Introduction

The COVID-19 pandemic has had a significant impact on people’s physical and mental health, leading to widespread disruptions in daily life and the implementation of government restrictions worldwide (Kuriala, 2021; Violant-Holz et al., 2020; Ganesan et al., 2021). These actions, which include lockdowns and social isolation, have raised stress and anxiety levels and negatively impacted people’s mental health (Buheji et al., 2020; Hawryluck et al., 2004; Doğan et al., 2020). Research indicates that a notable proportion of youth, outside the US, are experiencing mental health problems as a result of the uncertainty brought on by the global pandemic (Bavel et al., 2020;  Huang, 2020). Among the most often reported problems are psychiatric illness, stress, and fear of virus transmission (Krishnamoorthy et al., 2020; Rajkumar, 2020). Additionally, research indicates that health professional students are particularly susceptible to psychological distress and acute stress disorder linked to the COVID-19 pandemic, with prevalence rates as high as 37.73% (Li, 2021).

Nursing is widely recognized as a challenging profession, and nursing education can be stressful for students (Papazisis et al., 2014). Existing evidence shows that academic and clinical stressors are the two main sources of stress for nursing students, with the latter being felt more intensely by students across the board in nursing education (Pulido-Martos et al., 2012). While all university students experience academic stress, the unique aspect of nursing education lies in the practice-based component of the program, where the combination of academic and clinical courses provides the major stress for students (Bartlett, 2016). Thus, it is often known that stress levels among nursing students are higher than those of students in other health-related disciplines (Ching et al., 2020; McGrath, 2003).

Stress is thought to be beneficial in small doses since it boosts excitement and motivation (Gibbons & Gibbons, 2010). On the other hand, persistent, unmanageable stress or the inability to manage ongoing stress can be harmful to one’s health and well-being (Watson et al., 2008). Prolonged stress can impair nursing students’ ability to study, make decisions, think critically, and succeed academically in the end (Sheu, 2002). They might even think about quitting the nursing program as a result of stress (Watson et al., 2008). Their professional identity and health may suffer from extended exposure to unmanageable stress (Edwards, 2010; Altiok & Ustun, 2013). Studies have found that stressful life experience are linked to anxiety and depression in nursing students, but stress itself is positively correlated with depressed mood (Ross et al., 2005; Støen Grotmol et al., 2013). The continuation of the COVID-19 pandemic and the involvement of healthcare professionals on the frontlines could potentially have adverse effects on nursing students.

Professional identity in nursing refers to an individual’s positive attitude toward the nursing profession with the intention of fully practicing the nursing skills and sense of responsibility acquired from professional training (Zhang, 2021). In the fight against the COVID-19 pandemic, nursing staff have shown their professional strengths and values, which has considerably boosted nursing students’ sense of professional pride. Reports have indicated that the COVID-19 pandemic has increased professional identity among Chinese nurses (Li et al., 2021), and similar results have been observed among Chinese nursing students (Nie, 2021). However, on the other side, nursing students have had to reevaluate the hazards connected with their future employment, which may have an impact on their career choices, in light of public accounts of healthcare workers contracting infections or even losing their lives.

Coping mechanisms are necessary for managing stress and preventing its adverse consequences (Labrague, 2017). Coping styles can be categorized into positive and negative coping, where individuals adjust their cognitive and behavioral patterns to alleviate negative emotions under stress (Compas, 2001). When under stress, people who employ positive coping strategies may develop a positive mindset and seek out support in order to manage their negative feelings (Lazarus & Folkman, 1984). The COVID-19 pandemic is a stressor that has altered human physiology, brain, mind, and behaviour in multiple ways (Al-Hindawi et al., 2022). However, various nursing students have varied ways of seeing and responding to stressors, as well as different ways of coping with them. Therefore, it is crucial to investigate the stress levels and coping styles of nursing students during public health emergencies and to implement prompt and efficient interventions to enhance their mental health and promote their professional identity.

Although stress experienced by nursing students has been adequately documented, what is less known is whether there is heterogeneity of stress among nursing students, as well as variability in coping styles and professional identity. Most nursing research has adopted a variable-centered strategy, which focuses on examining the links between each aspect of stress and other variables. While this method offers insightful data regarding the specific and direct relationships between each aspect of stress and other variables, it fails to consider the possibility that (a) different stress profiles exist within the population and (b) these profiles could be associated with variations in other variables (coping, professional identity, etc.). This viewpoint is in line with the person-centered approach to conceptualizing stress, which acknowledges the possibility of different stress profiles. Most research focuses on the individual effects of stressors (Labrague et al., 2018; Bhurtun, 2019), but little consideration is given to the interactions among various stressors. To better assess inter-individual variability and explain the multidimensional nature of stress, a person-centered approach is required. Latent profile analysis (LPA) is a person-centered approach that identifies latent subgroups by examining how individuals naturally cluster together (Lanza et al., 2013). One major strength of this approach is that it can be used to “identify shared symptom patterns” in a sample (Au et al., 2013). This understanding can then be leveraged to identify the groups to which each nursing student belongs, guiding appropriate interventions tailored to the unique needs of each group, rather than just targeting the outcome variable.

To the best of our knowledge, this is the first study looking into nursing students’ stress profiles during the COVID-19 pandemic using latent profile analysis (LPA). The aim of this study is to identify subgroups of nursing students with different stress profiles during the COVID-19 pandemic using a person-centered LPA, and assess the differences in demographic characteristics, coping styles, and professional identity among these subgroups, providing a basis for early intervention and further development of individualized educational strategies. We hypothesized that:

Hypothesis 1

(H1). There may be heterogeneity of psychological stress among nursing students during the COVID-19 pandemic, which can be identified using latent profile analysis (LPA).

Hypothesis 2

(H2). Stress profiles based on LPA may demonstrate differences in coping styles and professional identity among nursing students.

Materials and methods

Data and study design

A cross-sectional study with latent profile analysis was conducted among nursing students in China from April to June 2022. Ethics approval was granted by the Institutional Review Board of Ruijin Hospital, Shanghai Jiao Tong University School of Medicine.

This was an online survey. We sent the questionnaire QR code to the nursing students in four colleges in Shanghai and Jiangsu, China. The students scanned the QR code and completed the questionnaire on the online survey platform. Participation was completely voluntary and no financial incentives were offered. Data were collected through the online platform, and all participants completed the questionnaire online providing informed consent on the survey platform. The questionnaire was administered in simplified Chinese. A total of 1978 valid questionnaires were obtained. We performed an analysis using G*Power 3.1 to calculate the sample size required for this study. The results showed that 107 was the minimum sample size needed to achieve sufficient power (95%) in detecting a medium effect size (f2 = 0.15). Thus, the number of participants (n = 1978) in this study was an adequate sample size.

Measures

The demographic characteristics of the survey included gender, grade, and reasons for choosing nursing program.

The Psychological Stress Questionnaire for College Students (PSQCS) was used to assess the sources and levels of psychological stress among nursing students (Cui, 2009). It consists of 36 items assessing stress in five domains: emergency stress, financial stress, employment stress, academic stress, and social and interpersonal stress. It is a self-reported measure rated by a 5-point Likert scale (0 no stress, 1 mild stress, 2 moderate stress, 3 high stress, and 4 very severe stress). The average score of each domain is the total score of the stress values of the questions in the domain divided by the number of related questions. Higher scores indicate greater psychological stress. The questionnaire has been widely used in China and has demonstrated good validity and reliability (Zhao et al., 2021; Li et al., 2021). The Cronbach’s alpha coefficient for the questionnaire was 0.926, indicating good internal consistency and high construct validity.

The Coping with Psychological Stress for College Students (CPSCS) was used to measure the coping strategies employed by nursing students in response to psychological stress (Cui, 2009). The scale has been widely used and has demonstrated good validity and reliability (Zhao et al., 2021; Li et al., 2021). It consists of 22 items assessing four coping strategies: problem solving, support seeking, expectancy, and avoidance. It is a self-reported measure, rated on a 5-point Likert scale (1 = “non-conformity” to 5 = “fully conforming”). The average score of each strategy is the total score of each item of the factor divided by the number of related items. If an average score is higher than 3, it indicates a strong tendency to respond to this strategy. Conversely, an average score lower than 3 indicates a weaker tendency to respond to this strategy. The Cronbach’s alpha coefficient for the scale was 0.811, with good internal consistency and high construct validity.

The Professional Identity Questionnaire for Nursing Students (PIQNS) was used to assess the professional identity among nursing students (Hao, 2011). The questionnaire has been widely used in China and has been proven to have good reliability and validity (Zhang, 2021; Gao et al., 2021). It consists of 17 items, rated on a 5-point Likert scale (1 = “not true at all” to 5 = “true nearly all the time”). The total score ranges from 17 to 85. Higher scores indicate better professional identity. The Cronbach’s α coefficient for the PIQNS in this study was 0.947.

Statistical analysis

SPSS 25.0 and Mplus 8.2 were used in the analyses. Latent profile analysis was utilized to identify potential stress profiles of nursing students. The one- to six-class groups were applied and compared based on a set of fit statistics. A good model fit was indicated by (1) lower comparative values of the Akaike information criteria (AIC), the Bayesian information (BIC), and the adjusted BIC (ABIC) values, as well as higher values of entropy with numbers closer to 1; (2) a significant Lo-Mendell-Rubin likelihood ratio test (LMRT) and bootstrap likelihood ratio test (BLRT) (Jung & Wickrama, 2008; Berlin et al., 2014). After determining the best-fitting profile model, chi-square tests and ANOVA were used to conduct inter group comparison. Multiple logistic regression model was used to explore the differences in demographic characteristics, coping styles, and professional identity among nursing students with different profiles of psychological stress.P < 0.05 was considered statistically significant.

Results

Latent profile analysis of psychological stress

A total of 1978 nursing students were selected for this study. In the latent profile analysis, the average scores of each dimension of PSQCS were used as the exogenous variables to develop the model. Starting with a model with one potential class, the number of potential classes was gradually increased, and the fitness of each model was evaluated one by one to determine the best-fit latent class model. The fit indices of the six LPA models were presented in Table 1. The values for AIC, BIC, and A-BIC showed the biggest reduction from the three-profile model to the four-profile model, starting with the two-profile. The six-profile model’s p-values for LMRT and BLRT were not significant (p > 0.05), indicating that the fitting effect of the six-profile model was not as good as that of the five-profile model. Although the fitting effect of the five-profile model was better than that of the four-profile model (p < 0.05), there was one category in its classification that only accounted for 2% (< 5%) and did not have classification significance. Additionally, the four-profile model’s entropy test value was higher than that of either the five-profile or three-profile model. Therefore, the four-profile model was considered to be the optimal solution.

Table 1 Model fit indices for one to six profile solutions of stress
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The average scores for each dimension of PSQCS for the four subgroups of nursing students were presented in Table 2, and the results were also displayed in Fig. 1. Among all five stressors, nursing students in subgroup-1 had the highest average scores on employment stress. Therefore, subgroup-1 was named High Employment Stress (HES). There were 356 nursing students in this subgroup, representing 18.0% of the total sample. Subgroup-2 had lower mean scores on each dimension compared to the other three subgroups. Thus, we named subgroup-2 as Low Stress (LS). It was the largest subgroup, with 796 students, accounting for 40.2% of the total sample. Subgroup-3 was named Moderate Stress (MS) because it had moderate scores on each dimension compared to the other three subgroups. Subgroup-3 consisted of 403 students, or 20.4% of the total. Subgroup-4 was named High Stress (HS) as the mean scores on each dimension were higher than any other subgroup. In total 423 students were in subgroup-4, accounting for 21.4%.

Table 2 Average score of PSQCS among nursing students (Mean ± SD)
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Fig. 1
figure 1

Four-profile solution of the latent profile analysis

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Profile differences in coping styles and professional identity

Univariate analysis revealed significant differences (P < 0.01) among the four profiles of psychological stress in terms of grade, reasons for choosing nursing program, coping styles, and professional identity. As shown in Table 3, HES nursing students were more likely to be fourth-year students and were more likely to have chosen nursing program primarily for easy employment compared to the other three subgroups. LS students were more likely to have enrolled in nursing primarily out of interest, while HS students were more likely to have transferred into the program. LS students scored highest on problem solving, while HS students scored highest on support seeking, expectancy, and avoidance. LS students also scored highest on PIQNS compared to the other three subgroups. Moreover, there were no gender differences among the four classes (P > 0.05).

Table 3 Differences among nursing students with different stress sub-profiles
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Multiple logistic regression analysis was conducted, using “Low Stress” as the reference group, to compare the characteristics of different stress profiles. As shown in Table 4, the results showed that HES nursing students were more likely to be fourth grade students (OR = 1.832, P = 0.001), and were positively correlated with expectancy (OR = 1.497, P < 0.001), avoidance (OR = 1.556, P = 0.001), while negatively correlated with problem-solving (OR = 0.714, P = 0.001), and professional identity (OR = 0.494, P < 0.001). Moderate stress nursing students were less likely to be fourth grade students (OR = 0.630, P = 0.018), and had a positive correlation with support seeking (OR = 1.686, P < 0.001), avoidance (OR = 1.494, P = 0.001), and a negative correlation with problem solving (OR = 0.462, P < 0.001). HS nursing students were positively correlated with support seeking (OR = 1.651, P < 0.001), expectancy (OR = 1.605, P < 0.001), and avoidance (OR = 2.672, P < 0.001), while negatively correlated with problem-solving (OR = 0.358, P < 0.001), and professional identity (OR = 0.577, P < 0.001). There were no significant differences in gender and reasons for choosing nursing program among the four potential stress profiles of nursing students (P > 0.05).

Table 4 Multivariate logistic regression analysis
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Discussion

In this study, four psychological stress characteristics of nursing students were identified based on five psychological stress sources through latent profile analysis: High Employment Stress (18.0%), Low Stress (40.2%), Moderate Stress (20.4%) and High Stress (21.4%). The results indicated that the psychological stressors and stress levels of nursing students were heterogeneous during COVID-19 pandemic. Nursing students from different subgroups exhibited unique stress profiles which implicated different supporting. For example, the HES group seems to need more guidance on job searching and establishing realistic career expectations. The number of nursing students with HS, MS, and HES accounted for 60% of the total sample, indicating that the psychological stress levels of nursing students were generally at moderate to high levels, similar to the findings of Liu et al. (Liu et al., 2020). This highlights the importance of identifying the stress characteristics of high-risk individuals early on and developing targeted counseling interventions.

Nursing students often encounter multiple interconnected stressors. The findings of this study revealed that nursing students in MS and HS groups exhibited high stress levels across all five stressors. Similarly, Liao et al. (Liao et al., 2018) identified stress profiles among university freshmen based on five stressors (academic, financial, intimacy, peer relationships, and parent-child relationships), where the general subgroup experiencing moderate to high stress showed elevated stress levels across all stressors. These findings suggest that nursing students are susceptible to concurrent or sequential superimposed stress. MS and HS nursing students reported the highest levels of emergency stress, which could be attributed to the impact of the COVID-19 outbreak during the survey period. Public health emergencies are sources of stress that trigger a range of effects in the daily life, work, and behavior of nursing students. Apart from concerns about their own and their families’ risk of infection, these students also worry about the negative impact of the outbreak on their studies, graduation, and future employment, thereby amplifying their psychological stress. Additionally, approximately 18.0% of nursing students reported high levels of employment stress coupled with high levels of financial stress and academic stress. The HES nursing students were mainly fourth-year graduates whose academic and employment-related issues formed the primary stressful events during the graduation phase. Job searching can be financially burdensome, and those nursing students with limited financial support from their families may experience heightened employment stress (Lavoie-Tremblay et al., 2022). On the other hand, the LS nursing students, accounting for 40.2% of the total sample, exhibited low stress levels across all five stressors due to effective stress regulation and coping skills. Since nursing students are exposed to numerous stressful life events, nurse educators should pay special attention to the possibility of simultaneous exposure to additional stressors when specific stressors affect individual nursing students, and help them improve their adaptive abilities to cope with stress.

The present study found that LS nursing students demonstrated proficient problem-solving coping skills and scored highest on the problem-solving dimension of the coping styles scale. Proactive coping helped mitigate the stress resulting from life events (Fornés-Vives, 2016). In contrast, HS nursing students were more prone to negative coping strategies such as expectancy and avoidance. This can be attributed to the positive association between the number and accumulation of stressful events and the use of negative coping mechanisms (Ferrari, 2020). It is worth noting that nurse educators should adopt a balanced perspective on nursing students’ coping strategies. Temporary use of negative coping styles like expectancy and avoidance may provide some relief from overwhelming psychological stress. However, nursing students experiencing high stress levels should be provided with timely and effective psychological counseling, guiding them to seek help and support, enhance their mental resilience, and choose positive coping styles that are appropriate for their situation.

Compared to LS nursing students, HS and HES students exhibited lower levels of professional identity. HES nursing students may lack job search assistance, face a competitive employment environment, and have high expectations for their careers, which may affect their professional recognition. HS nursing students, burdened with higher psychological stress, tend to have weaker professional identity, which is consistent with the findings of Zhong et al. (Zhong et al., 2020). Therefore, nursing educators and administrators should guide nursing students in improving their professional qualities, expanding their employment opportunities, establishing correct professional values, making suitable career choices, and leveraging role models as sources of support to enhance their psychological resilience and professional identity (Zhang, 2021).

Currently, the existence of gender differences in various stressors is still controversial (Helbig et al., 2017; Moksnes et al., 2016). The results of this study showed that male students scored significantly higher than female students only on the social and interpersonal stress dimension (1.83 vs. 1.73, F = 7.838,p= 0.005), which is consistent with previous findings (Liao et al., 2018). This could be attributed to male students being less inclined to communicate when faced with interpersonal conflicts. No gender differences were found in any other stressors (P > 0.05). To eliminate possible gender bias in the results, this study conducted separate LPA for male and female nursing students to identify psychological stress profiles. The results yielded the same latent characteristics, indicating that the present study was less influenced by gender differences and the results obtained were reliable.

Limitation

As far as we are aware, this is the first study to use latent profile analysis to try to identify stress profiles among nursing students during the COVID-19 pandemic. This will help with early intervention and future development of individualized educational strategies. However, there are several limitations to this study. Initially, a convenience sampling technique was employed, which could lead to bias in selection. Furthermore, there is limited generalizability of the study to the overall population of nursing students because it was conducted solely in China. It is necessary to conduct more research using a variety of samples from various locations and civilizations. Another disadvantage of this study that calls for future research is the absence of a reliable instrument to measure the stress among nursing students directly related to the COVID-19 pandemic.

Conclusion

Overall, nursing students suffer moderate to high levels of psychological stress. There is heterogeneity in psychological stress profiles among nursing students, which can be categorized as High Employment Stress, Low Stress, Moderate Stress, and High Stress. To support nursing students’ professional adaptation and identity, it is advised to identify stress profiles early on among high-risk groups (HS and HES) and establish focused counseling interventions to manage stress and improve coping abilities.