*3.3. Predictors of Poor Mental Health*

Table 1 shows bivariate Kendall's tau correlations between coping mechanisms and poor mental health. High resilience and high family functioning were negatively correlated with high stress, moderate-to-severe anxiety, and moderate-to-severe depression (*p* < 0.05). Similarly, there were significant negative correlations between high spiritual support and anxiety and depression. By contrast, none of the demographic variables correlated significantly with high stress, moderate-to-severe anxiety, or moderate-to-severe depression.



*\* p* < 0.05; \*\* *p* < 0.01; \*\*\* *p* < 0.001 by Kendall's Tau test. High stress = Perceived Stress Scale scores ≥ 27; moderate-to-severe anxiety = GAD-7 scores <sup>≥</sup> 10; moderate-to-severe depression = PHQ-9 scores <sup>≥</sup> 10. <sup>a</sup> CD-RISC-10 scores <sup>≥</sup> 29; <sup>b</sup> Family APGAR scores <sup>≥</sup> 8; <sup>c</sup> Spirituality Support Scale scores <sup>≥</sup> 36.

> The results of multivariate logistic regression procedures are shown in Table 2. High resilience was a significant predictor of lower risks of high stress (Odds Ratios (OR) = 0.46; 95% Confidence Interval (CI) = 0.22–0.98; *p* = 0.045), moderate-to-severe anxiety (OR = 0.47; 95%CI = 0.25–0.90; *p* = 0.022), and moderate-to-severe depression (OR = 0.50; 95%CI = 0.26–0.95; *p* = 0.036). Similarly, high family functioning was also a significant predictor of lower risks of high stress (OR = 0.41; 95%CI = 0.20–0.86; *p* = 0.018), moderateto-severe anxiety (OR = 0.41; 95%CI = 0.21–0.80; *p* = 0.009), and moderate-to-severe depression (OR = 0.41; 95%CI = 0.20–0.81; *p* = 0.011). In addition, high spiritual support was a significant predictor of lower risk of depression (OR = 0.48; 95%CI = 0.24–0.95; *p* = 0.035).

#### **Table 2.** Predictors of poor mental health during COVID-19 lockdown (*N* = 173).


OR = odds ratio; CI = confidence interval. High stress = Perceived Stress Scale scores ≥ 27; moderate-to-severe anxiety = GAD-7 scores ≥ 10; moderate-to-severe depression = PHQ-9 scores ≥ 10; <sup>a</sup> CD-RISC-10 scores ≥ 29; <sup>b</sup> Family APGAR scores ≥ 8; <sup>c</sup> Spirituality Support Scale scores ≥ 36.

#### **4. Discussion**

It is remarkable how much the COVID-19 lockdown has impacted the psychological wellbeing of nursing students. The proportion of students with high stress level during the lockdown jumped 6-fold compared to the pre-lockdown period, while moderate-to-severe anxiety and depression increased nearly 3–4-fold. Interestingly, psychological distress appears to be ameliorated by potentially modifiable factors, such as resilience, family functioning, and spiritual support. In multivariate analyses, high resilience and family functioning were independently associated with a 2- to 2.4-fold lower risk of high stress, moderate-to-severe anxiety, and moderate-to-severe depression. In addition, high spiritual support was also independently associated with 2-fold lower risk of moderate-to-severe depression. By contrast, demographic variables, such as age, educational background, or ethnicity, showed no correlation with poor mental health during the lockdown.

It is plausible that resilience, family functioning, and spiritual support among nursing students can be nurtured so that they can better manage unexpected challenges impacting psychological equilibrium. For example, a randomized controlled trial (RCT) of resilience training based on cognitive behavior therapy among newly licensed registered nurses showed significant decreases in stress, anxiety, and depression [30,31]. Perhaps, resilience and spiritual support are complimentary coping mechanisms. Spiritual support arises from a sense of connection to an external higher power, whereas resilience is one's internal capacity to bounce back and adapt to stressful circumstances [32–35]. In our study, about half of the students reported moderate-to-severe anxiety and depression during the lockdown, which is consistent with a study of nursing students in Israel that reported more than half with anxiety [10]. However, other dimensions of psychological distress, such as perceived stress and depression, were not assessed in this previous study. Another study among university students and associates in Germany also showed higher levels of health anxiety during the COVID-19 pandemic compared to pre-pandemic [36]. High family function as a protective factor against poor mental health is consistent with another previous study. Among college students in China, lower anxiety symptoms were associated with living with parents during the COVID-19 pandemic [16]. Although these authors did not assess family functioning as a coping mechanism, it is likely that simply living with parents during isolation reduces symptoms of anxiety and depression among college students.
