Chapter 1

INTRODUCTION

Background of the Study

Mental health is a dynamic state of internal equilibrium which enables individuals to

use their abilities in harmony with universal values of society. Basic cognitive and social

skills; ability to recognize, express and modulate one’s own emotions, as well as empathize

with others; flexibility and ability to cope with adverse life events and function in social

roles; and harmonious relationship between body and mind represent important components

of mental health which contribute, to varying degrees, to the state of internal equilibrium.

(Galderisi, Heinz, Katrup, Beezhold & Sartorius, 2015, p.231-232).

According to the World Health Organization, Depression is a common mental

disorder affecting more than 264 million people worldwide. It is characterized by persistent

sadness and lack of interest or pleasure in previously rewarding or enjoyable activities. It can

also disrupt sleep and appetite; fatigue and lack of concentration are common. Depression is

one of the leading causes of disability worldwide and a major contributor to the global burden

of disease. The effects of depression can be long-lasting or recurrent and can significantly

affect a person’s ability to function and live a rewarding life.

Depression is a mood disorder that affects a person’s ability to perform life activities,

including academic performance (Hysenbegasi, Hass, & Rowland, 2005, p.145). People with

depression often blame themselves, are confused, and feel hopeless. The loss of interest

aspect of depression was found to be associated with lower grade point averages and students

who experienced both anxiety and depression performed poorly in school. (Einsenberg, Hunt,

2009, p.6)

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 According to the study conducted by Puyat et. al, up to 8.9% of young Filipino adults

experience moderate to severe depressive symptoms and the prevalence is higher in females

(10.2%) than males (7.6%).

The American Psychological Association (APA) defines anxiety as “an emotion

characterized by feelings of tension, worried thoughts and physical changes like increased

blood pressure. In addition, The WHO reports that anxiety disorders are the most common

mental disorders worldwide with specific phobia, major depressive disorder and social phobia

being the most common anxiety disorders. According to WHO, 1 in 13 globally suffers from

anxiety.

Agboola and Evans (2015) conducted research to explore the relationship between

anxiety and academic achievement among international students in UK universities. The

results of the study showed that anxiety was significantly associated with academic

performance.

According to the World Health Organisation (WHO), stress is "the reaction people

may have when presented with demands and pressures that are not matched to their

knowledge and abilities and which challenge their ability to cope."

Academic stress emerges from experiencing stress due to factors such as scholarship

requirements, family-related pressures, competition in the class and course-related stress and

financial burdens experienced by students. (Misra and Castillo, 2004, p. 133)

The Covid-19 pandemic has delivered a lot of significant and inevitable changes in

the lives of students. This situation has led the education system to make necessary

adaptations in ways to learn despite the face-to-face restrictions made. Thus, came the need to

adjust to the new online learning environments.

In this study, we describe the occurrence of depression, anxiety, and stress among

level III nursing students who are engaging in online classes in RTRMF where the findings of

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the study will provide opportunity for future studies that will focus on outlining solutions on

the impact of the problem. The findings will serve a strong basis for medical education

institutions to outline interventions or curriculum that nurtures nursing students’ mental

health.

Statement of the Problem

This study aimed to analyze psychometric attributes of Depression, Anxiety, and Stress

among Level III Nursing Students Engaging in Online Class in RTRMF

Specifically, it answered the following questions:

1. What is the profile of the college students in Doña Remedios Trinidad Romualdez

Medical Foundation Inc. in terms of the following dimensions?

1.1 Age

1.2 Gender;

1.3 Type of community

2. What is the level of stress, anxiety and depression in students who engage in online

classes?

2.1 Stress;

2.2 Anxiety;

2.3 Depression;

3. How academic workloads affect the increasing rate of depression, anxiety, and stress

among Level III Nursing Students in this time of pandemic?

4. How internet connectivity that is encountered by the Level III RTRMF Nursing

students affects depression, anxiety, and stress during this pandemic?

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 5. What is the significant relationship between the profile of the students and the level of

stress, anxiety and depression of Level 3 nursing students in RTRMF engaging in

online classes?

6. What is the significant relationship between the academic workload and the level of

stress, anxiety and depression of Level 3 nursing students in RTRMF engaging in

online classes?

7. What is the significant relationship between internet connectivity and the level of

stress, anxiety and depression of Level 3 nursing students in RTRMF engaging in

online classes?

Purpose of the Study

The period of existence and spread of the corona virus has led to the use of online classes for

flexible learning for all. Therefore, the purpose of this quantitative research is to measure

psychometric attributes of depression, anxiety, and stress among level III nursing students

engaging in online classes in RTRMF.

Null Hypotheses

● There is no significant relationship between the profile of the students and the

level of stress, anxiety and depression of Level 3 nursing students in RTRMF

engaging in online classes.

● There is no significant relationship between the academic workloads and level

of stress, anxiety and depression of Level 3 nursing students in RTRMF

engaging in online classes.

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 ● There is no significant relationship between internet connectivity and level of

stress, anxiety and depression of Level 3 nursing students in RTRMF engaging

in online classes.

Theoretical Framework

Neuman Systems Model

According to McEwen and Wills (2019), Neuman Systems Model uses a systematic

approach that is centered on human needs for protection and stress relief. Humans are viewed

as an open system that responds to stressors in the environment. The environment is a

concentric ring structure that represents the internal, external, and created environments, all

of which influence the client's stressor adaptation. Workload of activities and internet

connectivity in this study is part of the human’s external environment. The profile of the level

III nursing students is considered as the human’s internal environment. The human’s created

environment is their unconscious process towards stability of the different variables that are

being laid to them. Wellness and illness are at opposite ends of the health continuum. For the

client, health is defined as optimal system stability, which is the best possible state of

wellness at any given time. Stressor invasion of the normal line of defense causes deviations

from wellness or varying degrees of system instability. In this study, depression, anxiety, and

stress will occur due to the client's instability of its stressors. The focus of the nursing

component is to maintain client system stability by accurately assessing environmental and

other stressors and assisting clients in making necessary adjustments to maintain optimal

wellness. It has a huge role in the client’s created environment to have a system of stability.

Stress, Coping, and Adaptation Theory

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 This study is anchored on the Stress, Coping, and Adaptation theory by Lazarus and

Folkman. According to the theory, stress is defined as a particular relationship between the

person and the environment. It occurs when situations are perceived as threatening to the

individual for their physical or mental integrity. Lazarus and Folkman explained that stress

happens when the demands tax or exceed the available coping resources. The stress that this

pandemic has placed on students, particularly in terms of learning method, is excessive, as is

the reality that not all students are financially secure and not all students live in locations with

reliable internet access.. This study will contribute to a better understanding of the level of

stress that level III nursing students are experiencing as a result of the pandemic.

Transition Theory

In the study of McEwen and Wills (2019), Transition theory by Afaf Meleis states

that humans face challenges as they adapt to changes in their health, well-being, and their

ability to care for themselves. In here, transition is defined as "a transition from one fairly

stable state to another fairly stable state, triggered by a change." Transitions are also indicated

by various stages, milestones, and turning points. In this study, students undergo changes in

learning to adapt in this pandemic. With this transition, students experienced challenges

resulting in the prevalence of depression, stress, and anxiety. These transitions or changes can

be supported or managed by the nurses while caring for the students. The goal of "nursing

therapy" is to conceptualize and address potential problems faced by these people during

transitional experiences and to develop preventative and therapeutic interventions to help

students during these difficult times.

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Conceptual Framework

The diagram shows the relationship between the profile of level III Nursing students

and the factors that affect the increased rate of depression, anxiety, and stress of the students.

The identified profile of the students that correlates to the study are age, gender, and type of

community.

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 The age of the chosen population, which are the level III nursing students, will help to

identify the enumerated challenges and factors affecting the increased rate of depression,

anxiety, and stress of the students. This is for the reason that depression, anxiety, and stress

affect everyone regardless of the age range of the students. On the other hand, this will also

allow us to estimate differences in depression, anxiety, and stress prevalence based on the

students' age groups. In the study of Varma, et al., (2021), younger people aged 18-34 years

old had higher levels of anxiety, depression, and stress, whereas older people had more

resilient coping skills but poorer sleep quality.

The gender of the level III nursing students will also help in determining the

prevalence of depression, anxiety, and stress. Although everyone could experience these

problems, this will help identify who are the vulnerable group between male and female of

the level III n

ursing students. In the study of Afifi (2007), females and males responded to stress in different ways

The level of depression, anxiety, and stress will correlate with the type of community

or the geographic location of level III nursing students in RTRMF. Unstable internet

connectivity is one of the most common problems students face when learning remotely. The

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majority of the time, this issue is caused by geographic location (Rotas, E. and Cahapay M.,

2020). According to a nationwide cross-sectional study, thirty-two percent (32%) and twenty-

two percent (22%) of 3, 670 Filipino medical students polled, respectively, have difficulty

transitioning to new learning styles and do not have dependable internet access (Baticulon et

al., 2020). According to Aboagye et al. (2020), poor internet connectivity is a common issue

for developing countries, like the Philippines, with underdeveloped telecommunications and

information and communication technology (ICT). Despite the fact that there are numerous

internet packages available in the country, they are "fluctuating" and not produced similarly

in terms of speed and stability (Amadora, 2020).

In addition, the profile of each student in connection to the academic workload will

also affect the level of depression, anxiety, and stress because of the loads of requirements

such as assignments, quizzes, and duty hours per week that level III nursing students have to

accomplish. In the study of Yangdon et al., (2021), when students are given multiple tasks to

complete and all deadlines fall on the same day, it becomes difficult for them to finish on

time. Many students frequently work beyond their physical limits to meet assignment

deadlines, study for exams, and manage other responsibilities, resulting in diminished

concentration and poor academic performance. Students experience stress, nervousness and

anxiety, depression, and low self-esteem as a result of this.

In the study of Sundarasen et al., (2020), findings revealed that the academic

workload had a significant impact on the students' stress and anxiety levels. This challenge in

remote learning was validated by university students in Malaysia, who voiced concern over

the overwhelming amount of assignments required by their professors, especially when poor

internet connectivity will intervene.

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Significance of the Study

This study will focus on the psychometric analysis of depression, anxiety, and stress

among level III students engaging in online classes in RTRMF. Through this research, the

researchers will be able to arrive at the right findings and results reliable enough to be used.

Thus, this study benefits the following:

Nursing Students. They will be able to enhance knowledge on the different levels of

stress, anxiety and depression that will guide them in their academic performance.

Furthermore, they can convey their thoughts, views, and worries, which contributes to a

general sense of trust and perception of one another, as well as increased openness and

relationship building.

Nursing/Clinical Instructors. They will be able to assist students overcome their

obstacles by providing advice and empowering their thoughts. Furthermore, they will help

students to be confident in their performance of their duties and responsibilities as well as to

provide opportunity to practice skills, and will have their learning outcomes evaluated

consistently.

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 Faculty. They will learn new technologies and instructional methodologies that will

adapt to the new learning set-up. They can provide flexible schedules and lighter nursing

academic activities via online educational programs.

Community. They will strengthen their roles as a community member by providing

ideas to lessen the occurrence of depression and anxiety in the community thus benefit the

researcher.

Future Readers. They will have a better understanding on how to adapt long distance

learning as well as to decrease the learner’s worries and concerns in engaging online classes.

Future Researchers. They will be able to gain a source of information about the study,

allowing them to enhance their expertise and provide solutions on the impact of the problem

as well as outline interventions that will nurture nursing students’ mental health.

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Scope and Limitations

This study will focus on the psychometric analysis of depression, anxiety, and stress

among level III nursing students engaging in online classes in RTRMF. This will involve an

online survey questionnaire addressed to students who may have experienced depression,

anxiety, and stress in engaging in online classes. This study will not cover other problems

that are not considered as depression, anxiety, and stress. The selected respondents are the

level III nursing students who are enrolled at Doña Remedios Trinidad Romualdez Medical

Foundation, Tacloban City. The respondents were limited to 100 students of Bachelor of

Science in Nursing. These students had a longer period of time to engage in synchronous

online learning compared to other medical courses, hence, the course will best represent the

students. Moreover, students from this course and year level have a heavy study load and

compatible schedule.

Time constraints only allow few educational institutions to be given and studied on,

which could affect the generalizability of the study. Synchronous online courses require

better time-management skills than on-campus classes. The researchers have no control over

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the time needed to send the survey to the level III nursing students via Facebook/Messenger.

Additionally, a Google Form link with the consent and survey questionnaire will be sent to

the respondents. Despite the limitations this paper has, the researchers have provided

significant pieces of information and data in this study.

Definition of Terms

In order to provide the reader a better understanding on the content of the study, the

following terms were defined as they were used in the study:

Academic Workload as used in the study, are the requirements such as assignments, quizzes,

and duty hours per week that Level III Nursing students have to accomplish.

Anxiety as found in the study means feeling of tension and having worried thoughts.

Anxiety Disorder as found in the study means the most common mental health disorder

worldwide with specific phobia.

Challenges as used in the study are the tasks or problems that are faced by the Level III

Nursing students to synchronous learning

Depression as found in the study means a common and serious medical illness that

negatively affects the performance of the Level III Nursing students of RTRMF.

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Internet Connectivity as used in the study refers to the way of people connect using

computers and other devices during synchronous learning by using different platforms (e.g.

Zoom, Google Meet)

Psychometric as found in the study means it is a field in psychology that tests, measures, and

assess related activities of Level III Nursing students of RTRMF

Psychometric Analysis as used in the study means a structured process to measure

psychometric attributes of Level III Nursing students by thoroughly analyzing the test data

and ensuring the quality of the test used meets the standards.

Social Phobia as found in the study means a common anxiety disorder worldwide.

Stress as found in the study means a situation in which Nursing students experience that

causes physical, emotional and mental strain.

Synchronous Online Learning as found in the study refers to all types of learning in which

learner(s) and instructor(s) are in the same place, at the same time, in order for learning to

take place. This includes in-person classes, live online meetings when the whole class or

smaller groups get together.

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 Chapter II

REVIEW OF RELATED LITERATURE AND STUDIES

Related Literature

The purpose of this study is to describe the occurrence of depression, anxiety, and

stress among Level III nursing students who are engaging in online classes in RTRMF. The

related literature discusses the information to enrich the conceptualization of the study.

Relevant literature from various sources of studies and literature were used to provide insight

and background to the readers of the current research work.

I. Student’s Profile

Based on a study entitled “Online Behavior Analysis-Based Student Profile for

Intelligent E-Learning” by Liang, et. al., 2017, the student profile is a novel method to

analyze the basic information and learn the behavior of online learners. Through the
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establishment of a student profile, it is to achieve personalized situation construction and

learn process guidance, which plays a positive role in promoting online learning. It is an

effective way to solve the emotional deficiency by constructing an intelligent learning

guiding mechanism in the student profile and providing some emotional help and support

services to the learners during the learning process.

According to a study on “Implementation of the Analytic Hierarchy Process for

Student Profile Analysis” by Sael, et. al, 2019, the analysis of student profiles offers more

and more information about students and helps the decision-makers to develop the most

adapted decisions to a specific context. Machine learning [1], data mining [2] and multi-

criteria analysis [3] techniques have contributed to the development of several studies in the

field, their aim being to better understand students and to improve learning contexts.

Based on a study entitled “Psychological distress associated with COVID-19

quarantine: Latent profile analysis, outcome prediction and mediation analysis” by Fernández

et al. (2020), latent profile analysis is contributed to better understand: possible mechanisms

associated with mental health outcomes during quarantine as COVID-19 related fear and

coping-skills. It suggested that quarantined people may require attention in the long-term. In

addition, policy makers, clinicians and media, could implement communication strategies and

mental health recommendations/programs, to reduce fear on the population, develop better

coping strategies and improve general well-being.

II. Academic Workload

In a study in “COVID-19 and Distance Learning: Effects on Georgia State University

School of Public Health Students” (Armstrong, et.al. 2020), the findings show that most the

students (64.5%) indicated that the transition to purely online classes increased their

academic workload. The increase in workload was primarily in the form of new assignments

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that were added including journaling, written assignments, reflection papers, monitoring

quizzes, and discussion posts, with written assignments (31.8%) and discussion posts (25.7%)

being the primary forms of assessments assigned. For other students (35.5%) there was no

increase in course workload

The COVID-19 pandemic is an illustrative-anxiety inducing stressor where

uncertainties and threats can’t be solved through individual efforts. When people are given a

few options for resources, ways, or abilities to deal with stressors, the tendency is that they

get stressed that would lead to negative consequences. The perceived stress may be

transmitting the effects of academic workload, separation from school, and fears of contagion

on health-related outcomes and in connection to this, it has been mentioned in a study that the

perceptions of stress and responses to them cause many psychological and health problems

such as depression (Siegrist, 2008; Wolkowitz, Epel, Reus VI, & Mellon, 2010), insomnia

(Akerstedt, 2006), coronary artery disease (Rosengren, Tibblin, & Wilhelmsen, 1991), worry

(Akerstedt, Kecklund, & Axelsson, 2007).

According to a study conducted by Won et.al., 2020, academic workload is one factor

that contributes to pandemic-specific stressors. A vast majority of students are experiencing

difficulty in concentrating on academic work due to various sources of distraction such fear

and worry about their own health and their loved ones as well. Due to longer periods of

lockdown and stay-at home orders, the COVID-19 pandemic brings a negative impact on

higher education. The effect of COVID-19 is considered inconclusive on class workload

among college students. About 54% or slightly over half of the students have stated that there

is an increase in academic workload due to COVID-19, and 36% indicated that the workload

has remained the same. Students who experienced an increase in workload have thought to

exert more effort in catching up with online classes and class projects considering that there

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is a lack of in-person support from instructors. Students have also observed that homeworks

had increased or became more difficult to do.

According to a study by Hassan et al. (2021), entitled “Academic Self-Perception and

Course Satisfaction among University Students Taking Virtual Classes during the COVID-19

Pandemic in the Kingdom of Saudi-Arabia (KSA)”, the sudden implementation of distance

education was associated with hiccups and required lots of quick adaptations in academic

regulations, less familiar modes, and methods of assessment in addition to frequent shifts in

the study and exam schedules. All these issues contributed to the academic workload and

were sources of stress for students. Preliminary studies regarding online learning during the

COVID-19 pandemic show that students developed mixed feelings about virtual classes and

reported low to moderate levels of satisfaction with remote/online studies. Online learning

environments require the practice of academic self-regulation and problem-solving skills and

students should be proficient in utilizing online learning resources to fulfill the demands of

undergraduate and post-graduate degree programs.

III. Internet Connectivity

Some Southeast Asian countries including the Philippines are confronted with

connectivity issues on the internet particularly in their countryside. Students are also

threatened with the belief that going up and going during a certain call of action.

According to Pew Research Center, 2018, most sub-Saharan Africans feel positively

about the role the internet plays in their country. Large majorities say the increasing use of

the internet has had a good influence on education in their country, and half or more say the

same about the economy, personal relationships and politics.

In a study on “Weaving the Western Web: explaining differences in Internet

connectivity among OECD countries” by Hargittai, et. al.; 1999, after examining the impact

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of economic indicators, human capital, institutional legal environment, and existing

technological infrastructure, the empirical analyses show that economic wealth and

telecommunications policy are the most salient predictors of a nation's Internet connectivity.

A study conducted by Alvarez (2020), majority of the participants reported a poor to

no internet access in their respective homes. Internet accessibility is described as a challenge

rather than an advantage on the students’ part. Despite having a widespread increase in

internet infrastructure, especially in urban areas in the Philippines, having reliable internet

access is still far behind to achieve duopoly of telecommunications, geographical disparities

and limited budget allocation in remote areas.

According to a study conducted by Hasan and Bao (2020), Due to resource inequality,

some students can learn all lessons in real-time. But most of them do not get online lessons

instantly. Many of those who may have Internet access facilities once a week cannot receive

instructions properly. Teachers also do not invest more time in overall instruction. Thus

students affect emotional damage and increase the psychological distress of students. e-

Learning stressors are linked to academic delays that affected student’s mental well-being

and were positively associated with anxiety symptoms.

IV. Online Learning

“Online learning is defined as ‘learning experiences in synchronous or asynchronous

environments using different devices (e.g., mobile phones, laptops, etc.) with internet access.

In these environments, students can be anywhere (independent) to learn and interact with

instructors and other students’ (Singh & Thurman, 2019)”. Online learning simply refers to

being able to utilize advanced technologies to facilitate learning through the use of the

internet. It can be done in a time where it is most convenient for the learner or it can be done

in real time with other students through online interactions or platforms. Virtual learning
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puts the importance of the connection between the learners and their teachers into the picture.

This connection can be lost if there is no ‘live’ contact element.

According to Beale, in an article posted by Dr. John L. Taylor “Online Distance

Learning: A Literature Review”, this does not necessarily mean that every lesson needs to

include a video meeting, though there is a beneficial psychological impact of knowing that

the teacher is still in contact and regular face-to-face online discussions can enable this. There

can be other forms such as a discussion on thread which begins during a lesson and is open

throughout and can perform the same role. Beale also emphasises the importance of a

supportive and encouraging online environment. As online learning can be a challenging

experience for learners, it could be de-motivating if technology fails, especially when there is

an internet connectivity interruption that affects the online class.

In a participatory action-based research conducted by San Antonio students, it has

been shown in their findings that more than 71% of the survey respondents consider virtual

remote learning as contributing more stress than the traditional in-person school. It has also

been found that among the high school upperclassmen and university undergraduate

lowerclassmen that had been surveyed by a team of teens, 75% of respondents report having

struggled with mental health issues during the pandemic. For most students, virtual remote

learning meant a disruption in their social lives among their peers in the school setting. As

there is limited socialization among the students, there is also an increased feelings of

isolation that drastically increases the depression rates .

A study entitled “Online course delivery: an empirical investigation of factors

affecting student satisfaction” by Beqiri et.al., 2009 investigated potential factors impacting

students’ satisfaction with online course delivery. The sudden shift from face to face to online

learning have resulted in students being dissatisfied with this method. Technical difficulties

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are one main reason why students experience dissatisfaction with online learning. Given that

some countries have below average telecommunication infrastructure and connection can be

lost anytime during class where students leave and relog into sessions, lose data, and power

outage schedule which can render the students unable to even catch class sessions or even

exams.

A quantitative study conducted by Kim et. al, (2021), entitled “Impacts of Coping

Mechanisms on Nursing Students’ Mental Health during COVID-19 Lockdown: A Cross-

Sectional Survey”. Indicated that for college students, the rapid shift from in-person to online

learning, as well as concerns over educational progress and future job opportunities,

contributed greatly to increased levels of stress and anxiety. Moreover, the COVID-19

pandemic has caused significant disruption in education worldwide. Although most colleges

have shifted to online learning, nursing schools must continue to have clinical practicums,

which require students to work in close contact with patients. The concern of viral

transmission and the unpredictable progression of the COVID-19 pandemic may further

increase students’ uncertainty of academic advancement and affect their mental health

negatively.

V. Challenges

According to a journal (Aldossary et.al 2020 in “Understanding Education Difficulty

during COVID-19 Lockdown: Reports on Malaysian University Students’ Experience", the

Internet speed and coverage differ based on students’ budget and location. In comparison to

the students who live in urban areas, some students who reside in rural areas are expected to

experience challenges in online education especially in securing sufficient and good Internet

access. If classes and assessments are fully conducted online, these students may receive

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unfair treatment. Therefore, less-privileged students may suffer more. They face a lot of

challenges such as lack of resources (devices needed for online classes/sessions, internet

access/stable internet connection) and a quiet space conducive to learning, apart from being

distracted by family responsibilities.

In an article “Academic and Emotional Effects of Online Learning during the

COVID-19 Pandemic on Engineering Students”, it has been mentioned that educational and

psychological research has raised concerns about students' mental health as they have had to

suddenly switch to online learning systems and follow classes under lockdown restrictions.

Investigations pointed out that students have experienced an increase in stress, anxiety, and

depression (Aslan et al., 2020; Odriozola-González et al., 2020; Saravanan et al., 2020; Son

et al., 2020), and have felt some negative feelings intensified, such as fear, worry, or

boredom (Aristovnik et al., 2020; Son et al., 2020).

According to Gilbert in his thesis “Online Learning Revealing the Benefits and

Challenges”, another challenge that online learners face is maintaining motivation in an

online course. Students who lacked independence and self-motivation overall had lower

success rates than their counterparts (Savenye, 2005). Learners with a lack of self-regulation

tended to not assign enough time to complete assignments, therefore turning in poor quality

work or late assignments all together (You and Kang, 2014).”

Related Studies

According to a study by Verma et. al., 2021, entitled “Depression, Anxiety, and Stress

During Times of COVID-19: An Analysis of Youngsters Studying in Higher Education in

India”, aimed to determine the stress, anxiety, and depression levels of students pursuing

higher education in India during the ongoing COVID-19 pandemic, which has created an

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uncertain environment for students, teachers, and institutions alike. Moreover, many students’

parents are struggling to pay tuition fees, as their incomes have been affected by the

pandemic. From a teacher’s standpoint, learning to plan and deliver lectures effectively

online has been difficult. Although teachers are adapting slowly, online teaching

effectiveness is far from benefiting students. Conducting assessments online has also been a

major challenge, and poor infrastructure has made it virtually impossible to conduct

proctored assessments on a large scale.

According to a study conducted by Kumaraswamy et. al., 2012, the most common

concerns among college students in the academe are stress, anxiety, and depression. There are

about up to 10 to 20% of the student populace suffering from psychological problems (stress,

anxiety, and depression). On a cross sectional epidemiological study of mental morbidity

among postgraduate and research students by Chandrashekar et al (1980), in which the

Goldberg’s 60 item General Health Questionnaire was used as screening tool, a person

scoring 12 and above was morbidity and selected socio demographic, motivational

psychological variables: certain life experiences in the campus were studied. Results showed

that factors such as sex, age, language, activities, educational status of the parents, birth order

and parental loss or separation did not have any significant relationship with the morbidity

rate. Low family income, student’s attitude towards opting for a particular course, who

described their home as unhappy positively correlated with mental morbidity. The

dissatisfaction arising from living arrangements, poor participation in extracurricular

activities, poor social relationships, poor staff-contact are all significantly related to high

mental morbidity.

According to a study by Lee et. al., 2021, particularly female, rural, low-income, and

academically low-performing students were more vulnerable to psychological distress. About

23
two-thirds of students with moderate to severe symptoms had not utilized mental health

services on- and off- campus. Mental health in college students is in crisis during the

pandemic and call for increased attention and interventions. More than 8 in 10 students had

moderate to severe stress, and more than one thirds of students experienced moderate to

severe anxiety and depression. These students have already faced multiple barriers in

pursuing higher education (e.g., Adelman, 2006; Byun et al., 2012), and additional mental

health issues would put them at a high risk of dropping out of college

A quantitative study conducted by Fawaz and Samaha (2020) in Lebanon, entitled “E-

learning: Depression, anxiety, and stress symptomatology among Lebanese university

students during COVID-19 quarantine” aimed at evaluating the prevalence of depression,

anxiety, and stress symptomatology among Lebanese University Students during the COVID-

19 Quarantine. E-learning has been adopted internationally as the alternative teaching or

learning strategy during the coronavirus disease 2019 (COVID-19) quarantine to fill the

academic gap that has been created by the existing reality of the pandemic due to nationwide

closures. However, learning through online platforms have given rise to depression and

anxiety disorders among undergraduate university students, where there was a significant

correlation between student satisfaction and prevalence of depression, anxiety, and stress.

Moreover, the sudden shift to exclusive e-learning methods of instruction have produced

anxiety and depression symptoms among a significant portion of the students due to the

stressful load of work required.

According to a study conducted by Rosenthal et al. (2021), elevated levels of stress,

anxiety, and depression are common symptoms in graduate students pursuing a degree in the

health care professions. The onset of the COVID-19 pandemic likely complicated these

existing issues. Based on the results of their study, nearly 25% of students expressed

24
moderate to extremely severe levels of negative emotional states on the Depression, Anxiety

and Stress Scale (DASS-21), and 23.8% of students scored within the area of clinical concern

for the presence of posttraumatic stress disorder on the Impact of Events Scale (IES-R).

However, understanding levels of mental health and associated factors that may contribute to

changes can assist administration, faculty, and staff in targeting resources and interventions to

support graduate nursing students to continue their education.

According to the study of Labrague (2021), the coronavirus disease 2019 (COVID-

19) outbreak has brought additional stress to those in nursing programs, who were already

under high pressure. This has resulted in increased mental and psychological issues in student

nurses. The role of resilience as a mediator reducing the effects of pandemic-associated stress

on student nurses’ outcomes remains unexplored. The study examined the direct and indirect

effects of stress associated with the pandemic on student nurses’ life satisfaction and

psychological well-being through the intermediary role of resilience. Results indicated that

Filipino student nurses experienced stress associated with the pandemic at a high level;

however, their resilience, life satisfaction and psychological well-being were found to be

moderate to high. Increased pandemic-associated stress was associated with reduced life

satisfaction and poorer psychological well-being. Further, resilience was found to reduce the

negative effects of pandemic-associated stress on the life satisfaction and psychological well-

being of student nurses. The study highlighted the importance of building resilience in

student nurses during the coronavirus pandemic to sustain their mental and psychological

well-being and improve their life satisfaction.

According to the study conducted by Mridul et al. (2020), entitled “Online Classes

during COVID-19 Pandemic: Anxiety, Stress and Depression among University Students''

aimed to assess the level of depression, anxiety and stress in grad students who were

25
undergoing online classes. COVID-19 pandemic has not only put people at risk of developing

physical illnesses but also face mental distress. As everything is virtual with no physical

movement most of the mental health illnesses were triggered rapidly such as depression,

anxiety and stress. To assess the psychological consequences, their study was conducted

using a standardized tool Depression, Anxiety and Stress Scale (DASS-21). Based on their

study results, majority of the students experienced moderate depression 27 (16.98%),

Anxiety 27 (16.98%), and Stress 23 (14.46%) during online classes. Their study suggest more

research is needed to find the best coping strategies to assure mental health and to find

innovative yet effective ways of learning.

According to a study conducted by Islam et al. (2020), depression and anxiety

among university students during the COVID-19 pandemic in Bangladesh. The pandemic

came out as the most devastating ad challenging crisis for public health in the contemporary

world. Apart from the soaring mortality rate, nations across the globe have also been

suffering from a spike of the excruciating psychological outcomes, i.e., anxiety and

depression. However, university students are no exception, as all the educational institutions

are unprecedently closed for more than usual. Moreover, it triggers a sense of uncertainty

about academic and professional. In addition, it intensifies mental health challenges among

univeristy students. Given such circumstances, the main goal of their study was to investigate

the prevalence of depression and anxiety among the Bagladeshi university students during the

COVID-19 pandemic and to explore the factors influencing the presence of depression and

anxiety disorder. Based on the findings of their study, the results show that 392 (82.4%)

students were found to have mild to severe depressive symptoms, and 389 (87.7%) students

were found to have mild to severe anxiety symptoms.. Their study suggest to create a friendly

26
and and positive environment for university students without imposing pressure on the future

academic and working career.

According to the study “Stress in Students after Lockdown Due to COVID-19 Threat

and the Effects of Attending Online Classes” conducted by Ra et. al (2021), on the analysis of

the data they have found that 34.4% of students have felt stressed “Sometime” in the week

22.6% of students felt stressed “Often” in the week and 15.1% of students are “Always” in

stress due to the threat of coronavirus. Overall, 51.4% of students are stressed in this

condition of threat.69.8% of students are stressed about their studies.78.5% students are not

comfortable with online classes.

A study conducted by Maqableh et. al (2021) entitled “Evaluation online learning of

undergraduate students under lockdown amidst COVID-19 Pandemic: The online learning

experience and students’ satisfaction” their surveys' analysis results show that students had

several problems with shifting to online learning during COVID-19 Pandemic such as

technological, mental health, time management, and balance between life and education. The

results also show that more than a third of the surveyed students are dissatisfied with the

online learning experience.

27
 Chapter III

RESEARCH METHODOLOGY AND PROCEDURES

Research Design

According to a study on “Taking the mystery out of research: descriptive correlational

design” by Lappe (2000), the aim of descriptive correlational research is to describe the

relationship among variables rather than to infer cause and effect relationships. A descriptive

correlational design was employed in this study to understand the relationship between the

psychometric analysis of depression, anxiety, and stress among level III nursing students of

RTRMF to describe and determine the extent of a relationship of the identified variables.

28
 This research design measured and observed variables that are involved, namely - age,

gender, type of community, stress, anxiety, depression, academic workload, and internet

connectivity at a specific point in time for a defined population while adapting the

synchronous learning modality.

Research Locale

The study will be conducted at Dona Remedios Trinidad Romualdez Medical

Foundation which is located at Calanipawan, Tacloban City since the chosen respondents are

the level III nursing students of the institution. The Dona Remedios Trinidad Romualdez

Medical Foundation started with a humble and strong foundation in the year of 1980. The

institution is a premier medical school that continues to be raised by excellent standards in

medical, professional and other post-graduate courses.

Dona Remedios Trinidad Romualdez Medical Foundation College of Nursing have been 8

consecutive years of being a 100% top notcher. The College of Nursing is one of the

programs, which aims to develop professionals who have mastered the skills and will

continue to be responsible for personal and professional development, contributing to the

nursing profession.

The foundation is the first to offer a graduate program in Masters of Arts in nursing in region

VIII with a pioneering class of 19 in the school year 1999 to 2000. By the year 2002, it has

produced 1,029 doctors, 1,170 nurses, 533 medical technologists, 244 biology graduates, and

238 physical therapists.

29
Population and Sampling

The study will presumably employ the sampling procedure Purposive Sampling

method to select the level 3 nursing students of RTRMF to be the respondents of the study. In

purposive sampling, the researcher deeply analyzes the context of the systematic

investigation and uses their discretion to choose variables that can provide relevant

information. A Google Forms link will be utilized and sent to the level 3 nursing students of

RTRMF through their batch group chat where they will be asked to accomplish the

questionnaire at their most convenient time. A total population of 100 Level 3 nursing

students will be the respondents of the study.

Respondents

The targeted population in this study are the level III nursing students of Doña

Remedios Trinidad Romualdez Medical Foundation Inc. - DVOREF, school year 2021-2022.

Respondents will be chosen from each section of the aforementioned school's level III

30
nursing students. The selection, on the other hand, will be based on the results of the

sampling procedure, which will be covered later in this chapter.

Research Instruments

The researchers will use standardized survey questionnaires as their research

instrument in gathering necessary data from level III nursing students of Doña Remedios

Trinidad Romualdez Medical Foundation Inc. - DVOREF. The survey questionnaire will be

composed of three parts to be accomplished only by the above-mentioned respondents. To

measure the strength or intensity of each statement, the research will utilize Likert Scale

whether it is : (1) Strongly Disagree, (2) Disagree, (3) Neutral , (4) Agree and (5) Strongly

Agree.

The first part of the questionnaire is the (1) personal data of the respondents wherein

it consists of (1) Name (Optional), Age, Sex, Date, and Type of Community.

The second part is (2) a 14 item self-structured questionnaire comprising the academic

workload affecting the increasing rate of depression, anxiety, stress and challenges

encountered by level III nursing students which uses a five point scale. They are to put a

check mark on the space provided that best describes their current situation whether (1)

Strongly Disagree, (2)Disagree, (3) Neutral, (4) Agree and (5) Strongly Agree.

The second part contains two different subscales which are (1) Academic Workload

(5 items) Questions 1-7, and (2) Challenges of the Level III Nursing students (9 items)

questions 8-14.

31
 The third part is (3) a 38 item standardized questionnaire retrieved from Beck’s

Depression Inventory (21 items), Generalized Anxiety Disorder Scale (7 items), and

Perceived Stress Scale (10 items). The above mentioned respondents are to put a circle, or a

check in the box that best describes their current situation.

The survey questionnaires will be disseminated through the internet by an online

platform Google Forms.

Scoring and Interpretation

The respondents are to answer every item by checking the box or encircling the item

according to their appropriate or corresponding selection. It will be tallied, scored, and

interpreted according to the frequency encountered of factors that affect the increasing rate of

depression, anxiety and stress among level III nursing students as follows:

● <1.80 - Strongly Disagree

● 1.81 - 2.60 - Disagree

● 2.61 - 3.40 - Neutral

● 3.41 - 4.20 - Agree

● >4.21 - Strongly Agree

For the Beck’s Depression Inventory Scale, the highest possible total for the whole

test is sixty-three. This would mean that the respondent circled number three on all twenty-

one questions. Since the lowest possible score for each question is zero, the lowest possible

score for the test would be zero. This would mean that the respondent circles zero on each

question. The questionnaire will then be tallied for the frequency of use and interpreted as

follows:

● 1-10 = Considered normal

32
 ● 11-16 = Mild mood disturbance

● 17-20 = Borderline clinical depression

● 21-30 = Moderate depression

● 31-40 = Severe depression

● >40 = Extreme depression

For the Generalized Anxiety Disorder Scale, the highest possible score for the whole

test is twenty-one. This means that the respondents put check in number three on all

questions. The questionnaire will then be tallied for the frequency of use and interpreted as

follows:

● <4 = Minimal anxiety

● 5-9 = Mild anxiety

● 10-14 = Moderate anxiety

● >15 = Severe anxiety

For the Perceived Stress Scale, the highest possible score for the whole test is forty.

This means that the respondents encircled number four on all questions. The questionnaire

will then be tallied for the frequency of use and interpreted as follows:

● 0-13 = low stress

● 14-26 = moderate stress

● 27-40 = high perceived stress

Data Gathering Procedure

33
 After the validation of the research instruments, following the rules in data gathering

procedure, the researchers will begin with securing permission to conduct this study that will

be sought from the research instructor. After the permission is approved, the data gathering

procedure will require consent from the Dean of College of Nursing and respondents from

RTRMF. In gathering the data needed, the questionnaires will be disseminated to the

respondents through Google Forms. The researchers will then collate the answered

questionnaires. And lastly, after the researchers gathered the answered questionnaires, the

researchers will then interpret and analyze the data to describe the respondents’ socio-

demographic profile and perceived stress, anxiety, and depression in order to make inferences

based on the findings by using Pearson Correlation. Further on, conclusions and

recommendations will follow and will be done.

Statistical Treatment

The data gathered will be presented in textual and tabular form, the mean, percentage

and frequency distribution will be utilized to analyze and interpret the data. The researchers

will use SPSS/Excel statistical software through Pearson Correlation to determine the

relationship of variables.

Frequency and percentage distribution will be employed to determine the profile of

the respondents:

Percentage

P = (f/n) *100
where,
P = percentage
f = frequency
n = total number of respondents

34
Sample Mean will be used to determine the total number of students who have stress, anxiety

and depression, using the formula:

Sample Mean

x= Σx / n
where,

x̄ = sample mean
Σx = sum of all data
N = number of respondents

Pearson’s correlation will be utilized to determine the following:

● Relationship between the profile of the students and the level of stress, anxiety and

depression

● Relationship between Academic workloads and and the level of stress, anxiety and

depression

● Relationship between internet connectivity and the level of stress, anxiety and

depression

Pearson's Correlation

Pearson's correlation is used to determine if a significant linear relationship exists in a

bivariate association. The three possible research hypotheses for this model are: positive

linear relationship, negative linear relationship, and no linear relationship (H0:). Correlations

may be used to test two quantitative variables. Correlations can be used to predict

relationships in longitudinal studies or to identify relationships between variables.

35
36
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