UNIVERSITY IN MARIBOR FACULTY OF HEALTH SCIENCES DUŠEVNO DOBRO POČUTJE MED ŠTUDENTI ZDRAVSTVENE NEGE V SLOVENIJI IN SEVERNI IRSKI MENTAL WELL-BEING AM

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1 UNIVERSITY IN MARIBOR FACULTY OF HEALTH SCIENCES DUŠEVNO DOBRO POČUTJE MED ŠTUDENTI ZDRAVSTVENE NEGE V SLOVENIJI IN SEVERNI IRSKI MENTAL WELL-BEING AMONG NURSING STUDENTS IN SLOVENIA AND NORTHERN IRELAND (Master thesis) Maribor, 2017 Leona Cilar

2 UNIVERSITY IN MARIBOR FACULTY OF HEALTH SCIENCES Mentor: Izr. prof. Dr (Združeno kraljestvo Velike Britanije in Severne Irske) Majda Pajnkihar Co-mentors: Prof Dr Owen Barr, Izr. prof. dr. Gregor Štiglic

3 ACKNOWLEDGEMENT I would like to express my gratitude to my mentor Izr. prof. Dr (Združeno kraljestvo Velike Britanije in Severne Irske) Majda Pajnkihar for her patience, motivation, enthusiasm, and immense knowledge. I would like to thank my co-mentor Prof Dr Owen Barr for all his help and suggestions. He allowed this paper to be my own work, but steered me in the right direction whenever he thought I needed it. I would also like to express my sincere gratitude to my co-mentor Izr. prof. dr. Gregor Štiglic for the continuous support throughout my study and research, useful advices and guidance. Finally, I would especially like to thank my family and friends for love, support, and constant encouragement throughout my years of study and through the process of researching and writing this thesis. Thank you, Leona.

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6 DUŠEVNO DOBRO POČUTJE MED ŠTUDENTI ZDRAVSTVENE NEGE V SLOVENIJI IN SEVERNI IRSKI POVZETEK Teoretična izhodišča: Duševno dobro počutje je ključni vir za uspešno in produktivno delovanje posameznika, osebno zadovoljstvo in kakovostno življenje. Do neravnovesja lahko pride zaradi različnih stresorjev in okolijskih dejavnikov. Posebej ranljiva skupina so študenti. Zaradi preobremenjenosti s študijskimi obveznostmi, finančnimi stiskami in oddaljenosti od doma se študenti pogosto srečajo s težavami v duševnem zdravju. Raziskovalna metodologija: Uporabili smo deskriptivno metodo dela. Literaturo smo iskali s pomočjo vključitvenih in izključitvenih kriterijev po domačih (COBISS, UM:NIK, Metaisklanik) in mednarodnih (PubMed, Science Direct, ProQuest) podatkovnih bazah. Izvedli smo kvantitativno raziskavo med študentih zdravstvene nege v Sloveniji in Severni Irski s pomočjo WEMWBS vprašalnika. Rezultati: V raziskavo je bilo vključenih 199 študentov zdravstvene nege, od tega 90 študentov bilo iz Slovenije in 109 iz Severne Irske. Študenti zdravstvene nege so v povprečju občutili srednje dobro počutje v zadnjih dveh tednih v obeh državah. Srednja vrednost WEMWBS rezultatov v Sloveniji (M=53.07, 95% CI [ ]) je višja, kot v Severni Irski (M= , 95% CI [ ]). Obstaja statistično značilna razlika (p < 0.001) med rezultati WEMWBS med državama. Zaključek: Čeprav rezultati kažejo, da študenti zdravstvene nege imajo povprečno stopnjo duševnega dobrega počutja, vedno moramo težiti k boljšemu. Na podlagi pregledanih študij ugotavljamo, da obstajajo učinkovite preventivne aktivnosti, ki bi se lahko uporabile tudi v Sloveniji in izboljšale duševno dobro počutje študentov zdravstvene nege. Velik pomen ima izobraževalna inštitucija, ki lahko z učinkovitimi intervencijami zmanjša stigmo in ozavesti študente o pomenu duševnega dobrega počutja. Ključne besede: duševno zdravje, duševne motnje, promocija duševnega zdravja, preventiva nastanka duševnih motenj, izobraževalna inštitucija. i

7 MENTAL WELL-BEING AMONG NURSING STUDENTS IN SLOVENIA AND NORTHERN IRELAND ABSTRACT Theoretical references: Mental well-being is a key resource for successful and productive living of each individual, personal satisfaction and quality of life. An imbalance can occur due to various stressors and environmental factors. Particularly vulnerable are university students. Due to academic pressures, financial burdens and distance from home, students often meet with mental health problems. Research methodology: We have used descriptive research methodology. We searched the literature using inclusion and exclusion criteria. We have reviewed domestic (COBISS, UM:NIK, Metaiskalnik) and foreign (PubMed, Science Direct, ProQuest) databases. Quantitative study was carried out among nursing students in Slovenia and Northern Ireland using the WEMWBS questionnaire. Results: The study included 199 nursing students. Of these, 90 students were from Slovenia and 109 from Northern Ireland. On average, nursing students have reached average mental well-being in the last two week in both countries. Mean value of the WEMWBS in Slovenia (M=53.07, 95% CI [ ]) was higher than mean value in Northern Ireland (M= , 95% CI [ ]). There is a statistically significant difference (p < 0.001) in results between countries. Conclusion: Even though results show that nursing students have average level of mental well-being we always need to strive for more. Based on reviewed literature, we have found out that there are effective preventive activities that could be used in Slovenia to improve mental well-being of nursing students. Big impact has educational institution that can, using effective interventions, reduce stigma and raise awareness of importance of good mental well-being. Key words: mental health, mental disorders, mental health promotion, prevention of mental disorders, educational institution. ii

8 TABLE OF CONTENTS 1 Introduction and description of the problem Purpose and aims of thesis Mental well-being among nursing students in Slovenia and Northern Ireland Definition of mental health and mental well-being Aetiology and prevalence of mental disorders The quality of life of person with mental disorders The programs of health promotion and prevention of the occurrence of mental disorders Slovenia Northern Ireland Mental health promotion among nursing students Instruments for measuring mental health and mental well-being and for detecting mental disorders The role of nurses in promoting mental health and preventing the occurrence of mental disorders Empirical part Research questions and hypotheses Methodology Research methods The research sample Methods of data collection Ethical view Limitations of the study iii

9 5 Results Interpretation and discussion Conclusion References Annexes... 1 iv

10 TABLES Table 1: Factors influencing mental health and mental well-being... 8 Table 2: Examples of potentially promising interventions at different levels Table 3: Questionnaires for measuring mental well-being Table 4: Gender and age distribution by countries Table 5: Distribution by year of study and field of practice among countries Table 6: Characteristics of students socio-demographic factors Table 7: Summary of WEMWBS scores in Slovenia and Northern Ireland Table 8: Results of WEMWBS questionnaire for each question by countries Table 9: Classification of mental well-being among nursing students in Slovenia and Northern Ireland Table 10: WEMWBS scores by gender and age in Slovenia and Northern Ireland.. 38 Table 11: Mean Ranks among age groups in Northern Ireland Table 12: Descriptive statistic by field of practice and year of study in Northern Ireland FIGURES Figure 1: PRISMA flow diagram Figure 2: WEMWBS score distribution in Slovenia (top) and Northern Ireland (bottom) v

11 1 Introduction and description of the problem Positive mental health is the foundation of an individual's health and well-being (World Health Organization [WHO], 2014). It provides the basis for optimal psychological development of the individual, developing and maintaining social relationships, effective learning, as well as good physical health (Clarke, et al., 2015). Mental health is an essential component of the society, productivity, peace and stability in the living environment that provides social services and economic development of a society (WHO, 2008). Mental health and well-being affect the social and economic achievements over the entire life of an individual (Barry, et al., 2013). Mental health problem is a term usually used for describing mental health difficulties, which can range from lower levels of mental distress to serious and specific mental illnesses (Department of Health, Social Services and Public Safety [DHSSPS], 2011). Mental health problems affect individual s way of thinking, feeling and behaving. Common mental health problems are depression and anxiety and rarer are schizophrenia and bipolar disorder (Dunn, 2016). The survey conducted in Scotland has found out that the most commonly experienced mental health problems are depression, panic attacks, severe stress and anxiety disorder (Braunholtz, et al., 2007). There are many factors, that can cause poor mental health, such as: school failure, childhood abuse, trauma, social isolation or loneliness, experiencing discrimination and stigma, severe or long-term stress, unemployment or losing your job, poverty, a long-term physical health condition, substance misuse, physical causes or genetic factors (Dunn, 2016). Poor mental health is associated with rapid social change, gender, workplace stress, social exclusion, unhealthy lifestyle, risk of violence and physical illness (WHO, 2014). In addition, the big impact has globalization, which causes changes in everyday life and stimulates stress among many people (Deeromram, et al., 2010). Some population groups are particularly exposed to factors which increase the incidence of mental health problems because of their higher exposure to adverse social, economic and environmental conditions. Those factors are related to gender, ethnicity and disability, and limited access to protective resources. Mental health problems and 1

12 mental health disorders appear more common in women, because of the difference in reacting to social, economic and environmental changes (WHO, 2014). On the other hand, men are more vulnerable to develop mental health problems because of resistance to talk about their problems, hesitation to talk with GP 1 and unemployment which is the result of closing many industries (DHSSPS, 2009). Although little research has been focused on mental health problems among different ethnic groups, there are significant differences between ethnical groups. Studies show that minority groups tend to develop more mental health problems, but have lower rate of using health system (White, 2015). Protective resources are related to higher level of education, permanent job, belonging to the ethnic majority and having supportive partner. Access to protective resources should be assured by reducing health inequalities (WHO, 2014). Particular attention should be paid to perinatal mental health, mental health of children and young people, elderly and minority groups (Mental Health Foundation, 2016). The DHSSPS (2009) points out, that particularly vulnerable groups are older people, people from ethnic minority communities, people who are hearing impaired, or with other communication difficulties, prisoners, and people with a learning disability. Another vulnerable population are university students. Aldiabat, et al. (2014) point out that university students around the world are vulnerable to developing mental disorders caused by a variety of stressors. This is due to changes they experience when transiting from being a high school student to university student. Surveys in Canada (MacKean, 2011) and the USA (Gallagher, 2008) have reported that university students, when compared with the general population of the same age, have more mental health problems, such as depression, anxiety, suicidal thoughts, psychosis, addiction, suicide risk, the use of mental health drugs and other chronic mental illnesses (Aldiabat, et al., 2014). A report issued by the Association of Psychiatrists in 2003, came to the conclusion that various stressors cause emotional demands caused by the departure from home, unstructured school environment, as well as exams and financial burdens (Student Services Committee, 2008). A study in the Philippines has shown that 1 General practitioner 2

13 university students with higher levels of perceived stress have worse physical, mental and social health (Labrague, 2013). Research conducted at The University of Birmingham suggests that at least cases of mental difficulties can be expected each year at a university with approximate total of students and staff. These mental difficulties can range from temporary emotional distress to mental illness which require treatment (Davis, 2010). Effective promotion of mental health in educational institutions includes promoting general mental well-being of staff and university students and also the care for individuals with mental health problems (Crouch, et al., 2008). Different cultures also develop different responses for coping with psychological stress. As a consequence, mental health interventions that emphasise individualism may not be appropriate for all cultures and belief systems (DHSSPS, 2009, p. 138). Mental well-being may differ among different countries because of various culture, habits and beliefs. That is why we wanted to investigate mental well-being among nursing students and compare results between the two countries. 3

14 2 Purpose and aims of thesis The purpose of this study is to determine the mental well-being of nursing students in Slovenia and Northern Ireland, and to compare the results obtained. Theoretical aims of the study are to: review and analyse the literature in the field of mental health nursing and mental health of nursing students, identify and describe mental health, review the questionnaires used to measure mental well-being, overview research designs used in the pilot trials, overview key variables involved in the research, overview criticism of the methods used. Empirical aims of the study are to: determine how the results obtained compare to findings from the previous research, determine whether there is a statistically significant difference between mental well-being among nursing students in Slovenia and Northern Ireland, identify ways in which the two countries provide for mental well-being of nursing students. 4

15 3 Mental well-being among nursing students in Slovenia and Northern Ireland Positive mental health and well-being is fundamental to a healthy society and a key requisite for a competitive and productive society. (DHSSPS, 2009, p. 23). In recent years, special attention has been paid to mental health and well-being of university students, due to new insight gained by research (Berger, et al., 2015). Part of being a university student involves dealing with problems such as being separated from one s family, questioning one s life choices, achieving personal objectives, dealing with relationships and balancing work, study, private life and finances (Rückert, 2015). Studies conducted in the USA have shown that mental health problems appear more frequent among female students than male students in the same year of college (Aldiabat, et al., 2014). In cross-sectional study conducted in the Philippines among nursing students they came to conclusion that the stress is very common among nursing students and it can occur due to various stressors. An important role in supporting university students, who are facing a variety of stressful events and mental difficulties, is held by their educational institution (Barry, et al., 2013). 3.1 Definition of mental health and mental well-being Mental health and mental well-being are important factors that affect a student s learning ability and academic success (MacKean, 2011). The World Health Organization (WHO, 2014, p. 12) has identified mental health as a state of well-being in which the individual realizes his or her abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community. The Mental Health Commission of New South Wales (2016) describes mental health as a positive concept which is associated with social and emotional well-being of individuals and communities. Mental health enables individuals to develop mental and emotional capabilities and fulfil their professional, social and personal roles (Slovenian Ministry of Health, 2014). Jeriček Klanšček, et al. (2009) point out that mental health is shaped in the family, in school and at the workplace. Therefore, an introduction of a multi-dimensional approach that focuses 5

16 not only on treatment, but also on the promotion of mental health, is essential (Roškar, et al., 2015). Nursing students perceive mental health as a combination of variables, such as emotional status, self-awareness, concentration and individual ability to adapt, all of which vary according to physical, physiological and environmental situations (Deeromram, et al., 2010). World Health Organization (WHO, 2014) says, Mental health is integral to this conceptualization of wellbeing, because it enables people to do and be things they have reason to value. Capabilities to do and to be are shaped by social, economic, and environmental conditions. Poor mental health also means a loss in economic terms. According to some estimates, at least 3% to 4% of the GDP 2 is lost in this manner (Slovenian Ministry of Health, 2014). The total cost of poor mental health in Northern Ireland is estimated at over 3.5 billion per year and that is about 12% of Northern Ireland s national income (DHSSPS, 2011). A healthy individual can contribute to the community, so good mental health is the basis of economic prosperity (Roškar, et al., 2015). Well-being is a term, which describes health in absence of illness. Important components of mental well-being are feeling good and functioning well (Naidoo & Wills, 2016). Mental well-being is a dynamic process in which individual external circumstances, in interaction with their psychological capabilities meet the psychological needs and cause positive emotions (e.g. happiness and satisfaction) (MacKean, 2011). It is the ability to develop and maintain sufficient balance, happiness and satisfaction with life (Taggart, et al., 2015). Mental well-being cannot be viewed simply as the absence of mental problems, but is defined as a combination of emotions (hedonic feelings and emotions, such as happiness, calmness, satisfaction) and mental functions (self-esteem, optimism, self-affirmation, autonomy) (Taggart & Stewart-Brown, 2015). Lack of positive mental well-being can lead to a variety of mental health problems. It also affects physical health and longevity (Taggart & Stewart-Brown, 2015). 2 gross domestic product 6

17 3.2 Aetiology and prevalence of mental disorders Mental health problems are indicators of the presence of certain difficulties and are risk factors for developing mental disorders. Those problems can be difficulties with handling problems, difficulties with self-esteem, substance abuse, unsuccessfulness at work or in school, sleep difficulties, and others (Slovenian Ministry of Health, 2014). Studies conducted in Northern Ireland have shown that mental health problems appear more among older people and among men. Older people are often faced with loneliness. That is why they experience depression. Men are more vulnerable to mental health problems because they do not talk much about their problems or feelings and they resist consulting with GP about mental and emotional health problems (DHSSPS, 2009). Young people today are faced with everyday pressures like school expectations and unemployment. Concerned problems are those coherent to self-esteem, social contact, and emotional problems, because those usually grow to mental disorders (Roškar, 2011). A mental disorder is defined as a mental or physical condition which is primarily characterized by a disorientation of personality, mind and emotions which seriously interferes with normal psychological functioning of an individual (MacKean, 2011). Mental disorders are classified in the International statistical classification of diseases and related health problems [ICD-10] (WHO, 1992) as: organic, including symptomatic, mental disorders, mental and behavioural disorders due to psychoactive substance use, schizophrenia, schizotypal and delusional disorders, mood (affective) disorders, neurotic, stress-related and somatoform disorders, behavioural syndromes associated with physiological disturbances and physical factors, disorders of adult personality and behaviour, mental retardation, disorders of psychological development, behavioural and emotional disorders with onset usually occurring in childhood and adolescence, 7

18 unspecified mental disorder, dementia in Alzheimer disease, dementia in other diseases classified elsewhere. In Table 1 factors that have influence on mental health and mental well-being are listed. Table 1: Factors influencing mental health and mental well-being Gender Age Factor Influence Authors Mental health is poorer Jeriček Klanšček, et among women al., 2009; Roškar, 2011; Flatt, 2013; Davoren, et al., 2013 Mental health is poorer Roškar, 2011; Wilson, Financial and socioeconomic status Education Study obligations and academic pressures Substance misuse among older people Mental health is poorer among low income families Mental health is poorer among people with higher education level Mental health is poorer when there is high pressure to achieve high grades Alcohol and illegal drug consumption may cause poorer mental health et al., 2015 MacKean, 2011; Roškar, 2011; Davoren, et al., 2013; Flatt, 2013; Rückert, 2015 Roškar, 2011 MacKean, 2011; Davoren, et al., 2013; Flatt, 2013; Labrague, 2013; Rückert, 2015 Davoren, et al., 2013 Mental Health Foundation (2016) highlighted, that Northern Ireland reported to have 25% higher overall prevalence of mental health problems than England. Northern Ireland has also higher levels of depression than the rest of the UK. That may be a consequence of years of violence associated with the Troubles in Northern Ireland. It contributed to high rates of mental health problems and substance abuse (O'Neill, et al., 2016). A study in the Republic of Ireland has shown the opposite than study in Northern Ireland. They found out that there is a statistically significant difference in mental 8

19 health between genders. Mean values of mental health were slightly higher in men than in women (Davoren, et al., 2013). The same conclusion was reached by studies in Slovenia (Roškar, 2011; Jeriček Klanšček, et al., 2009). Mental health is significantly associated with age. Mean values for the mental well-being measured by the WEMWBS become lower as age is increased. Mental well-being is poorer in older age (Wilson, et al., 2015). Mental disorders are a commonly occurring problem among university students (Zivin, et al., 2009; MacKean, 2011). During the transition from high school to higher education, university students are faced with various stressors and challenges. Therefore, they are exposed to factors which increase the incidence of mental disorders (Aldiabat, et al., 2014). Research shows that university students have poorer mental health than individuals not enrolled in university (MacKean, 2011; Labrague, 2013; Berger, et al., 2015). MacKean (2011) did a literature review and the study was conducted in Canada. It is a good evidence of work that has been done in the field of mental health in higher educational institutions in Canada. However, it should be interpreted with caution, because our school systems differ (Canada-Slovenia and Canada-Northern Ireland). School systems differ also between Slovenia and Northern Ireland. With cross-sectional study conducted in the Philippines, Labrague (2013) states that university students have poorer mental health than those who are not enrolled in higher education. This conclusion is not based on evidence, but on authors opinion. Berger, et al. (2015) carried out a cross sectional study in Germany. It was carried out among medical and psychology students. However, not among general population too. They cite:»compared to the general population students seem to be rather more affected by psychological complaints«. However, they cite that there was study conducted in the USA, which compared general population and university students. A survey in the USA (Zivin, et al., 2009) established that mental disorders occured in one third of the respondents; with the most common disorders being depression and eating disorders. Aldiabat, et al. (2014) also cite depression, in addition to anxiety and stress, as common mental disorders among university students. Rückert (2015, p. 38) gives a list of the most common problems among university students who seek assistance from the Counselling Center at the Freie Universität Berlin: 9

20 1. problems with academic work and achievement 2. enquiries about psychotherapy 3. problems with academic orientation and motivation 4. depression 5. problems with learning 6. anxieties/phobias. Study conducted in the Philippines has shown that the occurrence of stress among nursing students is influenced by various factors, such as study obligations, seminar papers, exams and overly demanding schedules with poorly coordinated clinical practice and academic obligations. They have also found out that the students who reported higher level of stress were significantly more likely to experience poor physic-psycho-social health. Perceived stress levels decreased with higher year of education. Senior students experienced less stress than junior students (Labrague, 2013). Although the inclusion to the study was randomised, the study was carried out among nursing students from one university and the number of included students (n = 61) was small. That means that results cannot be generalised to all nursing students. A study conducted in Northern Ireland in 2017 among university students shows that the stress is the most common negative feeling experienced by students. University students aged between 19 and 26 list the most significant factors that may have contributed to their mental health issues: course, work pressures, lack of money and lack of future career opportunities (National Union of Students [NUS], 2017). 3.3 The quality of life of person with mental disorders Health-related quality of life refers to the quality of the physical, emotional, social and behavioural aspects of life (Roškar, 2011). In a synthesis of qualitative research conducted in the UK, a good quality of life was characterised by the feeling of being in control, autonomy and choice, a positive self-image, a sense of belonging, engagement in meaningful and enjoyable activities, and feelings of hope and optimism. On the other side, a poor quality life was characterised by feelings of distress, lack of control, choice and autonomy, low self-esteem and confidence, a sense 10

21 of not being part of a society, diminished activity, and a sense of hopelessness and demoralization (Connell, et al., 2012). Stress experienced while still in education can affect an individual s health and wellbeing (Labrague, 2013). Health-related quality of life of young people can be affected by gender, age, socio-economic status, type of educational programme and other factors (Roškar, 2011). A survey conducted in the US (Zivin, et al., 2009) found that more than one third of the university students surveyed some kind of mental health problem. The survey also found a high rate of inadequate support, as well as a lack of support systems. In the research conducted in Northern Ireland, they found out that only 4% of university students seek help among their institution or Students Union (NUS, 2017). There are not many research studies done which investigate quality of life of nursing students. However, many of studies are focused on improving health related quality of life among children and young people. A big part of young population are university students and those findings can be very important to find out what their quality of life is like and how to improve it. The Slovenian Ministry of Health (2014) warns that the quality of support and care for the mental health of young people and adolescents is very important, because 14% of all mental illnesses start in childhood. The study Health Behaviour in School-aged Children [HBSC], conducted in Slovenia in 2010, found out that a third of young people (33%) shows a low health-related quality of life. The researchers also found out that girls suffer from a lower health-related quality of life, and that the difference between the genders increases with age (Roškar, 2011). At least one-tenth of children and young people assess their health as poor, regularly encounter certain problems (insomnia, nervousness, irritability, headache, depressive mood, back pain or abdominal pain) and are not satisfied with their lives (Slovenian Ministry of Health, 2014). Northern Ireland did not participate in this research in this last research conducted in Nevertheless, study conducted in Northern Ireland showed that mental health issues among university students have impact on everyday life and particularly on quality of life (NUS, 2017). 11

22 People who can overcome their mental health problems can have a good quality of life, which includes ability to manage their own lives, stronger social relationships, a greater sense of purpose, the skills for living and working, improved chances in education, better employment rates and a suitable place to live (Betts & Thompson, 2017) In 2015, the Organisation for Economic Co-operation and Development [OECD] launched survey about students well-being in which 15 years old students from 72 different countries, including Slovenia and Northern Ireland, were included (OECD, 2017). Also, students satisfaction of life was measured. On a scale from 0 to 10, the average OECD score was 7.3. Northern Ireland students scored 7.24, which is the highest score among all countries in the UK and Slovenian students scored 7.2. There is no big difference between scores in Northern Ireland and Slovenia and they show that students in both countries are satisfied with their quality of life. 3.4 The programs of health promotion and prevention of the occurrence of mental disorders Mental health promotion and prevention are multi-sectoral strategies focused on reduction of stigmatization, discrimination and human rights violations (WHO, 2013). Mental health promotion is the process of strengthening the capacities of individuals, families and communities to take control over their lives and improving the level of mental health. The purpose of the mental health promotion is to provide individuals with power of choice and control over their lives (MacKean, 2011). Mental health promotion is concentrated to (Cattan & Tilford, 2006, p. 43): strengthening individuals (interventions which promote self-esteem, life and coping skills), strengthening communities (interventions which increase social inclusion, neighbourhood environments, developing health and social services), reducing structural barriers to health (interventions which reduces discrimination and inequalities, and promote access to education and employment). 12

23 The incidence of mental disorders in Slovenia is steadily growing and is expected to increase from 10% to 15% in 2020, which will become a large economic burden. Therefore, prevention of mental disorders is essential (Šprah, et al., 2011). The same problem exists in Northern Ireland. Therefore, DHSSPS (2011) suggests changes in the field of mental health promotion. The new initiatives include home treatment, as an alternative to in-patient treatment, responsibly for healthcare in prisons has transferred to the health and social care sector, reform and modernisation of acute inpatient provision for children, adults, and older people who have mental health needs, and others. There are new interventions in Northern Ireland that promote positive mental health and well-being, such as TV advert Life changing, which encourages people to reach out and support someone they know who may be experiencing mental health problems (Change Your Mind, 2016). The Public Health Agency has realised few commercials that promote mental well-being. They are available on webpage of public information campaign Minding Your Head. First step towards recovery is talking about the problem and seeking help. With these interventions, Northern Ireland wanted to make people aware of appearance of mental health problems and ways to help in resolving them. Based on data from previous research, Clarke, et al. (2015) argue that certain interventions that promote mental health can have a positive impact on the mental health of young people. Interventions that aim at improving mental well-being focus on improving the lifestyle and mental endurance of subjects (Taggart & Stewart- Brown, 2015). The most effective programmes in mental health promotion are those which (Friedeli & Parsonage, 2007, p. 38): focus on the promotion of mental health rather than on the prevention of mental disorders, include social components and cognitive approaches, can adapt very well to the whole school approach: involving teachers, pupils, parents and the wider community, support peer tutoring and cross age tutoring. 13

24 There is a big emphasis on promoting mental health in schools in Northern Ireland. Mental health promotion has been effective in the following areas (Friedeli & Parsonage, 2007, p. 38): preventing mental health problems, notably depression, improving academic outcomes, improving emotional and social functioning, reducing health damaging behaviour (e.g. smoking and substance abuse), reducing bullying. Those interventions are intended on schools, but they can be implemented also in higher educational institutions. In Slovenia, the promotion of mental health and prevention of the occurrence of mental illness is implemented on three levels: primary, secondary and tertiary. Mental health promotion programmes are conducted within the framework of public educational programmes and projects. The examples include programmes promoting healthy habits and ecological awareness in schools, programmes focusing on safe schools without violence, responsible parties, the so-called Violence is "out," we are "in" programmes, programmes for children who are victims or perpetrators of violence, schools for parents, and others (Slovenian Ministry of Health, 2014, p. 27). Mental health promotion in Northern Ireland work on three levels as well as in Slovenia. There are many governmental programmes in Northern Ireland that support mental health and mental well-being among all generations. However, it was proposed that more financial resources had to be given to improve mental health promotion and prevention in Northern Ireland s schools (Wilson, et al., 2015) Slovenia The field of mental health in Slovenia is regulated by Mental Health Act (slo. Zakon o duševnem zdravju [ZDZdr]). Non-governmental programmes aimed at promoting mental health and preventing mental disorders among young people in Slovenia are the following (Slovenian Ministry of Health, 2014, pp ): School for Future Parents, 14

25 Health Education a programme that includes a variety of content related to health, including mental health, which is carried out for preschool and school children in the context of preventive health check-ups, Healthy Schools health promotion in primary and secondary schools, This Is Me (To sem jaz) preventive and promotional programme aimed at strengthening the positive self-image of children and adolescents, SEYLE (Saving and Empowering Young Lives in Europe) empowerment and rescue of young lives in Europe, Do You Get It (A (se) štekaš) deals with mental health promotion and primary prevention of suicidal behaviour in adolescents, Let's Talk About Suicide Among Young People, When a Student Gets Stressed Out a programme for teachers, A Healthy Lifestyle an educational programme, Where and How to Get Help When in Mental Distress. Programmes aimed at promoting mental health and preventing mental disorders in the adult population, carried out by non-governmental organizations, are the following (Slovenian Ministry of Health, 2014, p. 60): Papilot Institute for Promotion and Development of Quality of Life, Ozara National Association for Quality of Life, Altra Committee on Innovation in Mental Health, Slovenian Association for Suicide Prevention, Humana an association of relatives who provide mental health care, The Samarijan Helpline a mental health helpline Your Phone Association, Association for Helping People in Need, For You Helpline (Za te). There are no programmes for promoting mental health and well-being specifically designed for university students in Slovenia Northern Ireland Strategies and policies in the field of mental health in Northern Ireland are the following (DHSSPS, 2011, pp ): 15

26 The Ten Essential Shared Capabilities (shared and necessary competencies for all staff working in mental health practice), Wellness and Recovery Action Planning [WRAP] (a structured self-management and recovery system), The Recovery Star (a tool for supporting and measuring change when working with adults of working age who are accessing mental health support services), Developing Recovery Enhancing Environments Measure [DREEM] (a self-report instrument that is designed to gather information about mental health recovery from people who use mental health services to rate the effectiveness of services in supporting the recovery journey), The TIDAL Model (a recovery model for the promotion of mental health), THORN training (the provision of psychosocial interventions in the care and treatment of people with a diagnosis of severe mental illness), Protect Life: A Shared Vision (suicide prevention and patient safety plan), The Promoting Mental Health Strategy and Action Plan, Promoting Quality Care: Good Practice Guidance on the Assessment and Management of Risk in Mental Health and Learning Disability Services, Home treatment, The Mental Health Service Framework for Northern Ireland, Responsibly for healthcare in prisons, Reform and modernisation of acute in-patient provision for children, adults, and older people who have mental health needs, A Strategy for the Development of Psychological Therapy Services, Personality Disorder; A Diagnosis for Inclusion. Northern Ireland Personality Disorder Strategy, An action plan to support the development of peri-natal mental health services, The Workforce Planning Review for Mental Health and Learning Disability Services in Northern Ireland, NICE clinical guidelines within Northern Ireland (The management of Schizophrenia, The management of Personality Disorders, The use of non-drug therapies in the treatment of mild/moderate depression, The management of perinatal mental health), 16

27 The development of a Northern Ireland Dementia Strategy, The development of a joint protocol in Northern Ireland between adult and children s services in responding to the needs of parents with mental health problems and/or substance misuse, their children and families, The development of a single legislative bill amalgamating mental capacity and mental health legislation. There are also non-governmental organizations that promote mental health and prevent mental health disorders, known as Action mental health and Inspire mental health. Action mental health [AMH] is a local charity which wants to improve individual s quality of life and employment opportunities. It focuses on individuals with mental health needs and learning disability in Northern Ireland (Action Mental Health, 2017). Inspire (old name Northern Ireland Association for Mental Health [NIAMH]) is the largest and oldest independent local charity which focuses on mental health, learning difficulties and welfare services in Northern Ireland. Inspire also includes health promotion and supports mental health among the student populations. It covers several services, such as (NIAMH, 2015): Beacon Mental Health Services, Inspire learning disability services, Carecall workplace wellbeing services. Other non-governmental organization which support mental health and mental wellbeing in Northern Ireland are MindWise, Mental Health First Aid, Aware, Sane-line (helpline) and Live in care. There is also a web-page, which promotes positive mental health called Mind Your Head and a Lifeline, which is Northern Ireland crisis response helpline service for people who are experiencing mental health problems. 3.5 Mental health promotion among nursing students Educational institutions are required to provide help for students and employees who are faced with mental health-related problems (Davis, 2010; Aldiabat, et al., 2014). All university students need to have equal rights. Anyone who bears some responsibility in the sphere of higher education, be they lecturers, students, student 17

28 representatives, psychologists, health professionals or employees of government organizations, should be involved in solving the health problems that can befall any individual (Sarmento, 2015). The Special Educational Needs and Disability Order [SENDO] is a Northern Irelands document, which clarifies definitions of a disabled student or prospective student. There are also described rights of disabled students. It protects disabled people from discrimination by higher educational institutions (Equality Commission for Northern Ireland, 2010). Citing a study that showed international students to be at a greater risk of mental problems and disorders, Rückert (2015, p. 38) suggests the following support measures to be adopted by educational institutions in order to preserve the mental health of their international students: strategies for training and raising awareness, promoting the mental health of students in a manner that respects the cultural and religious diversity. supporting students who are experiencing mental health problems in a culturally sensitive manner, support for the educational staff. These measures can be adopted in any higher educational institutions, because many of university students can experience social discrimination, because of their age, race, gender, nationality, religion, disability, medical condition or sexual orientation. It is important to promote equality and equivalence among university students. Sarmento (2015) stresses that it would be a benefit if educational institutions regularly provided and carried out health promotion activities (lectures, seminars, campaigns, activities / initiatives) for the purpose of reducing the incidence of risk factors for mental disorders, as well as the incidence of mental disorders themselves. A potentially promising case is that of the UK, where there are quite a few systems in place that support mental health of university students, such as (MacKean, 2011, p. 33): Mental Health and Higher Education, student mental health websites, Healthy Universities, 18

29 University Challenge - Towards a Well-being Approach to Quality in Higher Education. As part of the project Mental Health First Aid (MHFA), staff and students of institutions of higher education in England have successfully completed a two-day training course. The questionnaire used during the course was adapted for solving problems that arise during the transition period between childhood and adulthood (Kitchener, 2016). Educational Institutions in Northern Ireland provide support to students with the Inspire (old name Carecall) student counselling service (NIAMH, 2015). Ulster University is one of them and is a good example of university which offers their students support. They provide support on following fields: academic issues, coping with stress, family and relationship problems, loneliness and isolation, keeping healthy. There is also a full working initiative, managed by students, called Mind Your Mood. Their aims are to raise awareness about mental health and mental well-being among university students, to improve mental well-being, and to de-stigmatise the topic of mental health (Ulster University, n.d.). Electronic media are innovative way to promote mental health among young people. The internet is very popular, because it provides an opportunity to stay anonymous. This is the modern way to overcome barriers to help-seeking (lack of awareness, physical access and stigma) (Cattan & Tilford, 2006). Evidence show that mental health promotion-module based online interventions can have positive impact on mental health and well-being of adolescents (Clarke, et al., 2015). 19

30 Table 2: Examples of potentially promising interventions at different levels Levels of action / Areas of intervention Increase MH 3 Awareness Identify Atrisk students Life skill development Social network creation Adequate, accessible, MH services A campus environment supports and promotes student MH Individual strategies information on opportunitie s to become involved access to services, students with disabilities accommoda ted in a responsive manner Source: MacKean (2011, p. 25) Group or interpersonal education programs for faculty & staff education programs for faculty, staff, and student leaders, MH Promotion Screen events workshops, classes, tutoring, coaching programs promote peer support programs, develop social networks students with disabilities supported to engage in peer support activities Campus campus wide awareness program using a variety of vehicles early alert systems skills development resources embedded into faculty sources create 1 st year undergraduate groups of to help students feel connected resources for high quality counselling, medical and accommodation s services, support a rightsbased approach healthy physical settings, healthy learning & work environments, student services Community or Society outreach admitted students to improve student s knowledge & attitudes about MH individual consultation provided to faculty and staff, online screening improved selfmanage ment skills & coping outreach to admitted students who self-identify with preexisting MH problems transition programs for high school, 1 st year and new students develop good linkages with community and hospital based MH services in the surrounding community physical settings, ensure community service programs 3 Mental Health 20

31 Table 2 shows the potentially promising interventions for university student mental health promotion. Action is needed at all levels in order to improve the mental health of university students. Actions at various levels aim at increasing awareness of mental health, identifying students at high risk of mental disorders, improving life skills, creating a social network, providing appropriate and accessible mental health support and modify educational environment so that it may support and promote good mental health of university students (MacKean, 2011). There is a lack of university student support in Slovenia. The purpose of listing those interventions is to investigate effective interventions for mental health promotion among university students, which can also be used among nursing students. Educational institutions need to be aware of need for mental health promotion among university students and staff working there. 3.6 Instruments for measuring mental health and mental well-being and for detecting mental disorders Improving the mental well-being is an important objective for the government. It is therefore important that mental well-being is measured by validated and reliable instruments. The role of measuring well-being is to ensure the acquisition of data on mental well-being of the population, which can be described with respect to age, gender, arrivals, socio-economic status, etc. (Taggart & Stewart-Brown, 2015). There are several questionnaires for measuring mental health and mental well-being (Table 3). 21

32 Table 3: Questionnaires for measuring mental well-being Name Number of items Score range Validation What it measures Age range WHO Yes Positive feelings, Adults happy emotions, energy WEMWMS Yes Positive emotions 13 and and physiological over functioning SWEMWBS Yes A subset of items from WEMWBS 13 and over BBC Subjective Yes The ability to well-being scale develop your potential Oxford Happiness Questionnaire Yes Happiness positive feelings, enjoyment and creativity Adults PANAS Yes Anxiety, depression Adults Satisfaction with Yes Subjective Adults life satisfaction with questionnaire life Questionnaire for Eudaimonic well-being Yes Self-discovery Adults The Everyday Feeling Questionnaire 10 Not known Yes Psychological wellbeing and distress Adults MHC-SF Yes Well-being MNW Yes Satisfaction with Adults life Source: Taggart & Stewart-Brown (2015) Table 3 lists validated questionnaires for measuring mental well-being or positive mental health. There is also a large variety of instruments that measure the direct factors that lead to mental disorders. The Physio-Psycho-Social Response Scale (PPSRS) has been used 4 Warwick-Edinburgh Mental Wellbeing Scale 5 Short Warwick-Edinburgh Mental Wellbeing Scale 6 Positive Affect, Negative Affect 7 Mental Health Continuum Short form 8 Measuring National Wellbeing Office for National Statistics 22

33 to measure the degree of stress and the stressors affecting nursing undergraduates (Labrague, 2013). Mental distress among university students has been measured by various scales of symptoms, such as the Psychosocial Complaints List (PCL), the Symptom-List (SCL-90) (Berger, et al., 2015) and the Brief Symptom Inventory (BSI) (abbreviated version of the SCL-90) (Sarmento, 2015). The Satisfaction with Life and Studies Scale (SLSS) has also been used (Berger, et al., 2015). University students deal with stress in different ways and use a variety of defence mechanisms. Defence mechanisms can be evaluated with a defense style questionnaire (DSQ) (Deeromram, et al., 2010). Depression among university students has been measured using the Patient Health Questionnaire (PHQ-9) (Zivin, et al., 2009). The mental health and well-being of Irish third-cycle students has been assessed with the WEMWBS questionnaire (Davoren, et al., 2013). The WEMWBS is a questionnaire that measures positive mental health and well-being. Its validity, variability and social usefulness on the general and student populations were confirmed in 2007 (Taggart, et al., 2013). It is important to measure various factors that have impact on mental health and mental well-being among university students. More research must be conducted to give a clearer view of situation of mental health and mental well-being among university students. Despite the recognition of the stressful nature of their role, there is also a lack of research in the field of mental health and mental well-being among nursing students. 3.7 The role of nurses in promoting mental health and preventing the occurrence of mental disorders Evidence suggest that nursing students are more likely to develop a positive view of mental health and have a positive attitude towards people with mental disorders if the educational content that familiarizes them with mental health is well structured and if their clinical practice is supervised (WHO, 2007). The quality of nursing provided to a patient is significantly and directly related to their health. Therefore, nursing students must be aware of the importance of health care and strive for high quality of clinical practice (Deeromram, et al., 2010). 23

34 A nurse s competencies include health promotion, health education, learning to understand the links between lifestyle and health, as well as understanding health problems and the processes needed to strengthen achieve and maintain health (Železnik, et al., 2008). The tasks of nurses in health promotion are (Nursing and Midwifery Council, 2010; Železnik, et al., 2008, p. 19): to understand the national policy on health and social health, to cooperate with other professionals and communities, to look at the individual, family and community from a holistic perspective and take into account all the determinants of health, to participate in health promotion and disease prevention, as well as participate in the evaluation, to apply knowledge of health promotion and health education, to mediate adequate health information to individuals, families and communities and to assist them in achieving optimal health and rehabilitation, to demonstrate and understand traditional medicine, to provide support in developing and / or maintaining independent living skills, to teach the implementation of nursing interventions, to use a variety of learning and teaching strategies for individuals, families and communities, to value learning about health practices and their understanding. The DHSSPS (2009) suggests that all mental health professionals must follow principles of autonomy, justice, benefit and least harm that will guide them through education and practice. Mental health nurses have a big role in mental health promotion, anticipatory care and early intervention to prevent crisis and relapse and referral into secondary services. It is therefore important that the principles of public health and early intervention are embedded into the practice of all mental health nurses in whatever service context they work (DHSSPS, 2011). In Slovenia, the educational system does not allow undergraduate or postgraduate programme or specialization in psychiatric nursing. That means that nurses who work in psychiatric units can acquire and renew 24

35 knowledge and skill only if there are practical workshops and seminars being performed. Without knowledge, new skills and practice nurses who work in the field of psychiatry may not give the patient proper care, which is based on the newest and best evidence. 25

36 4 Empirical part 4.1 Research questions and hypotheses In this thesis, we have set the following research question: What is the level of mental well-being of nursing students in Slovenia and Northern Ireland? In addition, we have tested the following hypotheses: Hypothesis 1: There is a statistically significant difference between the mental wellbeing among nursing students in Slovenia and Northern Ireland. Hypothesis 2: More than half of nursing students in Slovenia and Northern Ireland have felt above average mental well-being in the last two weeks. 4.2 Methodology We have used quantitative research methodology through which we wanted to determine mental well-being among nursing students in Slovenia and Northern Ireland. A cross-sectional study using a survey has been conducted in both countries Research methods Research methods are steps, procedures or strategies that help us with gathering and analysing data (Polit & Beck, 2012). In the theoretical part of the research, a descriptive method of work has been used in order to seek views and experiences in the field of mental health of nursing students. A review of international research literature has been performed to compare the existing studies that have been carried out in Slovenia, Northern Ireland and other countries. With keywords (mental health, mental well-being, nursing students), time limit from 2007 to 2017, and full-text paper availability used as search criteria we reviewed a local Slovenian databases COBISS, Metaiskalnik, UM:NIK as well as international databases PubMed, Science Direct, and ProQuest. We have also reviewed 26

37 Google Scholar. We have excluded articles older than 2007, articles that were not in English or Slovenian language and those which were not related to the studied subject. We have included total of 58 records (Figure 1). A comparative method has been used to compare the results obtained from the review of the research in Slovenia and Northern Ireland. Data have been collected using the survey to determine the level of mental well-being among nursing students in Slovenia and Northern Ireland. For the description and presentation of data, we have used descriptive statistics. By using inferential statistical methods (Student's t-test of independent samples and the corresponding nonparametric test) we approved and rejected hypotheses. Results are shown in the form of figures and tables. Figure 1: PRISMA flow diagram Identification Records identified through database searching (n = 1549) Additional records identified through other sources (n = 498) Records after duplicates removed (n = 1452) Screening Records screened (n = 1452) Records excluded (n = 1131) Eligibility Full-text articles assessed for eligibility (n = 321) Full-text articles excluded, with reasons (n = 263) Studies included in qualitative synthesis (n = 58) Included Studies included in quantitative synthesis (meta-analysis) (n = 58) 27

38 4.2.2 The research sample The survey has included 90 nursing students in Slovenia and 109 nursing students in Northern Ireland. Generalization of findings to the entire population of nursing students is limited due to convenience sampling. The sample has included individuals of various demographic characteristics (gender, age, etc.). Nursing students are future health professionals whose task is a promotion of mental health and mental well-being. To be able to help others, they must provide their own good mental well-being. Before carrying out the research, participants were introduced with the purpose of the research, their rights and obligations. They were also informed about the voluntary participation, anonymity and ability to leave at any stage of research Methods of data collection Warwick-Edinburgh Mental Well-being Scale (WEMWBS) is a scale that includes 14 items related to individual s state of mental well-being in previous two weeks. It is five-point scale ranging from none of the time to all of the time. The WEMWBS measures all attributes of mental well-being, except spirituality. The questionnaire was developed in 2006 through research in Scotland and was validated in the UK (Taggart, et al., 2015). The questionnaire is in English, and for the needs of the study conducted in Northern Ireland, no adaptation was needed. For the use in Slovenia, we had to translate the questionnaire to Slovenian language. Two independent researches (a specialist in the field of nursing and an expert in the field of language) have carried out the translation. After adjusting translations, the final entry has been examined and translated into English by a third expert. The final version has been compared to the original version and further improved to obtain the final version. Demographic questions related to age, gender, physical activity, accommodation through the academic year, alcohol consumption, smoking and drug use have been added to allow comparison of specific subgroups in the study. Demographic questions have been summarized and amended for the needs in our survey. Internal consistency of used questionnaires has been tested with Cronbach s α coefficient and it was excellent for Slovenian version of the questionnaire (α = 0.925) and good for English version (α = 0.898) used in Northern Ireland. 28

39 Data have been analysed using IBM SPSS Statistics (version 22). Student's t-test of independent samples has been used to analyse the differences in mental well-being between nursing students in Slovenia and nursing students in Northern Ireland. Also, non-parametrical tests like Mann-Whitney U test and Kruskal-Walis test have been used Ethical view Before the start of the study, ethical permission was sought from of the institutional ethical committee at the University of Maribor Faculty of Health Sciences to carry out the research. Permission was also obtained from School of Nursing Filter Committee of the University of Ulster (INHR Filter Ethics Committee). Participants in the study (nursing students in Slovenia and nursing students in Northern Ireland) have been informed about their rights and duties before the start of the study. The study has taken into account all the principles of the Code of Ethics in nursing and care (2014) and the requirements of the ethical permission in Northern Ireland. Participants have been informed about the purpose of research, anonymity and voluntariness Limitations of the study Although we reached our aims, the research has some limitations. First, we have used convenience sampling. For this reason, generalization of the findings to the entire population of nursing students is limited. For generalizing findings, we need to do extensive research and include more nursing students in Slovenia and Northern Ireland. There is also a lack of prior research studies on this topic. Only few studies have been done among nursing students that investigated mental well-being. Furthermore, only 28 students of mental health have fulfilled the questionnaire. That is a small sample size of students and we cannot compare it to the sample of adult nursing students. In addition, there are no other fields of nursing in Slovenia, except general nursing. Discovering those limitations can serve us as an important opportunity to identify new gaps and to describe the need for further research. 29

40 4 Results The results of the research conducted in Slovenia and Northern Ireland are shown in the form of figures and tables presented in this chapter. The study has involved 90 (45.3%) nursing students in Slovenia and 109 (54.7%) nursing students in Northern Ireland, 15.1% (n = 30) of which were male and 84.9% (n = 169) female students (Table 4). A total of 94.5% (n = 85) students in Slovenia and 56.9% (n = 62) in Northern Ireland belonged to an age group between 20 and 30 years. Table 4: Gender and age distribution by countries Total Slovenia Northern Ireland Gender Female n % Male n % Age < 20 n % n % n % n > 40 % n = total number; % = percentage Total distribution of the questionnaires was 60 (66.7%) among undergraduate nursing students and 30 (33.3%) among postgraduate nursing students in Slovenia (Table 5). Nursing students in Slovenia were not asked about the year of study. Distribution of the questionnaires in Northern Ireland was mostly among undergraduate nursing students. Distribution among undergraduate nursing students was the following: 34 (31.2%) of the 1 st year, 46 (42.2%) of the 2 nd year and 28 (25.7%) of the 3 rd year. Only one person (0.9%) in 2 nd year of postgraduate study has completed the questionnaire. 30

41 All nursing students (100%) in Slovenia were studying general nursing. On the other hand, 74.3 % (n = 81) of nursing students in Northern Ireland were studying adult nursing and 28.7% mental health nursing (n = 28). Table 5: Distribution by year of study and field of practice among countries Year of study undergraduate Postgraduate Slovenia 1 st n % nd n 46 % rd n 28 % st n 30 0 % nd n 1 % 0.9 Field of Adult n practice % Mental n 0 28 Health % n = total number; % = percentage Northern Ireland The WEMWBS scores were normally distributed among nursing students in both Slovenia and Northern Ireland (Figure 2). 31

42 Figure 2: WEMWBS score distribution in Slovenia (top) and Northern Ireland (bottom) We have asked nursing students about their socio-demographic factors, such as frequency of physical activity on a weekly basis, accommodation during academic year, consumption of alcohol, smoking and using illegal drugs (cannabis, cocaine, amphetamines, and ecstasy) (Table 6). Answers were similar between both countries. Almost half (48.9%) of nursing students in Slovenia are physically active once to twice 32