YJPNU-01114; No of Pages 6

Journal of Professional Nursing xxx (2017) xxx–xxx

Contents lists available at ScienceDirect

Journal of Professional Nursing

Relationships among sleep quality, coping styles, and depressive symptoms among
college nursing students: A multiple mediator model
Yuan Zhang ⁎, Anya Peters, Joseph Bradstreet
Susan and Alan Solomont School of Nursing, 113 Wilder Street, University of Massachusetts Lowell, Lowell, MA 01854, United States

a r t i c l e i n f o a b s t r a c t

Article history: Background: Poor sleep quality and depressive symptoms are common among college nursing students, and may
Received 26 April 2017 be associated with each other. However, the mechanism for this association has not been well understood.
Revised 4 December 2017 Purpose: The study is to examine the potential mediating role of coping styles in the association between sleep
Accepted 11 December 2017 quality and depressive symptoms among college nursing students.
Available online xxxx
Methods: 242 undergraduate nursing students at a public university in the northeast United States completed an
online survey delivered through SurveyMonkey® with self-reports of sleep quality, coping styles, and depressive
Keywords:
Sleep quality
symptoms from October to November 2015.
Coping Results: Multivariate linear regression models suggested that poor sleep quality was significantly associated with
Emotion disengagement depressive symptoms (β = 1.00, p b 0.01) in nursing students. The four coping styles (problem engagement,
Depression emotion engagement, problem disengagement, and emotion disengagement) together reduced the strength of
Mental disorders the association between sleep quality and depressive symptoms by 41%. Specifically, emotion disengagement
coping plays an important mediating role in this association.
Conclusions: In addition to sleep promotion, effective interventions to facilitate the development of appropriate
coping strategies among nursing students are needed to enhance their mental health and well-being.
© 2017 Elsevier Inc. All rights reserved.

Introduction
Mental disorders have been identified as the leading cause of disabil-
ity in the U.S. (Murray, Atkinson, Bhalla, et al., 2013). Depression, one of
the most common mental disorders, has been estimated to increase and
become the second leading cause of disability by the year 2020 (Murray
& Lopez, 1996). According to the Association for University and College
Counseling Center Directors Survey, depression is the second leading
concern among college students following anxiety (Mistler, Reetz,
Krylowicz, & Barr, 2015). Around 10–25% of college students are de-
pressed, and many of those individuals experience their first bout of de-
pression while in college (Zawadzki, Graham, & Gerin, 2013).
Depression generates concerns among college students because it can
lead to a variety of potentially dangerous consequences such as self-in-
jurious behaviors, non-suicidal self-injury, suicidal behaviors, and sui-
cide (Baetens, Claes, Muehlenkamp, Grietens, & Onghena, 2011;
Bebbington et al., 2010; Klonsky, 2011; Zawadzki et al., 2013).
Depression is disproportionally prevalent in women than in men,
with evidence supporting that female college students are two times
more likely to experience depression than male college students
(National Alliance on Mental Illness, 2012). The American College
⁎ Corresponding author.
E-mail address: Yuan_Zhang@uml.edu (Y. Zhang).
Health Association Survey (n = 23,863) reported that 45% of female stu-
dents and 36% of male students felt so depressed that it was difficult to
function (American College Health Association, 2007). Depression is
more of a concern for nursing students who are primarily female. Rec-
ognizing depressive symptoms and identifying potential risk factors
and mechanisms are important to promote mental health and well-
being of nursing students.
Review of the literature
Regarding depression, one possible related phenomenon is that col-
lege students do not sleep enough, and often experience disturbances in
their sleep. In a recent study, 75% of college students surveyed experi-
enced sleep problems such as delayed sleep phase syndrome, difficulty
falling asleep, sleep disturbances, and excessive daytime sleepiness
(Altun, Cinar, & Dede, 2012), while another study reported that as few
as 11% of college students meet the criteria for good sleep quality
(Zawadzki et al., 2013). Female college students have been shown to
have longer sleep latency, more awakenings, and poorer sleep quality
than male college students (Tsai & Li, 2004).
A complex and bidirectional relationship may exist between sleep
and depression. Previous studies have reported that sleep disturbances
contributed to depressive symptoms in college students (Moo-Estrella,
Perez-Benitez, Solis-Rodriguez, & Arankowsky-Sandoval, 2005).

https://doi.org/10.1016/j.profnurs.2017.12.004
8755-7223/© 2017 Elsevier Inc. All rights reserved.

Please cite this article as: Zhang, Y., et al., Relationships among sleep quality, coping styles, and depressive symptoms among college nursing
students: A multiple mediator mode..., Journal of Professional Nursing (2017), https://doi.org/10.1016/j.profnurs.2017.12.004
2 Y. Zhang et al. / Journal of Professional Nursing xxx (2017) xxx–xxx
Changes in sleeping patterns are part of the criteria for diagnosing de-
pression and multiple studies have shown through polysomnographic
techniques that depressed individuals have an increased sleep latency
and sleep disturbance (Walker & van der Helm, 2009). Nyer and col-
leagues reported that college students who experienced depressive
symptoms in combination with sleep disturbances would experience a
greater burden of comorbidities and a greater loss of physical and cogni-
tive functions than those same students without sleep disturbances
(Nyer, Farabaugh, Fehling, et al., 2013). Sleep disturbances, including re-
duced sleep, have been shown to intensify the risk of depressive symp-
toms in female college students (Regestein et al., 2010).
Nursing students deserve particular attention regarding their sleep
and mental health, as nursing students are primarily female and en-
counter some unique stressors from other college students, such as ir-
regular work hours from clinical practicum, which may increase their
susceptibility to poor sleep and depressive symptoms. Kaur and col-
leagues reported that 43.5% of nursing students experienced excessive
daytime sleepiness due to excessive workload, unregulated work
hours, and inadequate sleep hygiene (Kaur, Ghai, Grover, & Singh,
2015). Depressive symptoms among nursing students from different
countries have been linked to academic stress, inadequate coping, lack
of emotional support and self-esteem, insecurity about occupational fu-
ture, low perceptions of clinical practice, and poor balancing of school,
work, and personal life (Cha & Sok, 2014; Chatterjee et al., 2014;
Chernomas & Shapiro, 2013; Ross et al., 2005; Xu et al., 2014).
Coping, defined as “the cognitive and behavioral efforts to manage
specific external and/or internal demands” (Rappaport & Seidman,
2000), may vary by individual student. Broadly, coping strategies may
include engaged-coping (direct attempts to influence either the stressor
or response to the stressor) and disengaged-coping (efforts to distance
oneself emotionally, cognitively, and physically from the stressor), or
emotional-coping (reducing the negative emotional responses associat-
ed with stress) and problem-coping (reducing the stress by tackling the
problem or stressful situation that causes stress) (Rappaport & Seidman,
2000). Brougham and colleagues reported that emotion-focused coping
strategies dominated over problem-solving strategies among college
students, and female students reported a greater use of emotion-fo-
cused coping strategies than male students (Brougham, Zail, Mendoza,
& Miller, 2009). Another study reported that maladaptive coping was
the main predictor of depression in young college students
(Mahmoud, Staten, Hall, & Lennie, 2012). Sadeh, Keinan, and Daon dis-
covered that impaired sleep was linked to impaired coping styles in re-
sponse to stress (Sadeh, Keinan, & Daon, 2004).
Although the association between sleep and depression has been ob-
served, the exact mechanism for this association has not been well un-
derstood, especially in nursing students who are predominantly
female. Researchers have rarely examined the extent to which the link
between sleep quality and depressive symptoms may be influenced by
coping styles.
Fig. 1. A conceptual model for the relationships among sleep quality, coping styles, and depressive symptoms.
Please cite this article as: Zhang, Y., et al., Relationships among sleep quality, coping styles, and depressive symptoms among college nursing
students: A multiple mediator mode..., Journal of Professional Nursing (2017), https://doi.org/10.1016/j.profnurs.2017.12.004
Aims
The objectives of this study are (1) to explore the association be-
tween sleep quality and depressive symptoms; and (2) to examine
the potential mediating role of coping styles in the association between
sleep quality and depressive symptoms among college nursing stu-
dents. The conceptual model in Fig. 1 guides the study design and
analyses.
Methods
Study design
This study used a quantitative, cross-sectional design to explore the
role of coping styles in the association between sleep quality and de-
pressive symptoms among college nursing students.
Participants
This study collected an online survey from a sample of 242 under-
graduate nursing students at a public university in the northeast U.S. A
non-probability convenience sampling method was used to recruit
study participants. All nursing students over 18 years old and enrolled
in the Baccalaureate Nursing Program at the public university in fall
2015 (total number = 399) were eligible to participate.
Measures
Dependent variables
Depressive symptoms. Depressive symptoms were assessed with the
Center for Epidemiologic Studies Depression Scale (CES-D), the 10-
item version. This scale is used to identify current depression symptom-
atology in individuals age 18 and older during the past week (Radloff,
1991). Each item is rated on a 4-point Likert scale (0 = rarely or none
of the time; 1 = some or a little of the time; 2 = occasionally or a mod-
erate amount of the time; and 4 = most or all of the time) with a range
in total score from 0 to 30, and higher scores indicating greater severity
of depression symptomatology. A total score of 10 or more is indicative
of depression. This scale demonstrates good reliability with the study
sample (Cronbach's alpha = 0.88).
Independent variables
Sleep quality. Sleep quality was assessed with the Pittsburg Sleep Quality
Index (PSQI), a 19-item scale that assesses seven components of sleep
quality during the past month, including subjective sleep quality, sleep
latency, sleep duration, habitual sleep efficiency, sleep disturbances,
use of sleeping medication, and daytime dysfunction (Buysse,
 Y. Zhang et al. / Journal of Professional Nursing xxx (2017) xxx–xxx 3

Reynolds 3rd, Monk, Berman, & Kupfer, 1989). Each component is
assessed on a 4-point Likert scale with a range in global score from 0
to 21, with higher scores indicating poorer sleep quality. A PQSI global
score N 5 yields a diagnostic sensitivity of 89.6% and specificity of
86.5% in distinguishing good and poor sleepers (Buysse et al., 1989).
The reliability (Cronbach's alpha) of this scale with the study sample
is 0.68, which is consistent with its reliability reported in previous stud-
ies with nurses (Ruggiero, 2003).
Potential mediators
Coping styles. Coping styles were assessed with the Coping Strategies In-
ventory Short Form (CSI-SF), the 32-item version. This scale assesses
how an individual deals with an event or situation that has been very
stressful during the past month (Tobin, Holroyd, Reynolds, & Wigal,
1989). Each item is rated on a 5-point Likert scale (1 = not at all; 2
= a little; 3 = somewhat; 4 = much; and 5 = very much). The instru-
ment has eight primary subscales including problem solving, cognitive
restructuring, express emotions, social contact, problem avoidance,
wishful thinking, self-criticism, and social withdrawal (Tobin et al.,
1989). The primary subscales are aggregated to four secondary sub-
scales including problem engagement (problem solving and cognitive
restructuring), emotion engagement (express emotions and social con-
tact), problem disengagement (problem avoidance and wishful think-
ing), and emotion disengagement (self-criticism and social
withdrawal), with a range in score from 8 to 40 for each secondary sub-
scale (Tobin et al., 1989). The reliability (Cronbach's alpha) of the sec-
ondary subscales with the study sample averages 0.76.
Covariates
Socio-demographics. The survey collected information on nursing stu-
dents' socio-demographics, including age, gender, race, height and
weight, and sedentary behavior. Body Mass Index (BMI) was calculated
from self-reported weight and height, expressed as weight/height2, and
was categorized as normal (b25.0 kg/m2), overweight (25–29.9 kg/m2),
or obese (≥30 kg/m2). Sedentary behavior was defined as “exercise less
than three times per week (for at least 20-minute per session to work
up a sweat).”
Data collection
multivariate analyses. The correlations among sleep quality, coping
styles, and depressive symptoms were examined using Spearman cor-
relations (Rho). Rho was used to describe relationships among data
that are not continuous or not normally distributed (Field, 2013).
Baron and Kenny's method (Baron & Kenny, 1986) was utilized to
assess the potential mediating effect of each coping style (problem en-
gagement, emotion engagement, problem disengagement, and emotion
disengagement) in the association between sleep quality and depres-
sive symptoms by evaluating four criteria: (1) sleep quality association
with depressive symptoms; (2) sleep quality association with each cop-
ing style; (3) each coping style association with depressive symptoms;
and (4) reduction of the strength of the association #1 with inclusion
of each coping style. Then the four coping styles were introduced into
the model together to evaluate their aggregated mediating effect on
the association between sleep quality and depressive symptoms. Multi-
variate linear regression model was used to calculate coefficients and
95% confident intervals (CI). Outliers and multicollinearity assumptions
were checked and handled in the multivariate linear regression models
(Field, 2013). Two-tail significance level was reported at p b 0.05.
Results
Descriptive and bivariate analyses
A total of 242 out of 399 undergraduate nursing students completed
the survey in fall 2015 (response rate of 60.7%), primarily female
(91.3%) and white (80.9%) students (Table 1). Nearly 30% of the partic-
ipants were overweight or obese, and over half reported sedentary be-
havior (Table 1). Two thirds of the students reported poor sleep
quality (PSQI N 5), and over half reported depressive symptoms (CES-
D ≥ 10).
Poor sleep quality was positively correlated with depressive symp-
toms. Problem disengagement and emotion disengagement were posi-
tively correlated with poor sleep quality and depressive symptoms;
while problem engagement was negatively correlated with poor sleep
quality and depressive symptoms (Table 2).
Table 1
Socio-demographics, sleep quality, coping styles, and depressive symptoms among nurs-
ing students (n = 242).

The survey was administered and collected online through Variables Mean ± SD or percentage
SurveyMonkey®. In-class announcement and recruitment were made Age 19.8 ± 1.7
to undergraduate nursing students enrolled in fall 2015 at the public Gender
university before distributing the survey. Students were assured that Female 91.3%
the survey did not collect any personal identifier, participation was Male 8.7%
Race
completely voluntary, and non-participation would not affect their aca- White 80.9%
demic status. Students received a pre-survey email with the recruit- Black 5.0%
ment flyer, an invitation email with the survey link, three follow-up Others 14.1%
emails, and a final reminder and thank you email over the course of Class year
Freshman 24.0%
four weeks from October to November 2015. All emails were sent out
Sophomore 24.4%
directly through the office administrator at the School of Nursing. The Junior 24.8%
study was approved by the Institutional Review Board (IRB) at the Uni- Senior 26.9%
versity of Massachusetts Lowell (No. 15-034). Informed consent signa- BMI 24.1 ± 4.1
ture was waived by the IRB. The link to the survey started with an Normal 71.1%
Overweight 20.2%
explanation of the study, which required students' reading and agree-
Obese 8.7%
ment before going to the survey questions. The survey took about Sedentary behavior (yes) 56.8%
15 min to complete, and each participant received $10 cash incentive Poor sleep quality (PSQI N 5) 66.2% (7.3 ± 3.4)
for completing the survey. Depressive symptoms (CES-D ≥ 10) 54.5% (10.9 ± 6.5)
Coping styles
Problem engagement 26.0 ± 6.5
Data analyses Emotion engagement 26.4 ± 7.8
Problem disengagement 22.2 ± 6.6
All analyses were conducted using SPSS software 24.0.0 release on a Emotion disengagement 21.0 ± 7.5
Windows 10 operating system. Sleep quality, coping styles, and depres- Note. BMI = Body Mass Index; PSQI = Pittsburg Sleep Quality Index.
sive symptoms were treated as continuous variables in the bivariate and CES-D = Center for Epidemiologic Studies Depression Scale.

Please cite this article as: Zhang, Y., et al., Relationships among sleep quality, coping styles, and depressive symptoms among college nursing
students: A multiple mediator mode..., Journal of Professional Nursing (2017), https://doi.org/10.1016/j.profnurs.2017.12.004
4 Y. Zhang et al. / Journal of Professional Nursing xxx (2017) xxx–xxx
Multivariate analyses
A multivariate linear regression model of sleep quality and depres-
sive symptoms was adjusted for socio-demographics, including age,
gender, race, school year, BMI, and sedentary behavior. An analysis of
standard residuals was carried out and identified no outlier. Tests to
see if the data met the assumption of collinearity indicated non-
multicollinerity, with Variance Inflation Factor (VIF) ranging 1.0–2.5.
With every unit increase of the sleep quality score, the depressive
symptom score increased by 1.00 units (Model 1, R2 = 35%, β = 1.00,
p b 0.01) (Table 3).
Following the Baron and Kenny's method (Baron & Kenny, 1986),
the potential mediating effect of each coping style (problem engage-
ment, emotion engagement, problem disengagement, and emotion dis-
engagement) in the association between sleep quality and depressive
symptoms was tested with the multivariate linear regression models
after adjustment for socio-demographics. Table 3 reported that problem
engagement, emotion engagement, problem disengagement, and emo-
tion disengagement were separately associated with sleep quality
(Model 2a–2d) and depressive symptoms (Model 3a–3d). Each coping
style reduced the strength of the association between sleep quality
and depressive symptoms by 5%–28% (Model 4a–4d). The four coping
styles together reduced the strength of the association between sleep
quality and depressive symptoms by 41% (Model 5, Table 3, Figure 2),
for example, the association coefficient of sleep quality and depressive
symptoms reduced from 1.00 to 0.59 after introducing the four coping
styles. The data contained no outlier and multicollinearity was not a
concern (VIF ranges 1.0–2.5).
Discussion
In this study, over half of nursing students reported depressive
symptoms, which is similar to the prevalence of depression reported
in nursing students from other countries (Chatterjee et al., 2014; Ross
et al., 2005), however, is higher than the prevalence of depression re-
ported by the general college students in the U.S. (American College
Health Association, 2007; Moo-Estrella et al., 2005). Two-thirds of the
nursing students in this study reported poor sleep quality, which is
also a higher prevalence than that reported by the general college stu-
dents in the U.S. (Vargas, Flores, & Robles, 2014; Zawadzki et al.,
2013). Considering the gender disparities in sleep quality and depres-
sion, and nursing as a female-dominated profession, nursing students'
sleep quality and mental health deserve special attention among all col-
lege students.
We found in this study that poor sleep quality among nursing stu-
dents was closely associated with depressive symptoms. Previous stud-
ies with college students have reported similar findings (Moo-Estrella et
al., 2005; Slavish & Graham-Engeland, 2015; Zawadzki et al., 2013).
While troubled sleep is considered both a predictive sign and symptom
of many illnesses, it is not clear if poor sleep quality causes depression or
if depression causes poor sleep quality (Van Moffaert, 1994). Sleep has
been shown to play an integral part in mental wellness and poor sleep
quality has been reported to contribute to common mental disorders
Table 2
Spearman correlations among sleep quality, coping styles, and depressive symptoms
among nursing students.⁎
Sleep quality Depressive symptoms
Sleep quality 1.00 0.59⁎⁎
Coping styles
Problem engagement −0.24⁎⁎ −0.29⁎⁎
Emotion engagement −0.12 −0.18⁎⁎
Problem disengagement 0.29⁎⁎ 0.44⁎⁎
Emotion disengagement 0.35⁎⁎ 0.63⁎⁎
⁎ p b 0.05.
⁎⁎ p b 0.01.
Please cite this article as: Zhang, Y., et al., Relationships among sleep quality, coping styles, and depressive symptoms among college nursing
students: A multiple mediator mode..., Journal of Professional Nursing (2017), https://doi.org/10.1016/j.profnurs.2017.12.004
in college students (Byrd et al., 2014). On the other hand, depression
has been demonstrated to include intensified self-focused attention
which can place an individual at risk for maladaptive rumination
(Slavish & Graham-Engeland, 2015). This rumination can lead to nega-
tive self-reflection and non-constructive thoughts on past and present
difficulties and feelings often experienced by depressed persons
(Nolen-Hoeksema, Wisco, & Lyubomirsky, 2008). An expanding body
of literature ties rumination with sleep quality (Guastella & Moulds,
2007; Thomsen, Yung Mehlsen, Christensen, & Zachariae, 2003;
Zawadzki et al., 2013). Rumination appears to be a mechanism by
which depressed mood leading to chronic psychological stimulation
that can cause short- and long-term sleep disturbances and therefore
diminished sleep quality (Slavish & Graham-Engeland, 2015).
This study reported significant associations between sleep quality
and coping styles, and between coping styles and depressive symptoms
among nursing students. Previous research has reported that poor sleep
quality including shortened sleep indicated ineffective coping strategies
(Sadeh et al., 2004). Studies have also found that maladaptive coping
was predictive of depression, anxiety, and stress (Mahmoud et al.,
2012). Slavish and colleagues suggested that depressed mood and im-
paired sleep may induce negative health behaviors such as alcohol use
as a form of coping that perpetuates the cycle of depressed mood and
poor physical health as well as poor academic, social, and behavioral
outcomes (Slavish & Graham-Engeland, 2015). Alcohol use is bidirec-
tionally related to negative mood and poor sleep among college stu-
dents (Ham & Hope, 2003). These findings suggest that effective
interventions to improve coping skills of nursing students may have
critical and positive effect on reducing the risks of poor sleep quality
and depressive symptoms.
This study reported that the four coping styles (problem engagement,
emotion engagement, problem disengagement, and emotion disengage-
ment) together reduced the strength of the association between sleep
quality and depressive symptoms by 41%. As we expected, the mediating
role of coping styles is important, considering their significant associa-
tions with both sleep quality and depressive symptoms. Consistent
with previous findings (Brougham et al., 2009; Mahmoud et al., 2012),
we found that disengagement coping had a stronger association with
poor sleep quality and depressive symptoms than engagement coping.
In addition, emotion disengagement coping had a stronger association
with poor sleep quality and depressive symptoms than problem disen-
gagement coping. This may explain the important role of coping styles,
especially emotion disengagement coping, in translating poor sleep qual-
ity into depressive symptoms in this population of college students. For
example, when experiencing poor sleep quality, nursing students tend
to take more of emotion disengagement coping (tackling their affective
responses to the stressor), which in turn leads to depressive symptoms.
Limitations
This study has several limitations. Although the study avoids some
possible confounders at the institution level because all nursing students
were from a single public university, the generalizability of the findings
is limited as a result. Even though the response rate of 60.7% for an online
survey is moderately high, this may still cause selection bias of the
nursing student population. A follow-up study using a more nationally
representative random sample would improve the generalizability of
the findings. In addition, definitive conclusions about causal relation-
ships cannot be drawn with a cross-sectional design. Future analyses of
longitudinal data would be desirable to verify the study findings.
Conclusions
This quantitative cross-sectional study found that poor sleep quality
was positively associated with depressive symptoms among college
nursing students. Coping styles reduced the strength of the association
between sleep quality and depressive symptoms. Specifically, emotion
 Y. Zhang et al. / Journal of Professional Nursing xxx (2017) xxx–xxx 5

Table 3
Multivariate linear regression models for sleep quality, coping styles, and depressive symptoms among nursing students.

Analysis and model Independent variable Dependent variable β P R2 Adjusted R2 Mediating effect

Analysis I
Model 1 Sleep quality Depressive symptoms 1.00⁎⁎ b0.01 0.35 0.33

Analysis II
Model 2a Sleep quality Problem engagement −0.44⁎⁎ b0.01 0.14 0.11
Model 2b Sleep quality Emotion engagement −0.37⁎ b0.05 0.05 0.02
Model 2c Sleep quality Problem disengagement 0.48⁎⁎ b0.01 0.15 0.12
Model 2d Sleep quality Emotion disengagement 0.73⁎⁎ b0.01 0.19 0.16

Analysis III
Model 3a Problem engagement Depressive symptoms −0.27⁎⁎ b0.01 0.15 0.13
Model 3b Emotion engagement Depressive symptoms −0.17⁎⁎ b0.01 0.13 0.10
Model 3c Problem disengagement Depressive symptoms 0.39⁎⁎ b0.01 0.23 0.21
Model 3d Emotion disengagement Depressive symptoms 0.52⁎⁎ b0.01 0.43 0.41

Analysis IV
Model 4a Sleep quality Depressive symptoms 0.94⁎⁎ b0.01 0.37 0.34 6.0%
Program engagement −0.13⁎ b0.05
Model 4b Sleep quality Depressive symptoms 0.95⁎⁎ b0.01 0.38 0.35 5.0%
Emotion engagement −0.12⁎ b0.05
Model 4c Sleep quality Depressive symptoms 0.88⁎⁎ b0.01 0.40 0.37 12.0%
Program disengagement 0.23⁎⁎ b0.01
Model 4d Sleep quality Depressive symptoms 0.72⁎⁎ b0.01 0.56 0.54 28.0%
Emotion disengagement 0.39⁎⁎ b0.01

Analysis V
Model 5 Sleep quality Depressive symptoms 0.59⁎⁎ b0.01 0.58 0.55 41.0%
Program engagement −0.11⁎ b0.05
Emotion engagement −0.07 NS
Program disengagement 0.07 NS
Emotion disengagement 0.39⁎⁎ b0.01

All multivariate linear regression models were adjusted for age, gender, race, school year, BMI, and sedentary behavior. NS = Not Significant.
⁎ p b 0.05.
⁎⁎ p b 0.01.

disengagement coping plays an important mediating role in the associ-
ation between sleep quality and depressive symptoms. This study em-
phasizes the importance of improving coping skills as a way to
improve mental health of nursing students. In addition to sleep promo-
tion, effective interventions to facilitate the development of appropriate
coping strategies among nursing students are needed to enhance their
mental health and well-being.
Recommendations for nursing education
Nursing is a challenging major with multiple academic and non-ac-
ademic stressors leading to poor sleep quality and depressive symptoms
in nursing students. Furthermore, poor sleep and mental health of
nurses may lead to substantial safety and health implications for nurse
themselves and patients. Therefore, it is important for nursing students
to acquire appropriate sleep knowledge and understand the mechanism
between sleep and mental health before entering the workforce. Find-
ings from this study suggested that in order to prevent depressive
symptoms among nursing students, nursing education could consider
including programs, courses, or seminars targeting healthy sleep prac-
tices, coping strategies acquisition, and mental health promotion. Pro-
viding education about the causes, signs, and symptoms, and possible
resources for treatment of depression and poor sleep may help nursing
students identify symptoms in themselves and seek help.

Fig. 2. Results of the multiple mediator model.

Please cite this article as: Zhang, Y., et al., Relationships among sleep quality, coping styles, and depressive symptoms among college nursing
students: A multiple mediator mode..., Journal of Professional Nursing (2017), https://doi.org/10.1016/j.profnurs.2017.12.004
6 Y. Zhang et al. / Journal of Professional Nursing xxx (2017) xxx–xxx
In addition, school- and family-based programs to reduce nursing
students' disengagement coping behaviors should be developed and
implemented. For example, colleges should provide students with
easy access to counseling services which could develop and implement
targeted programs to improve students' coping skills. Understanding
the frequency and consequences of depressive symptoms in nursing
students is essential. College counselors, professors, and family mem-
bers should recognize that students may describe school difficulties, in-
terpersonal conflict, and/or physical complaints that are really
symptoms of their depression. Practical strategies for nursing students
to improve coping skills may include: distracting themselves from prob-
lems; developing insights about difficult situations; using problem solv-
ing strategies to overcome troubles; getting support from peers,
professors, or family members whenever needed; and learning relaxa-
tion techniques such as mindfulness and meditation to regulate emo-
tions. On the other hand, peer mentoring or support groups could be
more effective for nursing students because students may be more will-
ing to disclose their problems and/or emotions and get help from peers
(Demir, Demir, Bulut, & Hisar, 2014). Nursing schools could encourage
and help nursing students initiate and sustain a peer mentoring/support
program and provide continuous evaluation with constructive feedback
for program improvement (Botma, Hurter, & Kotze, 2013).
Funding source
This study was supported by the 2015 Sigma Theta Tau International
(STTI), Eta Omega Chapter Research Award to Yuan Zhang. This work is
solely the responsibility of the authors and the funding source had no
involvement with the study process.
Conflict of interest disclosure
The authors have no conflicts of interest to report.
Ethical considerations
The authors confirm that the research presented in this article met
the ethical guidelines, including adherence to the legal requirements
of the United States and received approval from the Institutional Review
Board of the University of Massachusetts Lowell (No. 15-034).
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