A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE MASTER DEGREE OF NURSING SCIENCE (INTERNATIONAL PROGRAM) FACULTY OF NURSING BURAPHA UNIVERSITY OCTOBER 2015

FACTORS RELATED TO MENTAL HEALTH AMONG
VIETNAMESE NURSING STUDENTS

BUI THI LOAN

A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE
REQUIREMENTS FOR THE MASTER DEGREE OF NURSING SCIENCE
(INTERNATIONAL PROGRAM)
FACULTY OF NURSING
BURAPHA UNIVERSITY
OCTOBER 2015
COPYRIGHT OF BURAPHA UNIVERSITY


2

ACKNOWLEDGMENT
With heartfelt gratitude and appreciation, I would like to express my deep
appreciation to many persons who did not only support me in completing this thesis, but
also in my journey to become a Master student of Nursing Science.
Firstly, I would like to sincerely thank my major advisor, Assistant Professor
Dr.Pornpat Hengudomsub, who was always besides me, encourage, and support me a lot
throughout my process of writing this thesis. She has been a great mentor. This thesis
would not complete without her enthusiastic guidance. My sincere thanks also go to my
co-advisor, Associate Professor Dr.Nujjaree Chaimongkol for her excellent comments and
suggestions.
I am grateful to the Dean of Faculty of Nursing, as well as Chairperson of Master
of Nursing Science Program (International Program), all of lectures and staffs in Faculty of
Nursing, Burapha University who provide the excellent teaching and supporting
environment during my study time in Thailand.
My special thanks go to the Health Human Resource Development project under

the Ministry of Health of Vietnam and the director of Hai Duong Medical Technical
University who gave me a great opportunity to pursue Master of Nursing Science Program
at Faculty of Nursing, Burapha University, Thailand. I also would like to thank the
baccalaureate nursing students who participated in this study from Faculty of Nursing at
Hai Duong Medical Technical University, Vietnam.
Last but not least, I wish to express my love and gratitude to my awesome family
and friends. I sincerely thank them for their support and encouragement throughout my
study.

Bui Thi Loan


3

56910479:

MAJOR: NURSING SCIENCE; M.N.S.

KEYWORDS: MENTAL HEALTH/ NURSING STUDENTS/ VIETNAM/
EMOTIONAL QUOTIENT/ SELF-ESTEEM/ SOCIAL SUPPORT
BUI THI LOAN: FACTORS RELATED TO MENTAL HEALTH AMONG
VIETNAMESE NURSING STUDENTS. ADVISORY COMMITTEE: PORNPAT
HENGUDOMSUB, Ph.D., NUJJAREE CHAIMONGKOL, Ph.D. 90 P. 2015.

Mental health is one of the significant components of health and associated with
both individual and environmental factors. The purposes of this descriptive cross sectional
study were to examine mental health and test its relationships with related factors including
education achievement indicated by Grade Point Average (GPA), emotional quotient, selfesteem, and social support among nursing students (Year 1 to Year 4) who are studying at
one of a university in Vietnam. The sample included 110 baccalaureate full time nursing
students who registered in academic year 2015. Simple random sampling technique was

used to recruit the sample. Self-report questionnaires were used to collect data which
included questionnaire about nursing students’ characteristics, GPA, the Schutte Emotional
Intelligence Scale (SEIS), the Rosenberg Self-esteem Scale (RSES), the Personal Resource
Questionnaire 2000 (PRQ2000), and the Mental Health Inventory: 18-item version (MHI18). The scales of SEIS, RSES, PRQ2000, and MHI-18 yielded Cronbach’s alpha of .83,
.81, .86, and .80, respectively. Data were analyzed using descriptive statistics and Pearson’s
product moment correlation coefficient.
The results showed that the mental health of these nursing students was at a
moderate level with a mean score of 64.91 (SD = 7.57). Mental health was positively
correlated with GPA (r = .24, p < .01), emotional quotient (r = .26, p < .01), self-esteem
(r = .33, p < .01), and social support (r = .37, p < .01).
This study results provided baseline information regarding mental health and its
related factors among Vietnamese nursing students. It could be used to develop for proper
strategies or program aimed at enhancing students’ academic achievement, emotional
intelligence, self-esteem and social support among these nursing students.


4

CONTENTS
Page
ABSTRACT ..........................................................................................................

v

CONTENTS ..........................................................................................................

vi

LIST OF TABLES ................................................................................................

viii

LIST OF FIGURE.................................................................................................

ix

CHAPTER
1 INTRODUCTION .......................................................................................

1

Background and significance of the problem .......................................

1

Research objectives ..............................................................................

7

Research hypotheses.............................................................................

7

Scope of study ......................................................................................

7

Research framework .............................................................................

7

Definition of terms ...............................................................................

9

LITERATURE REVIEWS ..........................................................................

11

Overview of mental health ...................................................................

11

Mental health among nursing students .................................................

14

Factors related to mental health in nursing students ............................

18

Conclusion ............................................................................................

22

RESEARCH METHODOLOGY ................................................................

24

Research design .....................................................................................

24

Setting of study ......................................................................................

24

Population and sample ...........................................................................

24

Research instruments .............................................................................

26

Psychometric properties of instruments .................................................

30

Ethical considerations ............................................................................

31

Data collection procedures .....................................................................

32

Data analyses .........................................................................................

32

RESULTS ....................................................................................................

34

2

3

4


5

CONTENTS (cont.)
CHAPTER

Page

Description of nursing students’ characteristics ....................................

34

Description of mental health among nursing students ...........................

35

Description of factors related to mental health among nursing
students ..................................................................................................

36

Description of relationships between mental health and its related
factors among nursing students ..............................................................

37

5 CONCLUSION AND DISCUSSION .........................................................

39

Summary of the study findings ..............................................................

39

Discussion ..............................................................................................

40

Study implications .................................................................................

48

Limitations of study ...............................................................................

49

Recommendation for future research .....................................................

49

REFERENCES .....................................................................................................

50

APPENDICES ......................................................................................................

63

Appendix 1...................................................................................................

64

Appendix 2...................................................................................................

67

Appendix 3...................................................................................................

70

Appendix 4...................................................................................................

74

Appendix 5 ...................................................................................................

81

Appendix 6 ...................................................................................................

88

BIOGRAPHY .......................................................................................................

90


6

LIST OF FIGURE
Figure
Research framework…………………………………………………….

Page
9


7

LIST OF TABLES

Tables

Page

1

Number of sample in each year of this study...............................................

26

2

Demographic characteristics of nursing students ........................................

35

3

Description of mental health among nursing students.................................

36

4

Description of education achievement, emotional quotient, self-esteem
and social support .......................................................................................

37

5

Correlation coefficients of mental health score with other measures ...........

38

6

Interpretation for the size of correlation coefficient ....................................

89

7

One-way analysis of variances of mental health score among nursing
students ........................................................................................................

89


8

CHAPTER 1
INTRODUCTION

Background and significance of the problem
Nursing occupies an important position in the healthcare system. Nursing students
are the future professional health care providers who play important roles in providing care
as well as supporting patients physically and psychologically. Thus, they themselves should
also have good mental health, which is one of the significant health components (Ni et al.,
2010). Nursing students are not only facing with the challenges like most of other college
students including accommodation, interpersonal relationships, financial burden, parental
pressure as well as their concerns about the future, but they also have to face with more
stressful academic learning and psychological stressors (Dutta, Pyles, & Miederhoff, 2005;
Sreeramareddy et al., 2007; Vaez, Ponce de Leon, & Laflamme, 2006).
Specifically, with the aims of equipping necessary skills for the students after
graduation, nursing students across the nations and Vietnam in particular have to learn both
theory-based classes and also practice in the clinical settings. In the first year of their
studies, heavy academic pressure, concerns about examinations, worrying about grades are

cited as a major source of stress for some students (Huong, Hengudomsub, &
Suppaseemanont, 2011; Shaban, Khater, & Akhu-Zaheya, 2012). In their subsequent years
of study, the students begin specific courses and start practicing in clinical settings such as
in the hospitals (Huong et al., 2011). This time period may be the most stressful for some of
the nursing students (Moscaritolo, 2009). The students are also required to have continuous
interaction with a variety of individuals including patients, their family members, and other
health care providers (Reeves, 2005). The students must be concern about their mistakes
which can seriously harm the patients, even cause death to the patients. Therefore, the
students are required high responsibility, circumspection, and discretion. Moreover, during
practical experience in hospital, they may encounter with conflicts between health staffs,
suffering situation of patients, such as pain, cancer disease in young patients, even death
sometimes (Augusto-Landa, López-Zafra, Berrios-Martos, & Pulido-Martos, 2012;
Gibbons, Dempster, & Moutray, 2009; Pryjmachuk, 2004). All of these cause stressful
situations for them, and these may lead them to have to physical and mental health
problems (Sreeramareddy et al., 2007).


9

There have been various studies that explored mental health among nursing
students worldwide (Liu & Jia, 2008; Wu, 2005). Mental health encompassed of positive
mental health or psychological well being and negative mental health which in other
words were psychological distress or mental health problems. The prevalence of mental
health problems or negative mental health among this population was varied. According to
the data from some epidemiologic studies among nursing students in China, 7.7 % to 28.7
% of the students experienced mental health problems (Liu & Jia, 2008; Wu, 2005).
Another study was conducted to examine the mental health of 1,686 first-year medical
science students in Iran using the General Health Questionnaire-28 (GHQ-28). The results
revealed that 35.7 % of these students had mental health problems. Among them, nursing
students showed the highest percentage of those who experienced mental health problems

(Lotfi, Aminian, Ghomizadea, & Noorani, 2009). Depression and anxiety have been
documented as the most common mental health problems among nursing students in
several studies (Cook, 2005; Moscaritolo, 2009; Vatanasin, 2005). A high prevalence of
depression was found among nursing students in the China, Kenya and India (Chatterjee et
al., 2014; Othieno, Okoth, Peltzer, Pengpid, & Malla, 2014; Xu et al., 2014). Other studies
also found a high prevalence of anxiety among this population in the United States and Iran
(Cook, 2005; Moscaritolo, 2009).
Mental health problems not only caused negatively impacts on the students’ lives,
but also on their families and society. As for the students themselves, there were some
studies which demonstrated a relationship between mental illness and academic problems
(Breslau, Lane, Sampson, & Kessler, 2008; Hunt, Eisenberg, & Kilbourne, 2010).
Specifically, the students who reported depressive symptoms tended to pay less attention in
their studies, decreased abilities for study concentration. Moreover, elevated anxiety which
produced a state of physiological arousal also indicated as a factor leading to the
impairment of their abilities to concentration on others (Wood, 2006). All of these can lead
to low academic performance among these nursing students.
In addition, the poor quality of student's life is also reflected as loss of interest in
leisure activities, having eating and sleeping disturbances, and even suicidal thoughts
(Vatanasin, 2005). According to Hawton, Agerbo, Simkin, Platt, and Mellanby (2011),
nursing students were at higher risk for suicide than other college students. A statistics from
Pennsylvania State University found that more than 30 % of students who seek services for


10

mental health issues reported that they had considered attempting suicide at some point in
their lives, up to be about 24 % in the year 2010 (Novotney, 2014). Another study was
conducted of 142 nursing students of the Technological Educational Institute of
Thessaloniki in Greece (Melissa-Halikiopoulou, Tsiga, Khachatryan, & Papazisis, 2011),
and it revealed that 43.9 % of them reported depressive symptoms. Also, 10.6 % said that

they had suicidal ideation, but they didn’t act on them, while two students (1.4 %) declared
that they could have done it if they had the chance to do so. In terms of profession, students
have regular contacts and direct patient care, so quality of care provided for the patients
may also be reduced. On the other hand, mental health problems among nursing students
can also create burden to their family caregivers and society as a whole. Families of the
students who experienced mental health problems may worry and stress about the illness of
their children. They also may feel guilty that they might contribute to the development of
their children's problems (Dzurec, Allchin, & Engler, 2007). These may lead them to isolate
themselves from friends, community, and social support networks that the families used to
have due to the fear of stigma or prejudice. In relation to financial burden, families of
mental illness persons also faced with financial problems and needed more support from
society. Due to high incidence of mental health problems and its related negative
consequences, it should be concerned about mental health among nursing students and the
issue of mental health and mental health problems are deserved more attention.
From literature review, mental health of the individuals related to both individual
and environmental factors (Lazarus & Folkman, 1984; Ni et al., 2010; Vatanasin, 2005).
These two factors serve as important factors contributing to mental health in both positive
and negative aspects. For this study, the three most promising individual factors associated
with mental health among nursing students include educational achievement (Parvizrad,
Charati, Sadeghi, Mohammadi, & Hosseini, 2014), emotional quotient (Tsaousis &
Nikolaou, 2005), and self-esteem (Ni et al., 2010). In addition, for the environmental factor
which has a significant impact on mental health of this population is social support (Jensen,
2007; Luo & Wang, 2009).
Educational achievement is an indicator reflecting learning outcome of students.
Grade point average (GPA) is considered as one of an indicator reflecting academic
achievement. The positive correlation between GPA and mental health among nursing
student has been found in some studies (Floyd, 2010; Xu et al., 2014). Nursing students


11

who had poor educational achievement are more likely to be stress. According to Vatanasin
(2005), when the high level of stress among nursing students lasted for a long time, it might
lead to depression or other mental problems. According to the studies conducted by Beck,
Hackett, Srivastava, McKim, and Rockwell (1997) and Parvizrad et al. (2014), better GPA
was significantly associated with less mental health problems among nursing students.
Emotional quotient (EQ) represents a person’s emotional intelligence (EI) which
can be defined as an individual’s ability to perceive, assess, and regulate his or her own
emotions and also understand the emotions of others (Mayer, Salovey, & Caruso, 2000).
This is an issue that can impact directly on individual’s life and make him or her has better
adjustment and adaptation to a new situation (Bar-on & Parker, 2000). Batool and Khalid
(2009) indicated that adaptive value of emotional intelligence served as a significant factor
contributed to maintaining and promoting individual’s mental health. Mood swings and
other psychological problems could be occurred if an individual is unable to understand and
manage his or her own emotion. In addition, inability to form strong relationships with
others may cause these individuals feel lonely and isolated. Although, there have been only
few studies examining the emotional intelligence among nursing students, the results
obtained from these studies showed consisting results which affirmed that there was a
significant relationship between emotional intelligence and mental health. Individuals with
better EI reported less subjective stress and experienced better mental health (DonaldsonFeilder & Bond, 2004; Tsaousis & Nikolaou, 2005). This means that nursing students who
acknowledge their own emotions and able to regulate their emotions somehow have lower
stress in their tasks or studies (Limonero, Tomas-Sabato, & Ferna´ndaz-Castro, 2004).
Thus, they are less likely to be at risk to develop mental health problems.
Self-esteem is another significant individual factor associated with mental health
(Merianos, Nabors, Vidourek, & King, 2013). Nursing students who have high self-esteem
tend to have positive evaluation towards themselves and have more confidence.
Conversely, those with low self-esteem are more likely to admit weaknesses and feel that
their lives are not worthwhile (Ootim, 1998). Negative appraisal towards themselves may
lead them to have distortion in their thinking structures and mental health problems
(Lazarus & Folkman, 1984). According to the study conducted by Ni et al. (2010), there

was a significant relationship between self-esteem and mental health among nursing
students, and a high level of self-esteem served as a protective factor which helps promote


12

positive mental health. Specifically, fewer days of mental health problems per month were
reported by those with higher levels of self-esteem than those with lower self-esteem.
Remarkable, Rosenfield, Lennon, and White (2005) indicated that mental health problems
including anxiety and depression were closely related to low self-esteem. Various studies
also revealed a negative association between self-esteem and depression among nursing
students (Furegato, Santos, & Silva, 2008; Huong et al., 2011; Vatanasin, 2005).
Finally, social support has been found to have association with mental health
among nursing students. Indeed, Maville and Huerta (1997) reported that nursing school
may possibly induce stress among nursing students. Social support has been an important
factor in helping nursing students to cope with stress during their nursing education (Huong
et al., 2011; Luo & Wang, 2009). Luo and Wang (2009) conducted a study to examine
mental health of 288 college nursing students in China by using social support
questionnaire and Symptom Checklist 90 (SCL-90) to identify both positive and negative
mental health. The findings indicated that social support was negatively correlated with
psychological symptoms (r = -.135, p < .05). The students who had more social support
reported better positive mental health and lesser negative mental health (Jensen, 2007;
Montes-Berges & Augusto, 2007). In contrast, less social support placed nursing students at
higher risk for mental health problems such as depression (Huong et al., 2011). This was
also reported in studies of Ratanasiripong (2012) and Vatanasin (2005).
From the aforementioned reviews, it can emphasize that mental health problems
among nursing students are commonly found along with its negative impacts. Even though,
there have been various studies around the world focusing on mental health of nursing
students, there have been only few studies that have placed an emphasis on exploring
mental health in both facets whether positive or negative mental health of these students.

Those few studies conducted with Vietnamese students included the studies of Do (2007),
Nguyen (2009), Thai (2010) and Huong et al. (2011). In the study of Do (2007) which
conducted with 351 first year medical students in Ho Chi Minh city, the results revealed
that 39.6 % of these students had scores indicating depression or negative mental health. In
addition, the prevalence of psychological distress or negative mental health including
depression, and anxiety showed the prevalence of 26.3 %, and 16.2 %, respectively. In the
study of Thai (2010), there were 1,226 students in Ho Chi Minh city participated in this
study. Notably, the percentages of these students who had had suicidal idea and some of


13

them reported attempted suicide during the past 12 months were 6.3 %, and 5.8 %
respectively. Based on literature review for the study conducted in Vietnam, only one
study investigated depression among 261 Vietnamese nursing students, and indicated that
45.6 % of the students reported mental health problem reflected by depression (Huong et
al., 2011).
Because of the importance of nursing students who will be the professional care
providers in the near future, as well as the alarming issue regarding mental health problems
experienced by nursing students across the countries, this study would like to conduct the
study in order to examine mental health and to test its relationships with related factors
among Vietnamese nursing students. Findings obtained from this study would serve as
baseline data for the prevalence of mental health among Vietnamese nursing students as
well as guidance for developing program or intervention aimed at promoting mental health
among the nursing students.

Research objectives
This study focuses on examining mental health and testing its relationships with
educational achievement, emotional quotient, self-esteem, and social support among
nursing students in Hai Duong Medical Technical University, Vietnam.

Research hypotheses
1. GPA is positively related to mental health among Vietnamese nursing students.
2. Emotional quotient is positively related to mental health among Vietnamese
nursing students.
3. Self-esteem is positively related to mental health among Vietnamese nursing
students.
4. Social support is positively related to mental health among Vietnamese nursing
students.

Scope of study
This study focused on examining mental health and testing its relationships with
related factors among nursing students in Hai Duong Medical Technical University,
Vietnam. The period time for data collection was from June to July, 2015.


14

Research framework
The research framework of this study was synthesized from literature reviews
related to mental health among nursing students. Mental health of the individuals is related
to the interaction between the person and the environment (Ni et al., 2010; Stuart & Laraia,
2005; Vatanasin, 2005). When this interaction exceeds the individual's resources, it can
endanger individual's mental health. Stress is an example. However, the level of negative
mental health or mental health problems depends on the individual's appraisal of the degree
of the threat in the transaction, and the relative power of the environmental demands
compared with the abilities of the persons to prevent or manage such harm (Lazarus &
Folkman, 1984). Selected factors associated with mental health among nursing students
examined in this study include both individual and environmental factors. The individual
factors included education achievement, the emotional quotient, and self-esteem. For

environmental factor, social support was examined.
Individual factors can affect the way that the person confronts stressful situations
and also how she or he reacts to such stressor. Nursing students may confront a variety of
stressors. The evidence showed that mental health was associated with academic success
among these students (Higginson, 2006; Shaban et al., 2012; Sreeramareddy et al., 2007).
The students who had low GPA are more likely to develop negative mental health, such as
having negative attitudes and behaviors, sadness, hopelessness, depression, and even
suicidal ideation (DeSimone, 2010). In addition, emotional quotient was found to be related
to mental health of nursing students (Brown & Schutte, 2006; Khosro & Khanzadeh, 2007).
The students who had good mental health were those who had better emotional quotient.
They were able to appraise and effectively regulate their own emotional state (Tsaousis &
Nikolaou, 2005). Whereas, those students who had a low level of emotional quotient
reported more negative mental health or psychological distress (Birks, McKendree, & Watt,
2009). Self-esteem was also another factor found to have relationship with mental health.
According to DeLongis and Folkman (1988), individuals with low self-esteem were more
vulnerable to develop mental health problems than those with higher self-esteem. Nursing
students with good self-esteem were more likely to understand themselves and accept the
problems realistically. They also had feeling of self-worth, which made them feel satisfied,
and which resulted in fewer mental health problems. Conversely, the individuals with low
self-esteem are more likely to have pessimistic ideas and feelings of guilt toward


15

themselves, which can cause a distortion in ideas and have an effect on their mental health.
Furthermore, social support was indicated as an environmental factor that serves as a
protective factor. It provided vital resources that the individual can draw upon to survive
and flourish (Baqutayan, 2011; Lazarus & Folkman, 1984). Social support helped to
strengthen an individual’s ability against the stressors and helped to reduce negative effects
of mental health problems (Lazarus & Folkman, 1984). Faced with stressful life conditions,

people feel better if they have more social support (Jensen, 2007; Luo & Wang, 2009).
Nursing students with more social support reported better mental health (Montes-Berges &
Augusto, 2007). In contrast, a lack of social support placed the students at a higher risk for
mental health problems.
In sum, nursing students who had good educational achievement (GPA), had a
sense of self-worth (self-esteem), had good interaction with others (emotional quotient) and
received good support from others (social support) had good mental health. The research
framework of this study is summarized in Figure 1.

Educational achievement

Emotional quotient
Mental health
Self-esteem

Social support

Figure 1 Research framework

Definition of terms
Mental health refers to a nursing student’s state of well-being which includes the
facets of positive mental health (i.e. psychological well-being) and negative mental health
(i.e. psychological distress). The Mental Health Inventory, 18-item version (MHI-18) which
was modified from the original 38-item scale developed by Veit and Ware (1983) was used
to examine mental health in both facets.


16

Educational achievement refers to the level of education success attained by

nursing student as reflected by cumulative grade point average (GPA) from the first
semester to the recent semester. According to GPA scores, the highest score that nursing
student can obtained is 4 and the lowest score is 0.
Emotional quotient refers to the capacities of nursing students to recognize their
own feelings, and those of others, able to motivate themselves and have well management
of their own emotions as well as in the relationship with others. It was measured by using
the Schutte Emotional Intelligence Scale (SEIS) developed by Schutte et al. (1998).
Self-esteem refers to overall sense of self-worth or personal value of nursing
students. In this study, self-esteem was measured using the Rosenberg Self-esteem Scale
developed by Rosenberg (1965).
Social support refers to the perception of nursing students towards the
availability of instrumental, informational, and emotional support they have. These would
lead them to believe that he/ she is cared for and loved, esteemed and valued, and that he/
she belongs to a society. It was measured by using the Personal Resource Questionnaire
2000 (PRQ2000) developed by Weinert (2003).


17

CHAPTER 1
INTRODUCTION

Background and significance of the problem
Nursing occupies an important position in the healthcare system. Nursing students
are the future professional health care providers who play important roles in providing care
as well as supporting patients physically and psychologically. Thus, they themselves should
also have good mental health, which is one of the significant health components (Ni et al.,
2010). Nursing students are not only facing with the challenges like most of other college
students including accommodation, interpersonal relationships, financial burden, parental
pressure as well as their concerns about the future, but they also have to face with more

stressful academic learning and psychological stressors (Dutta, Pyles, & Miederhoff, 2005;
Sreeramareddy et al., 2007; Vaez, Ponce de Leon, & Laflamme, 2006).
Specifically, with the aims of equipping necessary skills for the students after
graduation, nursing students across the nations and Vietnam in particular have to learn both
theory-based classes and also practice in the clinical settings. In the first year of their
studies, heavy academic pressure, concerns about examinations, worrying about grades are
cited as a major source of stress for some students (Huong, Hengudomsub, &
Suppaseemanont, 2011; Shaban, Khater, & Akhu-Zaheya, 2012). In their subsequent years
of study, the students begin specific courses and start practicing in clinical settings such as
in the hospitals (Huong et al., 2011). This time period may be the most stressful for some of
the nursing students (Moscaritolo, 2009). The students are also required to have continuous
interaction with a variety of individuals including patients, their family members, and other
health care providers (Reeves, 2005). The students must be concern about their mistakes
which can seriously harm the patients, even cause death to the patients. Therefore, the
students are required high responsibility, circumspection, and discretion. Moreover, during
practical experience in hospital, they may encounter with conflicts between health staffs,
suffering situation of patients, such as pain, cancer disease in young patients, even death
sometimes (Augusto-Landa, López-Zafra, Berrios-Martos, & Pulido-Martos, 2012;
Gibbons, Dempster, & Moutray, 2009; Pryjmachuk, 2004). All of these cause stressful
situations for them, and these may lead them to have to physical and mental health
problems (Sreeramareddy et al., 2007).


18

There have been various studies that explored mental health among nursing
students worldwide (Liu & Jia, 2008; Wu, 2005). Mental health encompassed of positive
mental health or psychological well being and negative mental health which in other
words were psychological distress or mental health problems. The prevalence of mental
health problems or negative mental health among this population was varied. According to

the data from some epidemiologic studies among nursing students in China, 7.7 % to 28.7
% of the students experienced mental health problems (Liu & Jia, 2008; Wu, 2005).
Another study was conducted to examine the mental health of 1,686 first-year medical
science students in Iran using the General Health Questionnaire-28 (GHQ-28). The results
revealed that 35.7 % of these students had mental health problems. Among them, nursing
students showed the highest percentage of those who experienced mental health problems
(Lotfi, Aminian, Ghomizadea, & Noorani, 2009). Depression and anxiety have been
documented as the most common mental health problems among nursing students in
several studies (Cook, 2005; Moscaritolo, 2009; Vatanasin, 2005). A high prevalence of
depression was found among nursing students in the China, Kenya and India (Chatterjee et
al., 2014; Othieno, Okoth, Peltzer, Pengpid, & Malla, 2014; Xu et al., 2014). Other studies
also found a high prevalence of anxiety among this population in the United States and Iran
(Cook, 2005; Moscaritolo, 2009).
Mental health problems not only caused negatively impacts on the students’ lives,
but also on their families and society. As for the students themselves, there were some
studies which demonstrated a relationship between mental illness and academic problems
(Breslau, Lane, Sampson, & Kessler, 2008; Hunt, Eisenberg, & Kilbourne, 2010).
Specifically, the students who reported depressive symptoms tended to pay less attention in
their studies, decreased abilities for study concentration. Moreover, elevated anxiety which
produced a state of physiological arousal also indicated as a factor leading to the
impairment of their abilities to concentration on others (Wood, 2006). All of these can lead
to low academic performance among these nursing students.
In addition, the poor quality of student's life is also reflected as loss of interest in
leisure activities, having eating and sleeping disturbances, and even suicidal thoughts
(Vatanasin, 2005). According to Hawton, Agerbo, Simkin, Platt, and Mellanby (2011),
nursing students were at higher risk for suicide than other college students. A statistics from
Pennsylvania State University found that more than 30 % of students who seek services for


19

mental health issues reported that they had considered attempting suicide at some point in
their lives, up to be about 24 % in the year 2010 (Novotney, 2014). Another study was
conducted of 142 nursing students of the Technological Educational Institute of
Thessaloniki in Greece (Melissa-Halikiopoulou, Tsiga, Khachatryan, & Papazisis, 2011),
and it revealed that 43.9 % of them reported depressive symptoms. Also, 10.6 % said that
they had suicidal ideation, but they didn’t act on them, while two students (1.4 %) declared
that they could have done it if they had the chance to do so. In terms of profession, students
have regular contacts and direct patient care, so quality of care provided for the patients
may also be reduced. On the other hand, mental health problems among nursing students
can also create burden to their family caregivers and society as a whole. Families of the
students who experienced mental health problems may worry and stress about the illness of
their children. They also may feel guilty that they might contribute to the development of
their children's problems (Dzurec, Allchin, & Engler, 2007). These may lead them to isolate
themselves from friends, community, and social support networks that the families used to
have due to the fear of stigma or prejudice. In relation to financial burden, families of
mental illness persons also faced with financial problems and needed more support from
society. Due to high incidence of mental health problems and its related negative
consequences, it should be concerned about mental health among nursing students and the
issue of mental health and mental health problems are deserved more attention.
From literature review, mental health of the individuals related to both individual
and environmental factors (Lazarus & Folkman, 1984; Ni et al., 2010; Vatanasin, 2005).
These two factors serve as important factors contributing to mental health in both positive
and negative aspects. For this study, the three most promising individual factors associated
with mental health among nursing students include educational achievement (Parvizrad,
Charati, Sadeghi, Mohammadi, & Hosseini, 2014), emotional quotient (Tsaousis &
Nikolaou, 2005), and self-esteem (Ni et al., 2010). In addition, for the environmental factor
which has a significant impact on mental health of this population is social support (Jensen,
2007; Luo & Wang, 2009).
Educational achievement is an indicator reflecting learning outcome of students.

Grade point average (GPA) is considered as one of an indicator reflecting academic
achievement. The positive correlation between GPA and mental health among nursing
student has been found in some studies (Floyd, 2010; Xu et al., 2014). Nursing students


20

who had poor educational achievement are more likely to be stress. According to Vatanasin
(2005), when the high level of stress among nursing students lasted for a long time, it might
lead to depression or other mental problems. According to the studies conducted by Beck,
Hackett, Srivastava, McKim, and Rockwell (1997) and Parvizrad et al. (2014), better GPA
was significantly associated with less mental health problems among nursing students.
Emotional quotient (EQ) represents a person’s emotional intelligence (EI) which
can be defined as an individual’s ability to perceive, assess, and regulate his or her own
emotions and also understand the emotions of others (Mayer, Salovey, & Caruso, 2000).
This is an issue that can impact directly on individual’s life and make him or her has better
adjustment and adaptation to a new situation (Bar-on & Parker, 2000). Batool and Khalid
(2009) indicated that adaptive value of emotional intelligence served as a significant factor
contributed to maintaining and promoting individual’s mental health. Mood swings and
other psychological problems could be occurred if an individual is unable to understand and
manage his or her own emotion. In addition, inability to form strong relationships with
others may cause these individuals feel lonely and isolated. Although, there have been only
few studies examining the emotional intelligence among nursing students, the results
obtained from these studies showed consisting results which affirmed that there was a
significant relationship between emotional intelligence and mental health. Individuals with
better EI reported less subjective stress and experienced better mental health (DonaldsonFeilder & Bond, 2004; Tsaousis & Nikolaou, 2005). This means that nursing students who
acknowledge their own emotions and able to regulate their emotions somehow have lower
stress in their tasks or studies (Limonero, Thomas-Sabato, & Ferna´ndaz-Castro, 2004).
Thus, they are less likely to be at risk to develop mental health problems.
Self-esteem is another significant individual factor associated with mental health

(Merianos, Nabors, Vidourek, & King, 2013). Nursing students who have high self-esteem
tend to have positive evaluation towards themselves and have more confidence.
Conversely, those with low self-esteem are more likely to admit weaknesses and feel that
their lives are not worthwhile (Ootim, 1998). Negative appraisal towards themselves may
lead them to have distortion in their thinking structures and mental health problems
(Lazarus & Folkman, 1984). According to the study conducted by Ni et al. (2010), there
was a significant relationship between self-esteem and mental health among nursing
students, and a high level of self-esteem served as a protective factor which helps promote


21

positive mental health. Specifically, fewer days of mental health problems per month were
reported by those with higher levels of self-esteem than those with lower self-esteem.
Remarkable, Rosenfield, Lennon, and White (2005) indicated that mental health problems
including anxiety and depression were closely related to low self-esteem. Various studies
also revealed a negative association between self-esteem and depression among nursing
students (Furegato, Santos, & Silva, 2008; Huong et al., 2011; Vatanasin, 2005).
Finally, social support has been found to have association with mental health
among nursing students. Indeed, Maville and Huerta (1997) reported that nursing school
may possibly induce stress among nursing students. Social support has been an important
factor in helping nursing students to cope with stress during their nursing education (Huong
et al., 2011; Luo & Wang, 2009). Luo and Wang (2009) conducted a study to examine
mental health of 288 college nursing students in China by using social support
questionnaire and Symptom Checklist 90 (SCL-90) to identify both positive and negative
mental health. The findings indicated that social support was negatively correlated with
psychological symptoms (r = -.135, p < .05). The students who had more social support
reported better positive mental health and lesser negative mental health (Jensen, 2007;
Montes-Berges & Augusto, 2007). In contrast, less social support placed nursing students at
higher risk for mental health problems such as depression (Huong et al., 2011). This was

also reported in studies of Ratanasiripong (2012) and Vatanasin (2005).
From the aforementioned reviews, it can emphasize that mental health problems
among nursing students are commonly found along with its negative impacts. Even though,
there have been various studies around the world focusing on mental health of nursing
students, there have been only few studies that have placed an emphasis on exploring
mental health in both facets whether positive or negative mental health of these students.
Those few studies conducted with Vietnamese students included the studies of Do (2007),
Nguyen (2009), Thai (2010) and Huong et al. (2011). In the study of Do (2007) which
conducted with 351 first year medical students in Ho Chi Minh city, the results revealed
that 39.6 % of these students had scores indicating depression or negative mental health. In
addition, the prevalence of psychological distress or negative mental health including
depression, and anxiety showed the prevalence of 26.3 %, and 16.2 %, respectively. In the
study of Thai (2010), there were 1,226 students in Ho Chi Minh city participated in this
study. Notably, the percentages of these students who had had suicidal idea and some of


22

them reported attempted suicide during the past 12 months were 6.3 %, and 5.8 %
respectively. Based on literature review for the study conducted in Vietnam, only one
study investigated depression among 261 Vietnamese nursing students, and indicated that
45.6 % of the students reported mental health problem reflected by depression (Huong et
al., 2011).
Because of the importance of nursing students who will be the professional care
providers in the near future, as well as the alarming issue regarding mental health problems
experienced by nursing students across the countries, this study would like to conduct the
study in order to examine mental health and to test its relationships with related factors
among Vietnamese nursing students. Findings obtained from this study would serve as
baseline data for the prevalence of mental health among Vietnamese nursing students as
well as guidance for developing program or intervention aimed at promoting mental health

among the nursing students.

Research objectives
This study focuses on examining mental health and testing its relationships with
educational achievement, emotional quotient, self-esteem, and social support among
nursing students in Hai Duong Medical Technical University, Vietnam.

Research hypotheses
5. GPA is positively related to mental health among Vietnamese nursing students.
6. Emotional quotient is positively related to mental health among Vietnamese
nursing students.
7. Self-esteem is positively related to mental health among Vietnamese nursing
students.
8. Social support is positively related to mental health among Vietnamese nursing
students.

Scope of study
This study focused on examining mental health and testing its relationships with
related factors among nursing students in Hai Duong Medical Technical University,
Vietnam. The period time for data collection was from June to July, 2015.


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Research framework
The research framework of this study was synthesized from literature reviews
related to mental health among nursing students. Mental health of the individuals is related
to the interaction between the person and the environment (Ni et al., 2010; Stuart & Laraia,
2005; Vatanasin, 2005). When this interaction exceeds the individual's resources, it can
endanger individual's mental health. Stress is an example. However, the level of negative

mental health or mental health problems depends on the individual's appraisal of the degree
of the threat in the transaction, and the relative power of the environmental demands
compared with the abilities of the persons to prevent or manage such harm (Lazarus &
Folkman, 1984). Selected factors associated with mental health among nursing students
examined in this study include both individual and environmental factors. The individual
factors included education achievement, the emotional quotient, and self-esteem. For
environmental factor, social support was examined.
Individual factors can affect the way that the person confronts stressful situations
and also how she or he reacts to such stressor. Nursing students may confront a variety of
stressors. The evidence showed that mental health was associated with academic success
among these students (Higginson, 2006; Shaban et al., 2012; Sreeramareddy et al., 2007).
The students who had low GPA are more likely to develop negative mental health, such as
having negative attitudes and behaviors, sadness, hopelessness, depression, and even
suicidal ideation (DeSimone, 2010). In addition, emotional quotient was found to be related
to mental health of nursing students (Brown & Schutte, 2006; Khosro & Khanzadeh, 2007).
The students who had good mental health were those who had better emotional quotient.
They were able to appraise and effectively regulate their own emotional state (Tsaousis &
Nikolaou, 2005). Whereas, those students who had a low level of emotional quotient
reported more negative mental health or psychological distress (Birks, McKendree, & Watt,
2009). Self-esteem was also another factor found to have relationship with mental health.
According to DeLongis and Folkman (1988), individuals with low self-esteem were more
vulnerable to develop mental health problems than those with higher self-esteem. Nursing
students with good self-esteem were more likely to understand themselves and accept the
problems realistically. They also had feeling of self-worth, which made them feel satisfied,
and which resulted in fewer mental health problems. Conversely, the individuals with low


24

self-esteem are more likely to have pessimistic ideas and feelings of guilt toward

themselves, which can cause a distortion in ideas and have an effect on their mental health.
Furthermore, social support was indicated as an environmental factor that serves as a
protective factor. It provided vital resources that the individual can draw upon to survive
and flourish (Baqutayan, 2011; Lazarus & Folkman, 1984). Social support helped to
strengthen an individual’s ability against the stressors and helped to reduce negative effects
of mental health problems (Lazarus & Folkman, 1984). Faced with stressful life conditions,
people feel better if they have more social support (Jensen, 2007; Luo & Wang, 2009).
Nursing students with more social support reported better mental health (Montes-Berges &
Augusto, 2007). In contrast, a lack of social support placed the students at a higher risk for
mental health problems.
In sum, nursing students who had good educational achievement (GPA), had a
sense of self-worth (self-esteem), had good interaction with others (emotional quotient) and
received good support from others (social support) had good mental health. The research
framework of this study is summarized in Figure 1.

Educational achievement

Emotional quotient
Mental health
Self-esteem

Social support

Figure 1 Research framework


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Definition of terms
Mental health refers to a nursing student’s state of well-being which includes the

facets of positive mental health (i.e. psychological well-being) and negative mental health
(i.e. psychological distress). The Mental Health Inventory, 18-item version (MHI-18) which
was modified from the original 38-item scale developed by Veit and Ware (1983) was used
to examine mental health in both facets.
Educational achievement refers to the level of education success attained by
nursing student as reflected by cumulative grade point average (GPA) from the first
semester to the recent semester. According to GPA scores, the highest score that nursing
student can obtained is 4 and the lowest score is 0.
Emotional quotient refers to the capacities of nursing students to recognize their
own feelings, and those of others, able to motivate themselves and have well management
of their own emotions as well as in the relationship with others. It was measured by using
the Schutte Emotional Intelligence Scale (SEIS) developed by Schutte et al. (1998).
Self-esteem refers to overall sense of self-worth or personal value of nursing
students. In this study, self-esteem was measured using the Rosenberg Self-esteem Scale
developed by Rosenberg (1965).
Social support refers to the perception of nursing students towards the
availability of instrumental, informational, and emotional support they have. These would
lead them to believe that he/ she is cared for and loved, esteemed and valued, and that he/
she belongs to a society. It was measured by using the Personal Resource Questionnaire
2000 (PRQ2000) developed by Weinert (2003).