Review of Related Literature

The review of literatures focuses on the impact of the nursing student's mental health on
online learning. Facts were gathered from books and Internet as references in order to get the
needed information for the study.

The Nursing Education

Nursing education refers to clinical education and training in nursing sciences. This
involves the roles and responsibilities of patient physical treatment, and a variety of various
disciplines that both facilitate and help sustain the patient's return to health (Ferrell, 2010). Over
the years, nursing and nursing education have undergone dramatic change. This history shows a
relentless battle for autonomy and professionalism (Ferrell, 2010). Many pressures have been
exerted on nursing practice, including women's struggle for professional recognition and status,
religion, conflict, technology, and social attitudes. Still today these factors affect nursing. During
the past decades, the profession worked to improve its image (Ferrell, 2010).

Currently, nursing education faces problems related to the implementation of nursing

expertise in clinical settings and the students' failure to follow nursing procedures in clinical
setting. The best way to recognize these issues is by the nursing students themselves (Ziaee et
al., 2018).

The evaluation of nursing wellbeing is a critical component of nursing practice

(Bradshaw and Merriman 2010). It offers the basis for high quality nursing care and
intervention. Practicing and improving the Health Assessment knowledge and skills, a nursing
student can gain trust in knowing and reacting to the needs of the client (Jarvis, 2012). According
to Lees & Hughes (2010), the performance of a hospital unit in patient safety depends on the
level of trust and competence of the entire nursing team in a patient's assessment. Without proper
knowledge in health assessment, nursing students cannot gain trust that their skills can be
implemented in a real situation, especially in their clinical duty, and their learning process can
also be impaired. Due to the propensity to go back and try and analyze vague details their
development might be slowing down. According to Etheridge (2010), the students' lack of trust
has a significant negative effect in learning new knowledge and skills and coping with difficult
circumstances, sometimes visualizing failure before it happens.
 Universities are responsible for the disseminating and transferring of knowledge, as well
as for providing specialized human resources. Also, they continually required to analyze and
update their services, and to identify problems and challenges to allow them to optimize
educational quality (Yazdankha-Fard, Pouladi, & Kamali, 2018). Ongoing educational
evaluation of various scientific disciplines is important, particularly for the medical sciences.
Educational evaluation helps define obstacles and challenges, solve problems, and recognize
strengths and weaknesses. The results of such evaluations allow positive aspects to be
maintained and efficient solutions to possible problems to be implemented (Ziaee et al., 2018).

Many research showed that the nursing education system needs to keep pace with
continuing changes in nursing practice. The literature suggests that apprenticeship outcomes are
unsatisfactory, which demonstrates the need for greater attention to this aspect (Adami & Kiger,
2018). While new nursing graduates have a good theoretical background and experience, but
they do not have the expertise and flexibility required to solve clinical-settings problems. Some
studies have also suggested that there is a large gap between classical nursing and obstetric
education and success in clinical care, indicating that the present clinical education system does
not provide the requisite clinical skills to students (Hadizadeh, Firoozi, & Shamaeyan-Razavi,
2015). Test findings on various clinical aspects show that the standard of the education is found
unsatisfactory by the students. Documented deficits included inability of instructors to
implement theoretical concepts in realistic circumstances, inconsistency of apprenticeships in
clinical wards, obligation of students to undertake other unrelated tasks, lack of proper
assessment by instructors and lack of continuity between theoretical learning and the clinical
nursing services (Adami & Kiger, 2018).

Online learning is attracting growing publicity as a convenient way to get technical

training. In many countries the number and popularity of online continuing education nursing
programs is growing rapidly. Understanding these will help to develop the programs to optimize
performance. Knowing the expectations and interests of online learning also helps to build and
direct online learning programs. The aims of this study are to display the perceptions of online
continuing education by nurses and to assess the expectations of different classes; area
communities, working firms, frequency of computer use and age.
 Few studies have established the views of the students on their educational problems and
limitations; hence the current research was conducted with the goal of explaining the perceptions
and views of the nursing students on the quality of online education through the qualitative
approach

History of Online Education

From the first offering of a fully online course in 1981 (Harasim, 2010) it was clear
that this new model of education had much potential to impact the design and delivery of
education at all levels. Initial attempts to offer education online tended to replicate existing
distance education practice. As such, online education was text heavy and mirrored the
previous postal packages of handbooks and required readings (Garrison 2011); Harasim
2010).. However, these early offerings did provide rapid and valuable lessons into what
constitutes effective learning in this new mode of education delivery. For instance, long
textual lectures were clearly not suitable for the online environment and students did not
readily engage in discussion activity. (Harasim, 2010).

Years later, the development of radio as a communication medium during World War I
opened the door for using that technology for distance education in colleges and schools such as
School of the Air established in Wisconsin in the 1920s (Mclsaac & Gunawardena, 2013).
With the popularity of television in the 1950s, visual instruction became possible for the first
time between teachers and students who were not in the same locations. As computer and
emailing technology blossomed in the 1970s and 1980s, distance education began to expand
dramatically. The first fully online course was offered in 1981, and the first online program was
established by the Western Behavior Sciences Institute in the following year (Harasim, 2010).
In the mid-1980s, the first online undergraduate and graduate courses were initiated by several
universities and schools. In the late 1980s, due to a shortage of teachers on math, science, foreign
languages, etc., some K-12 schools turned to commercial courses offered through the then-new
satellite technology, which greatly spurred still faster growth of distance education (Mclsaac
&Gunawardena, 2013). The advent of the World-Wide Web (WWW) in 1991 was a powerful
catalyst for moving distance education forward, and was a milestone in the rapid expansion and
growth of online teaching and learning. Maloney-Krichmar and Abras (2012) stated that
WWW “facilitated the widespread use of web sites and the development of online community
groups supported by web pages and various forms of communications software”. Since then,
colleges and universities both in the United States and around the world have offered not only
just online courses but entire degree programs online as well (Wallace, 2014).

Nine years later, after introducing the three presences – social presence, cognitive
presence, teaching presence – as primary elements for successful online education, Garrison,
Anderson, and Archer (2010) further examined the nature and quality of cognitive presence by
analyzing asynchronous text-based computer conference transcripts. Employing the theory of
critical thinking, they argued that its outcome can be best judged by practical inquiry that
included a triggering event, exploration, integration, and resolution.

In online education, learning is asynchronous or synchronous or a combination of both.

Asynchronous learning is teaching and learning that do not happen at the same time (Moore &
Kearsley, 2011), while synchronous learning refers to teaching and learning that happen at the
same time, both of which are conducted through technologies such as Internet. The invention of
@ symbol in 1972 for use in email (Maloney-Krichmar & Abras, 2010), and the advent of the
World Wide Web (WWW) in 1991 for the Internet connectivity (Harasim, 2011) have been the
latest adapted by online education. The universal use of web sites has provided opportunities for
the development of online communities and groups. Emailing, conferencing, chatting, working
together via Google drive, Google doc, Google hangout, dropbox, facebook, Twitter, etc. have
been widely used in online classrooms. On the other hand, Ke (2010), in his study of online adult
learning, pointed out that cognitive presence in adult learners was about how they perceived their
learning satisfaction. His study showed that “most adult students reported deep learning as the
dominant learning approach”

Regarding the aspects of the conversion from face-to-face classrooms to online, McIsaac
and Gunawardena Online Education and Its Effective Practice 160 (2010) defined distance
education as “no more than a hodgepodge of ideas and practices taken from traditional classroom
settings and imposed on learners who just happen to be separated physically from an instructor”.
Moore and Kearsley (2012) defined that “distance education is teaching and planned learning in
which teaching normally occurs in a different place from learning, requiring communication
through technologies as well as special institutional organization”. Regarding the aspects of
being distant, Finch and Jacobs (2012) defined it as “all forms of teaching and learning where
the student and instructor are separated geographically and temporally”. It is noted that there is
the purported need for conceptualizing distance education in rapidly changing technology and
exponentially growing online education, but its various aspects make it difficult to agree on just
one definition and on what constitutes distance education in practice.

In the Philippines, Hedberg and Lim (2010), cited a UNESCO report written in 2003
that the Philippines is part of a group of countries with newly created policies regarding
information and communication technologies, or ICTs, and they are just starting to apply various
strategies to integrate online learning in schools. We have come a long way after that report in
2003, but we are still shall we say, toddler stage in having online learning in the country. It has
been said in Pena-Bandalaria’s paper as well (2010) that using ICTs such as the internet and
supporting hardware and software puts us in a fourth generation of distance education, loosely
categorizing it from the most prominent technology used for delivering educational content and
its support systems. This shows us that we are already starting to institutionalize online learning,
but there are still areas in great need of improvement, especially with the support systems in
bringing online learning to more students and people who would want to experience online
learning.

Right now, papers and studies that look into online learning is mostly on how the
foundation for it can support the system, and if Filipinos are prepared for it in the first place.
There is concern to improve infrastructure if online learning is to be available to a large number
of people. Currently, a lot of Filipinos still do not own their own phone lines, much less even a
computer in their own homes. Consider the statistics: there is only seven percent of more than 16
million Filipino households that own personal computers, and only three out of 50 public high
school students have access to the internet of 2005 (Sunday, Inquirer, 2011). With the majority
of the population still in poverty and even under the poverty line, they would be more concerned
with fulfilling the basic needs rather than something they view as a luxury item (Trinidad,
2013). There are also plans to include the technology of the cellular mobile technology;
specifically, the smart messaging services (SMS) to facilitate online learning as well
(Bandalaria, 2010). This is because of the phenomenal increase of ownership of cell phones and
their services (Trinidad, 2013). Although the current use of cellular mobile technology is mostly
for entertainment and business purposes at the most.

And of course, there is still the urgent need to improve the quality of education. The social
and economic divide is still a major hindrance in getting good education, and that education itself
seems to having its part in widening that divide as well (Mcinardus, 2012). Contributing to this
is the “brain drain” of good teachers who immigrate to other countries to create a better quality
of life for their own families, making the public education system suffer even more (Mcinardus,
2012). There is also the significant lack of resources and infrastructure, where books, classrooms
and other school supplies are still not available to every public-school student. Aside from the
physical lack, there is also the curriculum where it lacks the functional literacy need for the
students to use what they’ve learned in the outside world (Orata, 2015).

Mental Health of Students

Stress is a physiological response that impacts the cognitive, emotional, behavioral, and
social components. It also involves the adaptation of the organism, the coping resources, and the
environment. In young people, stress can be triggered by social interactions or school
requirements. This chapter is a narrative review analyzing scientific bibliography from the main
databases (NIH, Scielo, Redalyc) that explored the main stressors and their effects on nursing
students. These stressors include the care of patients, assignments and workloads, academic
evaluations, and negative or hostile social interactions. Data include the deleterious effects of
stress in nursing students as anxiety, depression, inhibiting learning, and burnout, which
negatively impact their academic development and health. Finally, some interventions to reduce
the impact of stress are discussed. Conclusion: Stress responses in nursing students vary in
duration and intensity during their academic training; final effects depend on the coping
mechanisms, individual resources, and hospital environment. The effects of stress on nursing
students impact on academic performance but could also trigger several psychiatric disorders as
depression or anxiety, as well as other associated problems such as sleep disorders, alcohol, and
psychoactive drug consumption, which in the short and long term may affect the patient care.
 Exploring the effects of stress in students is important in many aspects, but two are
outstanding. First, most of the students are young, and the effects of stressful events in young can
last until adulthood, increasing the risk of suffering mental health disorders among other risks on
health. Mental health in nursing students will be reviewed in Section 5. Second, stress can reduce
learning skills indispensable in academic environments; the reduction of learning skills is a
factor of great importance since it reduces the resources of students to achieve academic success.
It is known that stress is triggered by stimulus according to the age of the person. In this sense,
school environments can expose individuals to stressors as harassment by peers, schoolwork
pressure, and being treated careless by teachers; all these stressors can be severe enough to
produce psychosomatic pain, psychological complaints such as feeling unsafe and nervous,
irritability, sadness, and depression. The effects of stress in school can negatively impact social
dynamics between peers and teachers, and these in turn can produce more stress that in
consequence triggers mental health problems such as anxiety and depression.

Prevalence of academic stress is very high in health students, especially in nursing and
medicine students according to several reports. Thus, the importance of studying the stressors in
nursing students lies in the deleterious effects on cognitive performance and health, i.e., the
development of mental disorders such as depression, anxiety, eating disorders, sleep, and
substance use, but also experience of stress can result in students experiencing ineffective
communication and inefficient at work, decreasing the quality of health-care services.

This prospective cohort study aimed to evaluate the long-term effects of virtual
simulation on nursing education by measuring undergraduate nursing students’ mental health
literacy. Students’ beliefs about the helpfulness of specific interventions for managing depression
and schizophrenia were compared between the simulation cohort (n = 149) and the non-
simulation cohort (n = 150) from a school of nursing in the U.S. Students in the simulation cohort
showed significant increase in knowledge and acceptance of available treatment options for
managing depression and schizophrenia over a one-year period. The finding supports the use of
virtual simulation in undergraduate mental health nursing education with active faculty
engagement.

Virtual simulation involves the recreation of reality depicted on the computer screen.
Nursing students can emulate the roles of registered nurses and provide therapeutic care to a
virtual patient in the same way they would with a real-life patient based on information provided
during simulation (Padilha et al., 2019). The integration of virtual simulation into nursing
pedagogy fits with the new generation of nursing students’ learning needs (Verkuyl et al., 2017).
Reported advantages of nursing students using virtual simulation include providing a safe,
nonthreatening practice environment (Cobbett & Snelgrove-Clarke, 2016), offering flexible and
reproducible learning experience (Peddle et al., 2016), and catering to a large number of learners
simultaneously (Sok Ying et al., 2014). Most importantly, virtual simulation permits access to
clinical practice and learning at times when clinical sites become unavailable to students. With
the emergence of the coronavirus disease 2019 (COVID-19) in the U.S., many health care
facilities have canceled clinical rotations for nursing students to prevent spread of the disease and
reserve essential personal protective equipment for the frontline health care workers. As a result,
many nursing programs in the U.S. have moved clinical experience to web-based formats and
opted to use virtual simulation to fulfill the clinical hour requirements for their students in spring
2020.

Despite the above noted advantages of virtual simulation, there has been limited research
conducted to explore the outcomes of virtual simulation in nursing education (Foronda et al.,
2013). Among the studies that reported effects of virtual simulation, the results are largely
inconsistent. Gu et al. (2017) in China reported positive changes in student knowledge scores
after vSim for Nursing was used in a Fundamentals of Nursing course. In Portugal, Padilha et
al. (2019) reported that integration of a virtual simulator, Body Interact into a Corporal Body
Response 1 course improved nursing students’ knowledge retention over a 2-month period.
Furthermore, Borg Sapiano et al. (2018) in a study conducted in Malta reported that second-
and third-year nursing students improved their knowledge scores after participating in virtual
patient deterioration scenarios supported by a program called FIRST2ACTWebTM. On the
contrary, Cobbett and Snelgrove-Clarke (2016) in a Canadian study reported no change in
student knowledge level and self-confidence after taking part in obstetrical virtual simulations
using vSim for Nursing. In the same vein, a study by Wright and colleagues (2018) in the U.S.
found that the use of vSim for a Nursing in Adult Health Nursing course did not improve
students’ unit examination and post-simulation quiz scores. Also in the U.S., Ward and Killian
(2011) reported equivalent learning outcomes between the students who participated in virtual
community internships in the fictious city of “Killardton” and the students who took traditional
lectures. In summary, studies differ from country to country concerning the efficacy of virtual
simulation as an education tool. The discrepancy in findings calls for more research using
rigorous methods to measure the effectiveness of student knowledge acquisition following
incorporation of virtual simulation into nursing education (Wright et al., 2018).

Student preparation for psychiatric mental health nursing can be challenging because it is
not always practical or safe for nursing students to be involved in complex care situations in
psychiatric clinical settings (Guise et al., 2012). Virtual simulation is well suited to the online
teaching environment. Therefore, it appears logical to adopt virtual simulation as an alternative
to psychiatric clinical training for nursing students. Despite the potential pedagogical and
practical benefits of virtual simulation in mental health nursing, there have been limited studies
investigating the use of virtual simulation in psychiatric nursing specialty. A relatively recent
systematic review by Vandyk et al. (2018) on the use psychiatry-focused simulation in
undergraduate nursing education only identified two studies exploring the use of virtual
simulation led by Kidd et al. (2012) and Sweigart et al. (2014) research teams in the U.S. Second
Life® was the virtual platform used in both studies. In Kidd and colleagues’ (2012) study,
students rated virtual simulation as a moderately effective teaching strategy for mental health
nursing education. Similarly, nursing students in Sweigart et al.’s (2014) study perceived that
participation in psychiatric virtual simulation enhanced their interview skills with patients. While
these findings can be promising, it must be noted that perception or experience does not
necessarily equate to learning outcomes, which is much harder to measure and define. Future
research needs to go beyond measuring educational effectiveness based on student experience to
answering the more important question if learning outcomes specific to subject matter have been
achieved, particularly in a long-term context (Guise et al., 2012; Kidd et al., 2012).
 Virtual simulation as an emerging technology will continue to evolve. While there is
some evidence to support the use of virtual simulation in mental health nursing education, we
have only scratched the surface in terms of knowledge about this new pedagogy (Foronda et al.,
2018). What remains unclear is the learning outcomes and knowledge acquisition of students
who use virtual simulation in their mental health nursing curriculum. To our best knowledge,
there has been little published research investigating the effects of mental health virtual
simulation on undergraduate nursing students’ long-term learning outcomes. This study could
potentially contribute to the dearth of research in this area.

The physical and mental health of students in Europe and the Unites States were an
emergent subject of research (Kolbe, 1993; Nauta et al., 1996; Symons et al., 1997). Findings
suggest that students suffer from more health-related complaints than their non-studying peers
(Nauta et al., 1996). These results are in conflict with the common knowledge that young and
educated people would benefit from a significantly better health status compared to non-studying
peers (Boot et al., 2007). However, the evidence is growing for the relatively poor health status
of students compared to non-studying young adults of the same age (Boot et al., 2007; Stewart-
Brown et al., 2000; Vaez et al., 2004). Non-help-seeking behaviour might be the explanation for
the discrepancy between the documented treatment records and reported health problems of
students. According to research on health problems among Dutch students, a significant amount
of students does not seek professional help for their health-related problems (Boot et al., 2007).

Recent studies support these findings and additionally found that non-help-seeking
behaviour is reported especially by students suffering from mental health complaints (ASVA
Studentenunie, 2010; Rosenthal & Wilson, 2008; Verouden et al., 2010). Furthermore, Boot
(2007) and Nauta (1996) reported more surprising findings such as the association between
physical complaints and mental health problems and the impact of healthrelated problems on
study progress. Many recent studies show similar results suggesting that mental health problems
among students relate to study progress, since students feel limited in their daily activities and
experience feelings of stress that cause their study results to decline (Boot et al., 2007; Pritchard
& Wilson, 2003; Stewart-Brown et al., 2000). A key problem is that the negative effect of those
unsolved problems on study progress might result in a vicious circle, in which mental health
complaints and stress related to study delay reinforce each other. On top of that, students with
mental health problems might be unable to finish their education at university. In the Netherlands
this is also a concern for the universities, as the Dutch government has aimed to increase the
completion rates and reduce the number of long-term students for many years (Nauta et al.,
1996; TeWinkel & Juist, 2012). Taken together, the reluctance to seeking professional help for
mental health problems among students is an alarming public health issue that needs further
exploration.

Today’s younger generation represents the largest group of students in history. The
transition from adolescence into young adulthood involves major changes in several areas –
financial, housing, social, and emotional – and this transition period can cause relational
challenges that some young adults experience as stressful. It has also been maintained that the
proportion of students who experience their student life as mentally stressful is increasing
(Nedregård and Olsen, 2014). This trend may suggest that student’s experience this period
increasingly demanding, and for some of them it may be a direct cause of mental illness
(Nerdrum et al., 2009).

Internationally, students’ mental health is highlighted as a major public health challenge

(Stallmann, 2008; Storrie et al., 2010). A systematic review found that half of the students who
reported mental distress symptoms also had experienced these symptoms before they began their
studies, while the remaining half developed symptoms during their studies. Other studies, from
the United States, Canada, and United Kingdom, confirm high(er) rates of mental health
problems among university students, compared to the general population in the same age group
(Adalf et al., 2001; Bewick et al., 2010; Keyes et al., 2012). Further, there may be factors
associated with both these factors operating on a number of levels, from individual factors to
interpersonal issues and institutional characteristics. Of individual level factors, previous studies
have reported that emotional problems had a negative effect on study progress and on the
dropout rate from higher education (Storrie et al., 2010). Internationally, and particularly in the
United States, a significant amount of research on the transition to higher education has been
carried out over the last 40 years. This has contributed to development of a broader theoretical
framework for understanding the factors important for college success. There are mainly two

Both anxiety and depression are detrimental to academic and social participation in
everyday student life (Byrd and McKinney, 2012; Keyes et al., 2012; Salzer, 2012).
Depressive disorders result in lowered mood, reduced cognitive function, lack of a sense of
coping and interest in others, as well as lack of energy (Mykletun et al., 2009). In turn,
depression and anxiety often affect memory and concentration, which makes it more difficult to
acquire new knowledge and cope with examination situations. This will often reinforce
perceptions of hopelessness and inadequacy, and in many people it will sustain the feeling of
anxiety and depressed mood in a vicious circle (Rice et al., 2006; Stallmann, 2008). On the other
hand, and depending on the symptom level, some uncertainty and anxiety in the academic
situation may contribute to increased work effort and possibly improved results (Andrews and
Wilding, 2004; Nedregård and Olsen, 2014).

The concept of self-efficacy refers to individuals’ own beliefs about capabilities to

organize and execute the courses of action required to produce given attainments (Bandura,
1997). In educational psychology research self-efficacy has been shown to predict Student’s
academic performance and progress across academic areas and levels (Pajares and Schunk, 2006;
Vuong et al., 2010). Academic self-efficacy has been proven to be a powerful predictor when the
critical performance is as global as the self-efficacy level measured (Choi, 2005; Zajacova et al.,
2005). In studies of academic performance and persistence, social cognitive theory has proved to
serve as a well-suited model (Brown et al., 2008). A central concept is self-efficacy describing
the individual’s belief in their own coping in different situations. Low self-efficacy affects both
achievements, ambitions, and motivation (Dinther et al., 2011). Further, Bandura (1997) also
linked experiences of persistent overthinking and negative self-esteem to the development of
symptoms of anxiety and depression.