Introduction

Stress is defined as a psychological and physical stimulus that disturbs the state of adaptation and negatively affects the dynamic interaction and adaptation between the individual and his response to the environment such as the learning environment around him [1]. Stress is considered one of the most important factors that affect the academic achievement of university students in general and nursing students in particular, where nursing students suffer from pressure and stress that leads to burnout [2,3]. This is because the study of nursing specialization requires theoretical and practical training for students and good education to be able to carry out the tasks of the nursing profession in the future and provide effective health care at a good level, and for this reason, nursing students suffer from a high level of stress and severe pressures [4-6]. Moreover, stress is considered one of the global problems that nursing students suffer from in various countries of the world [4]. In addition, it was found that the psychological pressure of nursing students affects their physical and mental health, which affects their professionalization process [4-6].

Sleep is defined as a basic physiological therapeutic phenomenon that results from the interaction between biological and biochemical processes with the social, environmental, and cultural aspects closely related to the lives of young people [7,8]. The duration of sleep is defined as the amount of sleep that the individual gets during the night period or within 24 hours, Also, sleep quality is defined as the individual's satisfactory expression of aspects of sleep onset, sleep experience, sleep quantity, refreshment upon awakening, and sleep maintenance [9,10]. Sleep is very important for maintaining the physical and mental health of university students because it helps give the body an opportunity to feel comfortable and plays an important role in the process of academic achievement and learning [11]. In addition, lack of sleep, deprivation of it, or lack of hours of sleep results in many negative effects and problems that university students and nursing students may face, among these effects are anxiety, fatigue, lack of concentration, decreased neurocognitive performance, daytime sleepiness, disturbed mood, high tension, difficulty paying attention, and inability to complete tasks [12-15]. Nursing students may suffer from a lack of sleep due to stress, as it is considered a major factor contributing to their lack of sleep, where many studies from different countries of the world have proven that stress leads to a lack of sleep and affects its quality and duration among students of medical colleges [16-21].

Many studies have shown that there is a clear impact of stress on sleep among medical students such as nursing [10,12,22,23], as students suffer from insomnia and lack of sleep, which affect the quality of sleep, this is because of the stress resulting from staying up late to get extra time to study in order to perform the exams well or to complete the tasks that determine their level in the study, in order to prepare for the future and compete for the best ranks [11,19].

All of these factors lead to stress, which in turn affects the quality and pattern of sleep for students. In addition to that, the quality of sleep is measured by the Pittsburgh Sleep Quality Index (PSQI) [12].Furthermore, there is a relationship and correlation between stress, sleep, and academic performance, when medical students suffer from high-stress levels, this negatively affects their mental and physical health, their level of focus, and their cognitive and academic performance.

While the effect of stress on sleep among students appears through disturbed sleep, lack of hours of sleep, waking up during sleep, and waking up early [12], which may also lead to weakness in the academic performance of students. In addition, it was found that sleep has a direct effect on perception, attention, and working memory among students, as working memory is responsible for the learning process and is an indicator of the quality of academic performance [24,25]. This memory is affected by sleep disturbance, which is also affected by a high level of stress in students [26].

Also, it was found that the disorder resulting from stress is widespread among students of medical colleges, which leads to an effect on the quantity and quality of sleep and thus contributes to poor quality of well-being and learning among students [16], and some studies also mentioned that high levels of stress among students are associated with a decrease in their academic performance [12,27-29].

There are some studies conducted in some Arab and foreign countries that dealt with the relationship between stress, quality of sleep, and academic performance of medical and nursing students [ 6,7,10-12,19], but there is not one study, at least has addressed this important topic in Jordan, where stress and lack of sleep are common problems among university students, especially nursing students, because they face more difficulties during the study, such as intensive curricula, increased academic requirements, difficult exams and their diversity and repetition, the need to adhere to appointments and timetables, and others.

On the other hand, the high levels of stress, the prevalence of sleep disorders, and the poor academic performance of nursing students represent a threat at the academic level and a concern at the health level. Therefore, the aim of conducting the current study was to evaluate and determine the impact of stress on sleep pattern and academic performance among nursing students during their studies in the pre-clinical stages at the Faculty of Nursing, Mutah University.

In addition to that, to investigate the relationship between stress, sleep pattern, and academic performance.

Materials and Methods

Study setting and design

This cross-sectional study adopted the descriptive analytical design and approach, it was conducted from August to October 2022 and targeted nursing students who were selected from different educational levels (first, second, third, and fourth) at the Faculty of Nursing at Mutah University, Jordan. The design of the cross-sectional study was adopted because it is appropriate to achieve the main purpose of the study, as well as its ability to respond to the desired sub-goals of the study in a manner that is appropriate to the time, capabilities, and sources of information. Data were collected and information was obtained through distributing questionnaires as research tools, which consisted of four parts: A questionnaire related to demographic characteristics and lifestyle, determination of stress levels by Kessler Psychological Distress Scale (K10), sleep quality assessment by Pittsburgh Sleep Quality Index (PQSI), and academic performance is assessed by the overall Grade Point Average (GPA).

The Kessler scale (K10) was used to determine the level of prevalence of stress among the participating nursing students. This scale consists of 10 questions that included an evaluation of stress and anxiety during the past three months. The items were evaluated on a five-point scale with scores in the range (10-50), So the symptoms of anxiety and stress are considered mild distress if their scores are in the range (20-24), moderate (25-30) scores, and severe (30 or higher) scores. Also, the Kessler scale is an effective and universally popular tool for studying and evaluating stress when conducting population studies [30].

The quality of sleep among the participating students was identified and evaluated by the PSQI [31], which consists of 18 questions that include seven components. Briefly, four questions were determined about sleep time, waking time, sleep latency time, and total hours of actual sleep during the past three months to measure sleep quality. In addition to the rest of the questions which included obtaining information about suggested factors that may lead to sleep disturbance such as daytime sleepiness and use of sleep medications, enthusiasm for productivity, and a final self-assessment question about the overall quality of sleep in three past months. Each question was classified and given from 0 to 3 points, and the maximum points for each component were 3 out of 3, while the total score range for the seven components that make up the total points was in the range (0-21). In addition to that, higher scores indicate poor sleep quality, for example, a score higher than 6 indicates poor sleep quality.

The academic performance of the participating nursing students was measured and evaluated using the current overall Grade Point Average (GPA). This measure was used to study and determine the academic achievement of students in many studies similar to this study. Moreover, the GPA scale is based on the student's cumulative average, which is obtained from the academic record, where the students' average grades for the first semester were adopted, and therefore the cumulative average was classified into three categories according to grades out of 5 were: 4.5-5 (excellent performance), 3.5-4.5 (very good performance), and <3.5 (good performance, pass) or (poor performance (fail)).

Participants and procedure

The study did not include certain inclusion criteria, i.e., all students in the nursing department are suitable for participation, except the students who are absent from attendance on the day on which the data was collected, or students who were not willing to participate in this study as out of 335 students, refused 15 students participated in the study procedures. The number of participating students was 320 from the Faculty of Nursing at Mutah University, and their ages ranged between 18 to 25 years, females represented 64% (n=204) of the total number of participating students, while males represented 36% (n=116). Data about the sociodemographic and lifestyle characteristics of the participating nursing students were collected and they included (gender, age, marital status, work status, residency, academic year, number of times intake of caffeine, and napping during the day). Moreover, all students reported their consent to participate and thus had a response rate of 100% and completed the questionnaire based on their availability during class. In addition, the person responsible for following up and distributing the questionnaires was one of the members of the research team, who clarifies the questionnaires, highlights the purpose of the study, and answers students' inquiries about the items and paragraphs of the questionnaire.

The data were examined, and statistical analysis was performed and entered into the statistical program using the Statistical Package for Social Sciences (SPSS) version 22. The data were analyzed by descriptive statistics, which are presented as categorical variables in the form of frequencies and percentages, while continuous variables are presented by the mean and standard deviation. The relationship between demographic variables, stress, sleep quality, and academic performance was examined using Pearson's Chi-square test, which is also used to analyze associations between categorical variables. Whereas the test result at p<0.05 was considered statistical significant.

Results

Sociodemographic characteristics of the study participants

The total of nursing students who participated in this study was 320, and their socio-demographic characteristics are shown in Table 1.The majority of the participants were females (n=204, 64%), while 116 were males (36%). The majority of the participants (n=196, 61%) were between the ages of 20 and 24 years. Regarding the marital status of students, most of them (n =314, 98%) are unmarried, did not work (n=256, 80%), and live with their families (n=308, 96%). Regarding the academic year, about one‑third of the participating students were (n=112, 35%) in the first academic year, (n=80, 25%) in the second year, (n=83, 26%) in the third year, and (n=45, 14%) in the fourth year. In terms of practicing dietary habits, the focus was placed on the number of times caffeine was consumed, where more than half of the participants (n=199, 62%) reported that they drink caffeine daily, (n=87, 27%) drink it weekly, and (n=34, 11%) more than once in the week.

In terms of the academic performance of the participating students that was measured by relying on their Grade Point Average (GPA), they were classified according to their academic performance into three categories, 32% of the participating students were excellent with a GPA of (4.5-5.0), 33% of them were very good with a GPA of (3.5-4), while 35% were good or below in their academic performance (<3.5).The sleeping habits of the participating nursing students were identified and examined using the PSQI global score as shown in Table 1. It is noted that there is a poor quality of sleep among the participants if the total score obtained for the PSQI is more than 5. In this study, the total score for the PSQI was obtained for the participants 76% (n=244) with a mean value of (8.42 ± 3.63). Table 1 also shows that more than half of the students (n=170, 53%) went to bed during the period (1:00-1:59), then comes the period from 00:00 to 00:59 and the participants were (n=74, 23%), while 21% reported that they went to sleep before midnight, and it is considered the normal bedtime.

Table 1: Sociodemographic characteristics of the study participants (nursing students) (n=320).

Therefore, the hours of sleep that the students took were less than seven hours per night, with a mean of 5.8 ± 1.58 hours out of the actual total hours of sleep, which ranged from 2 to 11 hours. In addition, 45% of the participating nursing students reported that they took a break by taking a nap during the day. It should be noted that most of the participants (n=260, 81%) reported that their sleep quality was poor, while only 19% reported that their sleep quality was as fairly good.

The prevalence of stress among the participating nursing students was prevalent as 63% (n=203) showed distress positively on Kessler Psychological Distress Scale (K10). Of the participating students, 40% (n=129) experienced moderate or severe symptoms of stress, while 23% and 15% experienced mild and moderate levels of stress, respectively. The mean K10 for the participating nursing student was 23.92 ± 8.72 and K10 scores included all ranges from 10 to 50.

The impact of stress on sleep pattern and Academic Performance (GPA) of nursing students.

Table 2 shows the relationship between stress and sleep pattern (poor sleep quality) and GPA, through study variables that also include the characteristics of participating nursing students. Where the majority of the participants reported that they suffer from stress, 82% of the females and 56% of the males. Therefore, there was a statistically significant relationship between stress and gender (p=0.001), as females suffer from stress more than males. The results showed that nursing students who take a nap during the day suffer from poor sleep quality, as 82% of the participants reported suffering from poor quality of their sleep even though they took a daytime nap, compared to 72% who did not take a nap. More clearly, there was a statistically significant association between daytime naps and poor sleep quality (p=0.036). In addition, statistically significant differences were found between stress and the GPA of the participating nursing students, as well as between GPA and poor sleep quality. According to the analysis, the most stressed 68% of participants had a GPA<3.5, while the least stressed 57% of participants had GPA of 4.5-5. This means that there is a statistically significant correlation between stress and GPA (p=0.025).Regarding the relationship between GPA and poor sleep quality, it was found that 82% of the participants with poor sleep quality had a GPA<3.5 and 69% of the participants with poor sleep quality had GPA of 4.5-5. Thus there was a statistically significant correlation between poor sleep quality and GPA (p=0.034).Moreover, 70% of the participating students reported that they suffer from poor sleep quality due to stress, compared to 47% of the participants who did not have poor sleep quality. It was found that there is a clear statistically significant relationship between stress and sleep pattern (poor sleep quality) (p=0.002).In addition, the results show that students with a higher level of stress suffer from poor sleep quality, as poor sleep quality was represented with each level of distress as follows: 70% of mild distress, 90% of moderate distress, and 96% of severe distress (p=0.002) (Table 2).

Table 2: Represents the association between stress and the characteristics of the nursing students by sleep pattern and academic performance (n=320).

Discussion

The results of the current study showed that the prevalence of stress among nursing students was high (63%) and the prevalence of poor sleep quality was high (81%). This result is consistent with the results of some studies, especially in Arab countries, where they found that the prevalence of stress and poor sleep quality among nursing students was high [12,19,21,28, 32,33]. The reason for the prevalence of stress and poor quality of sleep may be related to environmental factors surrounding nursing students in Jordanian universities and irregular sleep habits such as studying late at night, caffeine intake, long hours internet use, and increased numerous academic tasks. As sleep is considered a good indicator of the health status of students, but when they join the university, this leads to a change that clearly affects their sleeping habits, and thus increases the level of stress among students [7,34,35].

One of the most important results reached in this study is finding a significant association between gender and stress, as 82% of nursing students were females suffering from stress as well as from a change in sleep pattern. This result is consistent with some studies where it was mentioned that being a female university student studying in some medical departments, is considered a clear and important indicator of disturbed sleep pattern and, consequently, a high level of stress [19,36-38]. This means that there are differences between the sexes related to stress level as well as sleep pattern. In addition, the results showed that taking a nap during the day was significantly associated with a change in the sleeping pattern at night for nursing students, as 82% of them had a disturbance in their sleep pattern and they took a nap during the day. This result is consistent with the results of studies conducted in Saudi Arabia [12], America [35], and Alabama [39]. Moreover, it was found that naps during the day affect the sleep pattern of nursing students, because naps lead to irregular hours of sleep and do not compensate for the hours of night sleep, thus greatly affecting the quality of sleep among students.

In general, university students have responsibilities and demands related to the psychological and social aspects that make them vulnerable to a high level of stress, which may affect academic performance [40]. Specifically, nursing education is stressful and leads to more stress because it needs psychological and material capabilities, due to the clinical requirements, high academic tasks, and the multiple and complex challenges faced by nursing students in the clinical environment [41,42]. Based on this, an important and basic conclusion was reached in this study, which is that stress among nursing students affects academic performance. Where the results showed that 68% of the students who were suffering from a high level of stress had the lowest GPA (<3.5), and in contrast, the students with a high GPA had a low level of stress. This result is similar to the results of some national studies as well as studies at the international level as two studies conducted in Saudi Arabia [19,40,43,44], a study in Singapore [45], and another in Turkey [6].

Through the results related to the effect of sleep quality on the academic performance of nursing students, our study proved that there is a correlation between poor sleep quality and academic performance. Different sleeping habits affected academic performance, as 82% of students who suffer from poor sleep quality due to practicing bad sleeping habits had GPA of less than 3.5, meaning that their academic performance results are weak and not good. This result is similar to what some studies concluded [7,39,46-49]. Certainly, stress and sleep affect each other, as lack of sleep can lead to increased stress among students, in return, increasing the level of stress also leads to a change in sleep pattern and disturbances in it, and thus leads to the poor academic performance of nursing students. This is for several reasons, namely the preference for studying at night, which leads to irregular sleep and waking up, the use of technology before bedtime, the lack of a suitable environment for sleep and study, and a large number of tasks and academic activities.

According to the results obtained, the association between stress and sleep pattern (poor sleep quality) was shown, as 70% of the nursing students had poor sleep quality due to stress and the students with a higher level of stress had poor sleep pattern. This finding was similar to some previous studies that reported an association between poor sleep quality and stress [19,28,29]. The reason for the high level of stress among nursing students may be the social and academic factors that greatly affect their sleep pattern. On the other hand, some studies have shown that stress and sleep are linked from the physiological side, as they are closely and pivotally linked to the pituitary gland [29,50-53].

Conclusion

The current study concluded that the prevalence of stress and poor sleep quality among nursing students was high. Stress and poor sleep quality were more prevalent among females than males. Also, taking a nap during the day was an influencing factor and a cause for changing the sleep pattern at night among nursing students. One of the most important findings of the study is that academic performance showed a statistically significant correlation with stress levels or sleep quality. In addition, it has been confirmed that stress and sleep affect each other for nursing students on the one hand, and affect their academic performance on the other hand. We recommend that in this study, medical teachers, researchers, and officials in academic institutions pay attention to assessing and improving student's well-being by facilitating difficulties, creating regular study schedules, and developing teaching methods in order to reduce the level of stress and improve sleep quality, thus raising the level of academic performance for students, especially students in medical departments. Furthermore, researchers should conduct more comprehensive future studies aimed at improving the quality of sleep among students in different disciplines, raising the level of their academic performance, and identifying the factors that affect it and addressing them.

Limitations

The current study included some limitations, among these limitations is that the study included one educational institution and one department, and therefore the environment is specific and it is difficult to generalize the results and which affects their accuracy, as well as the fact that the study relied on the cross-sectional design that does not provide the establishment of an accurate causal relationship between the study variables such as stress and sleep pattern and academic performance. In addition, the results depend on the student's answers to the survey questions and there may be a bias in the reliability of the answers therefore the results can have a kind of bias if the students do not answer clearly and truthfully. One of the most important limitations is the difficulty in determining the effect of stress and poor sleep quality on the academic performance of nursing students because our perception of academic performance is not easy due to the intervention of various factors in determining its level among students, which include habits and attitudes, family environment, methodologies, and the educational system, as well on the social, economic and psychological status of students. Finally, the current study was applied to a limited group of nursing students, so future studies should be conducted that include a larger number of students from different medical departments and universities in Jordan to verify the validity of the results.

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Citation: The Impact of Stress on Sleep Pattern and Academic Performance among Nursing Students in Jordan: A Cross Sectional Study ASEAN Journal of Psychiatry, Vol. 24(4) April, 2023; 1-11.