design was used to explore perceptions and views of nursing students.

Participants and Procedure
The team approached potential participants from all academic programs of a private nursing institution in Pakistan.The reasons for selecting this study setting were its large and diverse pool of students representing various cultural backgrounds and the availability of student services that may not be found in other local institutions.
The team sent invitation emails to all students across nursing programs including a four-year Bachelor of Science in nursing program [(BSN) pre-licensure students], a two-year bachelor of science in nursing program for registered nurses [(Post-RN BSN) post-licensure students] and Master of science in nursing program [(MSN) post-licensure students].Interested students who contacted us via email were asked to complete a contact form.With targeted sampling, we recruited and allocated eligible participants to four predefined groups (Figure 1).Spots were filled on first-come, first-served basis.We assigned eight to ten students in each group representing all nursing programs and academic years, in addition to living status and gender.Participants were recruited after signing a voluntary consent form.Students who experienced mental health issues during the last six months were excluded.

Data Collection
We conducted four focus group discussions (FGDs) with a total of 28 students participating from across the undergraduate and graduate nursing programs.Each FGD was conducted for 60-120 minutes using a semi-structured interview guide.The interview guide focused on factors influencing students' mental well-being, practices students apply to maintain mental health, and recommendations for nursing institutions to promote students' mental health.FGDs were conducted primarily in English, but the participants were allowed to use Urdu (Pakistan's national language) to comfortably express their views and experiences.All FGDs were audio taped with the participants' consent.

Ethical Considerations
The ethics approval was obtained from the institution's review committee (2018-0312-370).Participants' privacy and confidentiality were ensured throughout the study.They were also reminded to maintain each others' confidentiality.The participation in this study was completely voluntary and participants were well informed about their right to withdraw from the study at any time without any disadvantage.All data were kept in a password protected computer, only accessible to the research team.

Data Analysis
Data were manually transcribed and translated into English.Each team member independently reviewed the transcripts and generated codes based on analytic interests [27][28], At the later stage, the entire team discussed the generated themes and clustered common sub-themes to form key themes.Continuous discussion and reflection among team members ensured the credibility of the findings [29][30].

RESULTS
A total of 28 students (age 18-33 years) participated in the study.Table 1 presents the demographic characteristics of the participants.Findings are presented under two research objectives: 1) factors influencing students' mental health and 2) Students' recommendations for mental health promotion.

Factors Affecting Students' Mental Health
Two main themes emerged: university/academic factors and personal factors (Table 2).The first theme of university factors includes two sub-themes: faculty members' attitudes, and academic/university environment.

University Factors 1.1 Faculty members' attitudes Support and Flexibility
Almost all participants appreciated their teachers' supportive, flexible, and student-centered approach and acknowledged their readiness to listen.Participants also valued the availability of faculty members, particularly those in the advisory role.One of the participants shared: "In my 2nd year, I was very stressed and worried due to my family issues.I had a wonderful experience with my (faculty) advisor.She allowed me to speak and listened to my concerns attentively."

Trust and Confidentiality
Participants also acknowledged that confidentiality was maintained by faculty members, which improved their trust and confidence, as one participant mentioned: "I felt that there is someone who is there to support me.She never shared my issues with anyone, which increased my trust in her."On the contrary, a few participants also shared some non-supportive experiences.They found some faculty members 'strict' and 'inconsiderate' and seem to be focusing on students' weaknesses rather than their strengths.As a result, some students develop feelings of 'fear' and 'demotivation' that adversely impacted their personal and professional lives.

Communication and Clear Expectations
Some students also elaborated that 'lack of clear instructions, timely feedback, and guidance on assignment expectations' from teachers increased their level of stress and pressure of failing assignments.They also mentioned how inconsistent expectations shared by faculty members teaching in the same course create stress and anxiety in students.Participants further commented on a method of communication utilized by a few faculty members that contributes to high stress.One participant mentioned that receiving late night text messages for tasks to be completed on the very next day makes her anxious.

Academic and Environmental Factors Heavy Academic Demands
Many students described demanding semesters and challenging course assignments and schedules as key stressors.One participant mentioned: "To me, the most stressful thing is completing several assignments on a clinical day... Going back home after a hectic clinical day and then studying late-night is stressful."Students also felt that collegiality among their peers is often hindered because of a sense of competition for achieving higher scores.Participants further shared that group assignments make all of them eligible for receiving equal marks, regardless of individuals' contributions.This causes frustration and disappointment for those who work harder than others in a group task.They believe such criteria often end up in 'conflicts' and 'arguments' among peers.One participant said: "Students do pass comments like 'this person can't do anything or contribute productively.'Such comments negatively affect our self-esteem."

University Events and Initiatives
Almost all participants appreciated existing facilities, students led activities, and events at the university.They perceived them as key motivational factors.These activities include recreation activities, access to sports facilities, availability of counselors, and the reputation and image of the institution.They also recognized the support and guidance received from senior nursing students as one of the positive factors in dealing with anxieties and worries.

Personal Factors Family and Financial Responsibilities
Participants from the post-licensure programs (Post-RN BSN and MSN) highlighted their struggles to maintain balance between their academic and family/ financial responsibilities.

One participant responded: "I often get stressed and disturbed because of the back-to-back assignments' timelines and pressure from group arguments and conflicts. Poor time management influences my relationships with my children and other family members." Cultural Barriers
Language and cultural barriers were also indicated as sources of mental distress by some of the participants.One participant added: "Some of us have come from small cities and different cultures and are not very fluent in English.Sometimes, we cannot actively participate in class discussions and group activities, which makes us feel low."Participants who were living in the university hostel shared anxieties about being away from their families for the first time.They expressed how homesickness impacts their mental health.One participant noted: "Sometimes I feel homesick and miss my family…but when I talk to my parents/family/friends on the phone, it gives me strength… I feel energetic and with that energy, I am able to concentrate on my studies."

Strategies Supporting Students' Mental Health
Another important objective of this study was to explore nursing students' perspectives about institutional activities that facilitate mental health and to identify their recommendations for better mental health.
Almost all participants appreciated student-led activities and initiatives happening at the nursing school and largely at the university, such as students and alumni social events, fundraising events, and sports activities, etc.Another strategy that all participants unanimously recommended to ease their academic burden was to have explicit course guidelines and realistic course expectations, especially in online and asynchronous learning environments.Additionally, students suggested to continue regular meetings with program coordinators so they can timely communicate their academic concerns.One participant stated: "Having regular meetings with our program coordinator is very useful.This provides everyone an opportunity to share their issues related to courses and schedules." In order to support students' mental health, participants proposed placing a rigorous support mechanism at the school.One of the suggestions was to assign neutral (non-teaching) faculty members in advisory roles so students could reach out to them comfortably.They recognized the importance of having student counselors at the university.However, some participants articulated their preference to have an exclusively dedicated student counselor for nursing students.
Participants also acknowledged motivational sessions that were organized in the past at the school.They suggested that continuing such sessions would help many students feel motivated and inspired.One participant acknowledged: "I remember I had a tiring clinical day and I happened to attend a motivational session on the same day arranged by the nursing school.The session made me feel relaxed and motivated to come back the next day with full energy."Many participants valued formal and informal student forums at the university and identified those platforms as effective ways to enhance peer-to-peer and student-faculty relationships.They suggested continuing programs like recreational events, alumni networking, mentorship sessions and student exchange programs.Some participants believed that music and physical education are beneficial for students' mental health.They recommended introducing music and physical education into the nursing curriculum.

DISCUSSION
A growing burden of healthcare needs and stigma around mental health problems among healthcare providers and especially nurses are common and often lead them to disregard their own feelings and needs.Nursing students are the future of healthcare workforce; therefore, understanding needs and preferences pertinent to their own mental well-being is of utmost importance [10].Specific to low-and middle-income countries like Pakistan, many students coming to nursing institutions belong to socio-economically disadvantaged settings and may experience high stigma and risk towards mental health issues.Promoting students' mental health should be one of the prime responsibilities of nursing institutions.
Our findings present perceptions of nursing students' personal factors along with academic and university factors that influence their mental health.Our findings resonate with other studies that highlight the association between academic/ clinical demands and nursing students' stress [16,23,[31][32].In the present study, clinical demands were not explicitly highlighted; however, the majority of participants mentioned faculty attitudes as key influences for their mental health.Building on previous studies, our findings added faculty student-centered approach, their availability, and ability to maintain students' confidentiality as protective factors for mental health.
A number of personal factors associated with mental health of nursing students have been highlighted in previous studies [33][34][35].However, the current findings add family and financial responsibilities of students as key sources of stress, which are not commonly reported in the literature.It was noted that active engagement of nursing students in university initiatives and events makes them feel valued and respected.Several studies on students' engagement support this notion and conclude that having their voices in constructive activities makes them feel empowered and improve their self-efficacy [36][37].This strategy may be common in the Tier 1 countries' context; but this has not yet been fully implemented in nursing education's systems of low and middle income (Tier 3) countries.
It is encouraging to know that nursing students are not only aware of factors affecting their mental health but are also able to suggest measures to enhance their mental well-being.Several strategies were proposed: having clear course expectations, continuing student-led initiatives, integrating music and physical education in nursing curriculum, and establishing a robust mechanism for mental health support.These findings align with strategies that are recommended for mental health promotion in other sources [38][39].
Ensuring the wellness of the healthcare force is essential for quality patient care.The environments of nursing institutions have a significant impact on students' mental health and overall wellness.This study is among a very few studies that have been conducted to explore mental health needs of nursing students in Pakistan and addresses a key gap by engaging future nurses in improving their own mental well-being during training.Our findings are significant for nursing education systems, practice, and research.In order to prepare healthy and resilient nurses for the challenging future healthcare demands, nursing institutions must prioritize students' mental health.Educators should ensure that academic requirements are not perceived as a burden by students.Having well-established monitoring and support mechanisms such as neutral faculty advisors and student counselors at institutions is crucial; students who need mental health support should have comfortable access to services.In addition, active student engagement in university-based initiatives is essential to empower them.Further research can reach students in public nursing institutions and develop culturally relevant interventions for mental health promotion so student nurses can be trained in a positive learning environment.

LIMITATIONS
Though the study findings have the potential to bring positive influences in nursing institutions, it is important to acknowledge a few limitations of this study.First, the present findings only reflect nursing students' insights from a single large private nursing institution.However, as mentioned above, the study setting captures a wide variety of individuals who represent students across the country.We also believe that exploring the views of nursing students from public institutions would have added additional insights to this issue.The second limitation is that the findings do not outline differences in perceptions across academic years.However, the FGDs of mixed participants provided rich data with different views and opinions.Although the study participants included male participants, the findings may not extensively echo the voices of all genders as most of the enrolled students were female in the nursing programs.

CONCLUSION
Recognizing factors and interventions for mental health is essential for nursing students' overall well-being and quality patient care.Nursing students identify academic influences, teachers' attitudes, university environment and family and financial responsibilities as key factors affecting their mental health.Participants acknowledged that nursing institutions play a vital role in providing a safe and healthy environment for students' mental health.Recommendations for nursing institutions have potential to guide healthcare institutions to inform student-oriented measures that support mental health in curriculum, educators' training, and institutional facilities and services.