research paper on stress management among teachers

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• Volume 79, Issue 7
• Effectiveness of interventions on the stress management of schoolteachers: a systematic review and meta-analysis
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• http://orcid.org/0000-0002-7030-8129 Netra Raj Paudel 1 ,
• Bidhya Acharya Adhikari 1 ,
• K C Prakash 1 , 2 , 3 ,
• Saila Kyrönlahti 1 , 4 ,
• Clas-Håkan Nygård 1 , 4 ,
• Subas Neupane 1 , 4 , 5
• 1 Unit of Health Sciences, Faculty of Social Sciences , Tampere University , Tampere , Finland
• 2 Department of Public Health , University of Turku , Turku , Finland
• 3 Department of Psychology, Stress Research Institute , Stockholm University , Stockholm , Sweden
• 4 Gerontology Research Center , Tampere University , Tampere , Finland
• 5 Tampere University Hospital , Tampere , Finland
• Correspondence to Netra Raj Paudel, Tampere University, Tampere, Finland; netra.paudel{at}tuni.fi

Background This systematic review aimed to analyse the effectiveness of interventions on the stress management of schoolteachers.

Methods We searched the Medline, PsycINFO, CINAHL and Education Research Complete until 30 November 2021, to identify relevant studies using relevant key words. Job or occupational stress was used as the outcome measure. Stress was defined as Perceived Stress Scale, Teacher Stress Inventory, Maslach Burnout Inventory, Teacher’s Distress, Brief Symptoms Inventory or Global Severity Index. Study selection, data extraction, risk of bias assessment was performed by two independent reviewers. The pooled estimate of the effect by the type of outcome measurement tool and by type of interventions used was calculated using random effects meta-analysis. We used Grades of Recommendations, Assessment, Development and Evaluation to assess the overall quality of the evidence.

Results We reviewed 26 studies, of which 24 were randomised trials and 2 pre-test/post-test studies. Based on meta-analysis, a positive effect of intervention (pooled estimate −1.13, 95% CI −1.52 to −0.73) with high heterogeneity among studies (χ 2 =426.88, p<0.001, I 2 =94%) was found by type of interventions used. Cognitive–behavioural therapy had the strongest positive effect, followed by meditation among the types of interventions studied. We identified evidence of a moderate quality for interventions aiming to manage the stress level of schoolteachers.

Conclusions The meta-analysis showed a positive effect of interventions, suggesting that interventions might reduce the stress level among teachers. The quality of the evidence was moderate.

PROSPERO registration number CRD42021225098

• public health
• occupational health

https://doi.org/10.1136/oemed-2021-108019

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Key messages

What is already known about this subject.

Teaching profession is one of the most stressful jobs with a high level of psychological morbidity.

Stress may occur together with mental health problems, such as common mental disorder, which is one of the leading causes of disability worldwide.

Several interventions have been designed to help schoolteachers cope with the stress associated with their job.

What are the new findings?

A positive effect of interventions was found among teachers to manage their stress level.

Cognitive–behavioural therapy had the strongest positive effect, followed by meditation among the types of interventions studied to manage teachers’ stress levels.

We found evidence of a moderate quality for the interventions aiming to reduce the stress level of schoolteachers.

How might this impact on policy or clinical practice in the foreseeable future?

Through effective intervention tools, workplace health can be enhanced, and the individual well-being of schoolteachers maintained.

Introduction

Stress is the feeling of being overwhelmed or unable to cope with mental or emotional pressure which can happen together with mental health problems, such as depression. 1 Depression is one of the leading causes of disability worldwide: approximately 264 million people of all ages suffer from depression globally. 2 In 2019, depressive disorders were the sixth leading contributor for disability-adjusted life-years among 25–49s years. 3

Occupational stress is the most common form of stress, and the degree of stress varies among different occupations. A study from the UK 4 found that teaching was one of the most stressful occupations, because of its direct human-oriented nature. 4 5 The afore-mentioned study measured stress in terms of physical health, psychological well-being and job satisfaction. Likewise, a follow-up study in West England reported a higher level of psychological distress among a cohort of teachers than among comparable professionals from the general population. 6

Teaching is an occupation with high work demands and it requires a diverse range of tasks under complex working conditions, dealing with students, school authorities, colleagues and parents. 4 Potential stressors for teachers are low job support, student apathy, overcrowded and noisy working environments, excessive mental work, low wages, unsupportive parents and changing curricula. 7 Stress can be suppressive and hinder thought processes and somatic stimuli. 8 It is characterised by physical and psychological exhaustion, depersonalisation and cynicism, a sense of helplessness and low self-efficacy. 6 9 Lacking management of chronic workplace stress may result in burn-out syndrome. Prolonged stress becomes permanent, over time, because it is hard to recover and as a result, the individual faces chronic fatigue, musculoskeletal problems or cardiovascular disease and professional burn-out syndrome. 10

Previous studies have recommended stress management and coping interventions to reduce and prevent stress among teachers. 11–13 Such interventions include a variety of approaches like mindfulness training 14 cultivating awareness and resilience, 13 standardised meditation 15 and gratitude interventions (GI). 11

Although several interventions have been designed to help schoolteachers cope with the stress associated with their profession, the evidence based on a systematic examination and synthesis is limited. Each intervention represents a distinctive strategy to cope with stress, providing plentiful prospects to compare the strategies used for stress management among schoolteachers. Such comparisons could be helpful in investigating key strengths of the interventions in terms of effectiveness, delivery method and design. Further, determining the most effective intervention and content could be helpful in planning new strategies or improving existing delivery methods and strategies aimed at helping schoolteachers cope with and manage occupational stress. Therefore, the main aim of this systematic review is to examine the effectiveness of interventions targeted at schoolteachers’ stress management.

This study was performed in accordance with the criteria of the Preferred Reporting for Systematic Reviews and Meta-Analyses statement. 16 , 17

Search strategy

We conducted a systematic literature search to identify the relevant studies on interventions for schoolteachers’ stress management. The literature search was undertaken on the following electronic databases: Medline, PsycINFO, CINAHL and Education Research Complete. The search strategy includes a comprehensive list of key terms and combinations of Medical Subject Headings (MeSH) describing the outcome and the interventions. The search was limited to English-language publications. No limit in year of publication was used to capture all/eligible past and contemporary work environment interventions. We also searched the bibliographies of the included studies to find relevant studies potentially missed in the systematic search. The search strategy was modified for each electronic database ( online supplemental file 1 ).

Supplemental material

Selection of studies.

We selected literature that have studied the effect of interventions on schoolteachers’ stress management. The following inclusion criteria were applied: (1) randomised control trials, controlled trials, quasi-experimental or pre-test/post-test studies, (2) literature published until 30 November, 2021, (3) studies conducted among school (primary or secondary) teachers, (4) interventions provided for stress management or to reduce teachers’ stress levels, (5) interventions provided during/after school hour and (6) studies including perceived stress (PSS), job stress, occupational stress or burn-out as outcome. We excluded studies, if the intervention was delivered by teachers, not to teachers.

All citations were exported to RefWorks software and duplicates removed. Two reviewers (NRP and BAA) independently screened each study title and abstract for their eligibility. In case of disagreement between reviewers, a third reviewer (SN) was consulted. The same two reviewers assessed the full texts of all the selected studies for their eligibility. The third reviewer was consulted to resolve any disagreements during the study selection process.

Outcome measure

The included studies used various definitions of stress, summarised below in table 1 .

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Definition of the outcomes used

Data extraction

Data were extracted from all the included studies using customised form. Two reviewers (NRP and BAA) independently extracted data from each individual study on research characteristics (authors, year of publication, country of origin), study population (sample size, age and gender distribution), intervention and comparison (type of intervention used, procedure, controls), follow-up time, outcome (definition, methods/tool used), study results (number of participants analysed, mean value and SD of the outcome at baseline and follow-ups for intervention and controls), and the effect measure (if the intervention effect was positive or negative). Discrepancies were resolved through discussion with the third reviewer (SN).

Quality assessment

We used the Cochrane Handbook 18 recommendation for systematic reviews of intervention of randomised control studies to assess the quality (risk of bias) of the included studies. Two reviewers (NRP and BAA) independently assessed the studies. The risk of bias was assessed for six major domains: selection bias, performance bias, detection bias, attrition bias, reporting bias and other bias. Each domain contains one or more items: (1) random sequence generation, (2) allocation concealment, (3) group similarity at baseline, (4) blinding of outcome, (4) timing of outcome assessments, (5) outcome data complete, (6) free of selective reporting, (7) co-interventions avoided, (8) compliance acceptable and (9) intention to treat (ITT) performed. Each item was assessed as high, low or unclear risk. The risk of bias associated with ITT analysis was assessed as high if >20% lost to follow-up occurred with no ITT analysis present. 19 Studies were classified as overall low risk of bias if all items were rated as low risk of bias according to the Cochrane Handbook recommendation.

Two of the included studies were non-randomised which comprised only pretest and post-test measurement; therefore, we used Risk Of Bias In Non-Randomized Studies—of Interventions (ROBINS-I) 20 tool to assess the risk of bias in non-randomised intervention studies. ROBINS-I includes domains dealing with pre-intervention, at intervention and post-intervention in seven items (pre-intervention: bias due to confounding, bias in selection of participants into the study; at intervention: bias in classification of interventions; postintervention: bias due to deviations from intended interventions, bias due to missing data, bias in measurement of outcomes and bias in selection of the reported results). Each of these seven items were rated as low, moderate, serious, critical risk of bias or no information. Overall risk of bias was classified as low, if all seven items were rated as low, and otherwise as high risk. 20

Data synthesis

A meta-analysis was conducted to pool the results from the included studies using Review Manager V.5.3 developed by the Cochrane Community. Studies used different questions to measure the stress outcome, however, most studies reported stress as an outcome with mean values and SD from the baseline (pretest) and one or more follow-ups (post-test). Included in the meta-analysis are studies reporting mean, SD or SE and sample size for both the intervention and control from the last round of follow-up, and studies reporting changes in mean and SD from baseline to follow-up. The pooled mean difference (intervention minus control) and their 95% CIs are reported as an overall synthesised measure of effect size using random effect models. Heterogeneity (0%–100%) among studies was assessed via χ 2 test indicating heterogeneity when p<0.05. We first synthesised the effect size from all studies included in the meta-analysis, grouped by type of tool used to measure teachers’ stress, then by type of intervention used. As a sensitivity analysis, we analysed studies among special education teachers separately. To see the long-term effectiveness of the intervention, we analysed studies stratified by time of follow-up (1–4 months vs 5–12 months). We separately synthesised the effect size of two studies using only pre-test and post-test with no comparison group. The results are presented as a forest plot. Publication bias was determined using funnel plots.

Evidence synthesis

We used the Cochrane Handbook Grading of Recommendations Assessment, Development and Evaluation (GRADE) 21 to synthesise the quality of evidence. Evidence quality was assessed in relation to study design, risk of bias or study limitations, consistency of results, indirectness, precision, and publication bias. 22 Four authors (SN, NRP, BAA and KCP) undertook the GRADE process with consensus reached by discussion.

Starting level of evidence was high for randomised studies. We then downgraded the quality of evidence for the above six criteria. An overall level of evidence was assessed for each study in four ratings: (1) high quality—further research is very unlikely to change our confidence in the estimate of effect or accuracy; (2) moderate quality—further research is likely to have an important impact on our confidence in the estimate of effect or accuracy and may change the estimate; (3) low quality—further research is very likely to have an important impact on our confidence in the estimate of effect or accuracy and is likely to change the estimate; (4) very low quality—any estimate of effect or accuracy is very uncertain. Accordingly, for two non-randomised studies a low grade was given as the starting level and was upgraded due to the quality of evidence for the above six criteria.

Literature search

The initial search of literature through Medline, PsycINFO, CINAHL and Education Research Complete generated 4898 records ( figure 1 ). After removing duplicates, the titles and abstracts of 4896 records were screened for eligibility. Full-text assessment of 123 records was performed. In total, 26 studies (27 articles) met the inclusion criteria and were included in this review. Two studies 13 23 were regarded as one in the analysis because they involved the same study population, resulting in 26 studies. Out of these, 24 studies were randomised controlled trials and two studies 11 24 were pretest and post-test studies. Six of the studies were conducted among special education teachers ( online supplemental table 2 ). A detailed study selection process is summarised in figure 1 .

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Modified PRISMA flow chart of the included studies. PRISMA, Preferred Reporting for Systematic Reviews and Meta-Analyses.

Study characteristics

Four studies were conducted in the UK, 14 24–26 seven studies were from the USA, 12 13 15 27–30 four from Hong Kong, 11 31–33 four studies from Nigeria. 34–37 Others were from Spain, 38 Australia, 39 Netherlands, 40 Japan, 41 India, 42 Germany 43 and Poland. 44 These studies were published between 1999 and 2021. The details of the data extraction are provided in online supplemental table 2 . Population size in these studies ranged from 18 12 to 337 participants. 43 Six studies were conducted among special education teachers, 30 34–37 majority conducted in Nigeria. Overall, the study sample was primary-to-secondary-level teachers, or teachers of students with behavioural problems or disabilities (eg, autism) recruited from public or private schools. One study also included other staff than teachers. 30 Participants were invited through emails, posters, local conferences and courses offered as stress prevention for teachers, etc. Some studies used a convenience sample, as the target population was not clear in those studies. The randomisation was done at school or at individual level. All studies involved both male and female teachers, except the one 42 conducted among female teachers only. The age range of the teachers in the included studies was between 22 and 64 years, except for one, 14 where age was not reported.

Nine studies used meditation as an intervention. Meditation training may vary in its activity and amount of training recommended, depending on its purpose. Basic meditation mantra, however, is meant to focus the mind through breathing observation. 45 The most frequently used meditation techniques in literature were Mindfulness-Based Stress Reduction, Mindfulness in Schools Project, Stress Management and Relaxation Techniques, Cultivating Awareness and Resilience in Education, Mindfulness-Based Emotional Balance. Other nine studies used cognitive–behavioural therapy (CBT), which includes elements such as awareness of stress, relaxation training, identification of dysfunctional thoughts, cognitive restructuring, problem solving process training, anger and time management. 46 Other interventions were Written emotional disclosure interventions, 26 Workplace Triple Positive parenting programme and telephone consultation, 39 Teacher Classroom Management (TCM) workshops, 27 Teacher-focused coaching intervention (Key2Teach intervention), 40 group session 40 and stress management workshop. 44 The two pre-test/post-test studies involved a gratitude intervention (GI) 11 and TCM training. 25 The last follow-up time reported in studies varies between 1 month 42 44 and 12 months. 11

Eight of the included studies used Maslach Burnout Inventory (MBI) tool to measure the teacher’s stress, seven used PSS, three used Global Severity Index (GSI) and nine studies used other tools (TSI, Positive Symptoms of Distress Index, Teacher Occupational Stress Factor Questionnaire, Subjective psychological distress and Depression, Anxiety and Stress Scale). Three studies 12 15 38 used two different tools to measure the teacher’s stress. Twenty-five studies reported the positive effect of the intervention of reducing the teachers’ stress levels, while one 27 reported negative effects.

Meta-analysis

The pooled estimates of intervention effect on teacher’s stress were calculated and are presented by the type of stress measurement tool used ( online supplemental figure 1 ). A total of 2657 subjects were analysed. A positive effect of intervention (overall pooled mean difference −1.09, 95% CI −1.46 to −0.73) with high heterogeneity in the effect size (χ 2 =436.20, p=<0.001; I 2 =94%) was found. The pooled standard mean difference between intervention and control for studies that used MBI, PSS or other tools was positive (favouring intervention), while also positive effect but not statistically significant for studies using GSI.

A pooled estimate from the two studies with no control group ( figure 2 ) showed small positive effects of the intervention from pre-test to post-test. However, the estimate was not statistically significant.

Forest plot of the standard mean difference (pre-test vs post-test) and their 95% CIs for teacher’s stress. IV, inverse variance.

The standard mean differences of the intervention and control by the type of intervention used are presented in figure 3 . Among 2272 subjects studied, the overall pooled estimate shows positive effect of intervention (pooled estimate −1.13, 95% CI −1.52 to −0.73) with high heterogeneity among studies (χ 2 =426.88, p<0.001, I 2 =94%). The pooled estimate from nine studies shows a strong positive effect of meditation interventions on stress management (pooled estimate −1.09, 95% CI −1.60 to −0.59) with very high heterogeneity between the studies (χ2=70.05, p<0.001, I 2 =87%). A strong positive effect of CBT was also found in the pooled estimate of nine studies (standard mean difference −2.34, 95% CI −3.32 to −1.35) with high heterogeneity between studies (χ 2 =294.74, p<0.001, I 2 =97%). Six studies used other types of intervention with small positive effects, but the estimate was not statistically significant.

Forest plot of the standard mean difference (intervention minus control) and their 95% CIs for teacher’s stress by type of intervention used. IV, inverse variance.

The meta-analysis of the studies among special education teachers ( online supplemental figure 2 ) shows strong positive effect of intervention (standard mean difference −4.55, 95% CI −6.59 to −2.50) with high heterogeneity between studies (χ 2 =153.69, p<0.001, I 2 =97%). Further sensitivity analysis by the length of follow-up time shows pooled estimate of −1.58 (95% CI −2.18 to −0.99) among studies with short (1–4 months) follow-up ( online supplemental figure 3 ). Small positive effects but statistically no significant pooled estimate was found for the long follow-up studies.

Funnel plot ( online supplemental figure 4 ) shows the risk of publication bias of the included randomised studies by type of interventions used. Standard mean difference is presented in x-axis and SE of the mean difference in y-axis. The results show that the mean difference was both positive and negative, meaning that the studies had a mixed effect, suggesting a low risk of publication bias.

Risk of bias

Risk of bias was assessed as low, high or unclear. The summary of the risk of bias assessment is presented in table 2A,B . Four studies 27 34 37 39 had low risk of bias in ten items while three other studies 13 36 41 had low risk of bias in nine items. Other studies had up to three items rated as high risk. Overall, the risk of bias ratings was low in many studies. Whether the study had an ‘ITT’ analysis performed, was the most common item rated ‘unclear’ as many studies did not report it. Random sequence generation was rated as ‘high’ risk in eight and allocation concealment in seven studies, respectively. These studies were mostly lacking clear information on population selection or due to inadequate generation of randomised sequence and inadequate concealment of allocations prior to assignments in one of the study groups.

(A) Summary of risk of bias analysis of the randomised controlled trial studies (B) Summary of risk of bias analysis of non-randomised (pre-test/post-test) studies

Quality of the evidence

We evaluated the quality of evidence of the studies by the type of intervention used ( table 3 ). We used integrative GRADE criteria to assess the quality of evidence considering six criteria: study design, risk of bias or study limitations, consistency of results, indirectness, precision and publication bias. For nine studies (n=635) using meditation interventions, a moderate quality of evidence was assessed. We started with a high grade as a starting point and downgraded it by one step due to high risk of bias in five out of nine studies. No downgrade or upgrade was considered due to inconsistency, indirectness, imprecision or publication bias, as there was no difference in outcome measures in studies, the pooled effect estimate was precise (although the effect estimates of each individual study varied but still all had positive effect), and no publication bias was detected. Similarly, the quality of evidence for other nine studies (n=946) using a CBT intervention was rated as moderate. A one-step downgrade was considered due to high risk of bias, but no further downgrade due to inconsistency, indirectness, imprecision, or publication bias. The effect size based on meta-analysis had a strong positive effect with huge variation between studies. For studies with other types of intervention, including two non-randomised studies, the quality of evidence was rated as low. A one-step downgrade was considered due to serious risk of bias in four studies and another step was downgraded due to inconsistencies and indirectness of the effect estimates, as the pooled effect was small and inconsistent.

Summary of findings GRADE

This systematic review evaluated the available evidence for interventions designed to reduce schoolteachers’ stress levels. Twenty-six studies (27 articles) met our inclusion criteria, of which 24 were randomised controlled trials and two were pretest/post-test studies, and 6 out of 26 were conducted among special education teachers. Overall, meta-analysis shows that the interventions are effective in reducing the stress level of schoolteachers with meditation (nine studies) and CBT (nine studies) being more effective than other types (eight studies) of interventions. We found moderate quality of evidence for meditation and CBT interventions, whereas low quality of evidence was found for other interventions to reduce teachers’ stress. The follow-up from baseline to postintervention in the included studies varied between 1 month and 12 months and studies with shorter follow-up were found more effective in reducing teachers’ stress.

Earlier, a Cochrane review evaluating organisational intervention effectiveness in reducing work-related stress in teachers found low-quality evidence of the interventions leading to improvement in teacher well-being 47 based on four studies. We found no other systematic review evaluating the effectiveness of interventions for reducing teacher’s stress. Two non-systematic reviews of interventions for teacher well-being suggested self-directed interventions. 48 All the included studies in our review used individual-focused interventions.

Various types of interventions have been in practice for the last few decades to reduce teachers’ stress. Overall, 10 different types of intervention were used in these studies. Meditation is one of the most effective interventions in producing well-being and reducing teachers’ stress. 12 14 15 These studies show that even in a short duration (2–5 times/week) of meditation practice, teachers became more relaxed, organised, and gained a greater sense of emotional balance and confidence. However, the intervention seems to be less effective in a long follow-up. Teachers were less worried, had improved sleep, and realised their increased capacity for dealing with problems. Yet, the willingness of participants is a determining factor for the achievement of mediation. 15 This obviously indicates that meditation produces positivity in a person and, in turn, reduces stress. This argument is consistent with other earlier studies, which found that mindfulness meditation is effective in teachers’ occupational stress management 49 and enhancing their well-being. 14 Moreover, mental health and well-being of teachers were reported to be positively affected in the studies that used multicomponent interventions. 50 Meditation reduces personal distress such as depression, anxiety, hostility, interpersonal sensibility and promotes well-being. 38 Another study reported that mindfulness meditation reduces stress and enhances well-being and sleep quality but does not improve workability. 51

Interventions integrating individually directed behavioural and cognitive approaches have become popular. 52 These cognitive‐behavioural approaches integrate stress appraisal with physiological stress reduction. 53 In schools, this approach may be particularly effective due to the multifaceted nature of teacher stress. A significant amount of teacher stress arises from teachers’ cognitive perception of student behaviour and difficulty with classroom management. 54 Nine of the included studies employed CBT intervention in teachers’ stress management. The authors of these studies claimed that the conducted training enhanced coping skills, and reduced stress and stressors that teachers were facing. A similar finding was reported in a previous study which stated that teachers experienced reducing dysfunctional thoughts and enhanced stress management behaviours. 55 However, paradoxically, three studies 31 32 41 also stated that CBT did not improve mental and physical well-being or teaching efficacy. Because teaching is one of the more stressful occupations, several technical measures at individual and organisational levels should be considered, in order to reduce teachers’ stress and improve their job satisfaction and well-being. 44 47

Likewise, studies employing GI as a stress reducing technique found it effective on occupational stress. Gratitude training gave effective results in promoting teacher well-being and life satisfaction and mitigating teacher burn-out. 11 The authors highlighted that for those who favoured and valued a meaningful life and happiness, the intervention resulted in reducing stress and vice versa. This finding corresponds to the findings of a previous study, 56 which reported that a GI programme was effective for improving psychological distress and job performance among workers.

All the included studies employed individual-directed interventions, which means that no studies using organisation-directed interventions were found. Studies with a meditation or mindfulness intervention were conducted in the USA (seven studies), UK, Spain, Hong Kong and India with no studies identified from Africa and Latin America which may further limit the applicability of the evidence. Studies that employed CBT were from Nigeria (four studies), Hong Kong (two studies) and Japan only, which means that studies from other than Asian and African regions were not found. All four African studies were from Nigeria and all were conducted using a similar approach among special education teachers. These studies from Nigeria found huge, unusual reduction in the mean level of stress among those who received an intervention. Studies that used other types of interventions were mostly from Europe (UK, Netherlands, Germany, Poland) and one study from Australia. Two studies, Haslam et al , 39 and Hayes et al , 26 were well-conducted trials with low risk of bias in all domains and provided clear justification for the choice of study design and had adequate sample sizes. Haslam et al 39 employed a ‘workplace triple positive parenting programme’ as their main intervention technique which focused on parents who are better able to predict and manage work–family conflict. Moreover, a second set of mindfulness techniques for stress prevention and management, such as identifying and challenging unhelpful thoughts, progressive muscle relaxation, diaphragmatic breathing, diet guidance and exercise tips, were also provided. This study found positive effects of the intervention at 4 months of the follow-up period. Hayes et al 26 found negative effects of an intervention in stress management at 9 months follow-up (2 months after the intervention ended). A TCM workshop was provided to teachers in Hayes et al 26 as the intervention.

We included randomised controlled studies and pretest and post-test studies published in English language only, which probably means that we missed studies published in other languages. Randomised controlled design is considered as a golden standard to study the effectiveness of interventions as well as highly regarded in systematic reviews over other designs. 57 Further limitations that may limit the generalisability of our findings is the use of different tools and interventions, as well as the high female domination among the study subjects. A short duration of follow-up in some of the studies may have affected the outcome which we have analysed stratified by follow-up time. The heterogeneity of the tools used to measure the stress of teachers was one of the challenges to undertake the meta-analysis. Various tools such as PSS, TSI, MBI or Teacher’s Distress, BSI, GSI, etc were used to measure the stress in different studies. Although these are well-established and validated tools, the number of items used, the measurement scale of each item, as well as total scores, differed between studies. Nevertheless, we undertook meta-analysis stratified by types of tools used to see the separate pooled effects of the studies using different tools. We compared all studies that used randomised controlled design to assess the risk of publication bias and ascertain direction of results. The direction of results was mixed, many with positive effect, and some with negative effect which suggests a low risk of publication bias. We used structural groupings in our main results by types of intervention versus no interventions by study group to study which interventions are more effective in reducing stress. Grouping studies in another way is also possible. The variation of tools used to measure stress across studies may influence the study findings. Furthermore, the effectiveness of interventions may differ between teachers with low stress-levels compared with teachers with high stress which we could not separate out in this study which would probably require methodologically stricter criteria in recruiting studies. This may limit the generalisability of the results for a specifically defined group of teachers.

In conclusion, we found moderate quality of evidence for meditation (eg, mindfulness, mind relaxation) interventions and CBT interventions, and low quality of evidence for other intervention types to reduce teachers’ stress. Further studies focusing on a larger sample size and wider population of teachers, a longer follow-up, a larger variety of demographic backgrounds and the counterweight of confounding variables are recommended for stronger evidence.

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Not applicable.

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Supplementary materials

Supplementary data.

This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

• Data supplement 1
• Data supplement 2
• Data supplement 3
• Data supplement 4
• Data supplement 5
• Data supplement 6
• Data supplement 7

Contributors Concept and design: SN and NRP. Acquisition, analysis or interpretation of data: NRP, BAA, SN and KCP. Drafting of the manuscript: NRP, BAA, KCP and SN. Critical revision of the manuscript: SN, SK, C-HN and KCP. Statistical analysis: SN. Administrative, technical or material support: SN and C-HN. Supervision: SN and C-HN.

Funding This work was supported by Juho Vainio Foundation Finland (grant number: 202100245 to KCP).

Disclaimer The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests None declared.

Provenance and peer review Not commissioned; externally peer reviewed.

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ORIGINAL RESEARCH article

The relationships between teachers’ emotional health and stress coping.

• Faculty of Medicine, Vilnius University, Vilnius, Lithuania

Introduction: Teaching is a profession that involves challenges to emotional health. Teachers experience high levels of work-related stress, which causes symptoms such as anxiety, depression and burnout. Teachers’ mental health affects not only their own well-being, but also the quality of education and student achievement. Coping strategies can effectively improve teachers’ emotional health. The aim of this study is to assess the relationship between teachers’ emotional health and stress coping.

Methods: The sample consisted of 385 teachers from Lithuania, with an average age of 50.2 (±9.62) years and 24.9 (±11.8) years of school experience. The WHO-5, the Kessler Psychological Distress Scale (K6), the Spanish Burnout Inventory, Educational Version (SBI-Ed) and the Coping Strategies Scale were used in the study.

Results: The study results show that teachers’ age, seniority, size of residence, and marital status do not affect their emotional health, but their financial situation and hobbies have a positive impact on enthusiasm. Effective coping strategies such as problem solving, exercise, and hobbies improve emotional well-being, whereas negative coping methods such as self-isolation and alcohol consumption lead to psychological distress and lower enthusiasm at work.

Introduction

Teaching is a socially valuable, meaningful and influential profession. However, rapid social and technological changes and constant monitoring of society are increasingly challenging for teachers ( Carroll et al., 2022 ). Due to the emerging challenges and uncertainties of the social world and professional complexity, including collegial competition, standardized performance, increasing accountability, and rapid assessment, the teaching profession is considered to be at high risk ( Zhang et al., 2023 ). Teaching has been associated with increased stress ( Carroll et al., 2022 ; Li et al., 2022 ). High teacher stress is associated with physical and mental health problems, and can have negative occupational consequences. The latter are associated with professional burnout and turnover of qualified teachers ( Puhakka et al., 2021 ; Gearhart et al., 2022 ). Therefore, teachers’ well-being is not only important for teachers and the school community but also for future society ( McCallum et al., 2017 ; Yu et al., 2022 ).

Although empirical evidence is still scarce, new research results suggest that teachers’ well-being impacts their relationships with students, school climate, and student achievement ( López et al., 2017 ). Thus, empirical findings suggest that teachers’ psychological states affect not only their own personal well-being but also their well-being, and that students’ mental health and well-being are related to teachers’ well-being ( Harding et al., 2019 ). Research also shows that teacher well-being is critical to young people’s potential for innovation and productivity ( McCallum, 2021 ), is related to teaching effectiveness, and influences students’ academic achievement ( Harding et al., 2019 ; Hascher and Waber, 2021 ). In addition, teacher well-being impacts educational management ( Hascher and Waber, 2021 ), and interpersonal relationships within the teaching team and students’ academic achievement are significantly interrelated ( Göktaş and Metin, 2022 ).

While several studies have demonstrated the importance of teacher well-being, previous research has focused on the ‘dark side’ of teacher well-being ( Li et al., 2022 ). This research highlighted that teaching is a highly demanding, anxiety-provoking, and stressful profession that can lead to job dissatisfaction, mental illness, and impaired well-being. However, ideas from positive psychology ( Seligman and Peterson, 2003 ) have led researchers to focus more specifically on well-being in education. At present, there is growing interest and concern among researchers, managers, and policymakers about the well-being of teachers, not only to find ways to reduce the risk of stress, exhaustion, and burnout but also to help teachers flourish – to increase their optimism and self-efficacy.

Teachers’ well-being

Well-being is determined by several interacting social, psychological, and biological factors as well as general levels of health and illness ( Klapp et al., 2023 ). Indeed, ‘well-being’ is part of the concept of health and is related to physical, mental, and social health. The World Health Organization (WHO) notes that well-being is “...not merely the absence of disease or infirmity” and that mental health is “...a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community” ( WHO, 2014 ). The understanding of the WHO definition of well-being is meaningfully expanded by the salutogenic perspective on health, which defines health as “the process by which individuals maintain their sense of coherence and ability to function in the face of changes in themselves and their relationships with their environment” ( Antonovsky, 1987 ).

Thus, well-being must be understood in a broader sense than in the absence of illness. Rather, it refers to the healthy and successful functioning of teachers in their work and the ability of teachers to create a positive balance between the available resources and the challenges and demands (psychological, physical, individual, social, and environmental) that arise ( Benevene et al., 2020 ). Well-being encompasses cognitive and affective as well as physical and mental components, and dispositional, personal, organizational, and environmental factors ( Benevene et al., 2020 ). Well-being can be conceptualized and assessed as (1) objective well-being, which reflects what others can objectively measure and observe, such as economic resources, political circumstances, physical health status, number of social connections, and literacy, and (2) subjective well-being, which reflects individuals’ subjective experiences, such as happiness, emotions, engagement, life satisfaction, quality of social relationships, competencies, and achievements ( Forgeard et al., 2011 ).

Research shows that teachers’ well-being is related to many aspects, such as personal characteristics and job engagement ( Jelińska and Paradowski, 2021 ), workload or students’ classroom behavior ( Chan et al., 2021 ), positive relationships with students, colleagues and families, as well as students’ better academic performance ( Baumeister et al., 2003 ), emotion regulation, a positive work environment and teachers’ self-efficacy (feeling successful as a teacher) ( Collie et al., 2015 ; Sohail et al., 2023 ); and contextual factors such as institutional resources and the amount of support received ( Kumpikaitė-Valiūnienė et al., 2021 ). Negative work environments and negative emotions, as well as feelings of being ostracized or bullied by colleagues, are factors in teacher burnout ( Sohail et al., 2023 ). Thus, teachers’ well-being reflects their professional satisfaction and happiness, and is perceived as a multidimensional and multilayered psychological construct ( Li et al., 2022 ). It has been associated with other phenomena, including positive emotions and satisfaction, motivation and commitment, resilience and thriving, and negative associations with teacher stress and burnout ( Burić et al., 2019 ; Hascher and Waber, 2021 ).

Psychological distress and burnout

Psychological distress refers to non-specific symptoms of stress, anxiety and depression ( Viertiö et al., 2021 ). Psychological distress manifests itself in a series of mental disorders such as anxiety, sadness, irritability, reduced self-confidence, and emotional distress, and is closely linked to physical and mental illnesses and poorer quality of life ( Ozoemena et al., 2021 ). Distress is also associated with worthlessness, hopelessness, helplessness ( Kessler et al., 2002 ), and burnout ( Näring et al., 2011 ; Chen et al., 2022 ).

Burnout is defined as a reaction to prolonged stress at work, which results from a sustained mismatch between an employee’s resources and the demands placed on the employee ( Bakker and Demerouti, 2017 ). Burnout is related to the work environment and motivational factors ( Fernet et al., 2012 ), and manifests itself with different physical and mental health impairments. Burnout syndrome manifests itself as fatigue, characterized by loss of motivation, lack of energy, and apathy resulting from the persistent stress experienced in challenging work situations ( Gabriel and Aguinis, 2022 ). Burnout is associated with reduced personal satisfaction and depersonalization ( Bianchi et al., 2015 ), high levels of distress and multiple physical and mental problems, sleep disturbances, reduced productivity and motivation, and an increased risk of sickness absence ( Stier-Jarmer et al., 2016 ). Burnout is characterized by feelings of physical, emotional, and mental exhaustion, manifested by emotional strain, negative attitudes toward work-life balance ( Schilling et al., 2018 ), indolence, and guilt ( Figueiredo-Ferraz et al., 2021 ).

Emotional exhaustion is a key symptom of burnout ( Arens and Morin, 2016 ). People who are burnt out are emotionally exhausted and feel negative and disengaged from their work, which leads to lower productivity, stifled creativity and innovation, work accidents, absenteeism, and physical and mental illnesses. Studies in the field of education have shown that teachers’ enthusiasm drops sharply when burnout increases ( Voss et al., 2023 ). Teachers’ emotional exhaustion leads to less engagement and effort in lesson planning, as well as more negative attitudes toward students ( Frenzel et al., 2021 ).

The present study

Compared to other professions, teachers are at high-risk of different mental health issues. While stress is a normal response to distressing or threatening events, it becomes pathological when chronic ( Seo et al., 2017 ). A study on work-related stress in 26 professions ( Johnson et al., 2005 ) found that teachers had one of the lowest levels of psychological well-being among all professions studied. Teachers around the world still face problems of stress and burnout, which cause anxiety and depression ( Agyapong et al., 2022 ).

Educators consistently report higher levels of behavioral, psychological, and physiological symptomatology due to work-related stress ( Ormiston et al., 2022 ). Changing working conditions, social acceleration, digitalization, and working with children with special needs place increasing demands on teachers. Consequently, the difficulties and challenges experienced reduce job satisfaction and commitment, cause tension and anxiety, and may lead to depression or burnout. These symptoms are risk factors of poor physical and mental health.

Stress management strategies can reduce stress and its consequences, and improve mental health. Although the mental health of teachers is becoming an increasingly important issue, there is a lack of research on the use of stress coping strategies in this area. To address this societal issue, it is important to empirically assess the impact of coping strategies on teachers’ mental health. Therefore, our study adopted a multidimensional approach that included a range of factors related to teachers’ mental well-being, symptoms of stress and burnout, and ways of coping with them. The aim of this study is to assess the relationship between teachers’ emotional health and stress coping.

Materials and methods

Participants.

A cross-sectional study of teaching staff based on cluster (area) random sampling. The study involved 385 teaching staff (90.9% of whom were women), representing all regions of the country ( Table 1 ). Teachers from 56 schools were invited to take part in the study. The study sample was selected across all 10 regions of Lithuania. Two thirds of the participants (65.6%) represented metropolitan schools, the rest represented small towns and rural areas. The average age of the participants was 50.2 (±9.62) years, the youngest participant was 25 years old and the oldest was 69 years old. The average number of years of schooling was 24.9 (±11.8) years.

Table 1 . Baseline characteristics of the participants ( n  = 385).

Study design and procedure

This is a cross-sectional study. Nested random sampling was applied. At least one school from each county was selected in all 10 counties of Lithuania. The researchers received permission from the school administration to collect data. The researchers provided the school administration with links to the online questionnaires and informed consent. School administrators shared links to the questionnaires with teachers through internal communication channels. The study was carried out in accordance with the Declaration of Helsinki and the protocol was approved by the Ethics Committee of the Department of Nursing, Vilnius University, Faculty of Medicine ((1.3) 150000-KT-214). All teachers who agreed to participate in each selected school became a participant. Filling out the questionnaire took about 30 min. Data collection took place between February and April 2023.

A questionnaire was developed for the study, which consisted of three parts:(1) a guide for participants and informed consent, (2) socio-demographic variables, and (3) variables describing teachers’ psychological well-being, psychological distress and signs of burnout, and the psychological environment at work. The inventories were selected on the basis of their suitability to the aims of the study and on the basis of their well-established psychometric properties.

Sociodemographic data

All respondents were given a standard set of sociodemographic variables (e.g., age, gender, occupation, social status, and perceived income). Information on the respondents also includes data on the size of the settlement and the size of the school where they work.

Psychological well-being was assessed using the WHO-5 scale (Cronbach’s α - 0.888), which measures how often a person is active, energetic, rested, relaxed, has hobbies, and is in a good mood, with responses on a Likert scale ranging from 0 - “never” to 5 - “all the time” ( WHO, 1998 ). The WHO-5 scale has been translated into more than 30 languages and is used in research projects around the world to assess general well-being in a wide range of research fields ( Topp et al., 2015 ).

WHO-5 index score, which is the sum of 5 items multiplied by 4 (ranging from 0 to 100), was used for statistical analysis. Good well-being is defined as having an index score between 51 and 100; poor well-being is defined as having an index score between 29 and 50; and the risk of depression is defined as having an index score of 28 or less. The dependent variable (WHO-5 well-being index) was transformed into three categories and coded as follows: 1 – “good” 2—“poor,” 3—“depression risk.”

Teachers’ psychological distress was assessed using the Kessler Psychological Distress Scale (K6; Cronbach’s α - 0.877) ( Kessler et al., 2002 ). The scale contains 6 questions that reflect the frequency with which symptoms of anxiety or stress have been experienced in the last 4 weeks. The responses were scored on a 5-point scale, ranging from ‘all the time’ (score 0) to ‘never’ (score 4) and afterwards were rescored in order the higher total score to indicate greater psychological distress.

Teachers’ burnout symptoms were investigated using the Spanish Burnout Inventory, educational version (SBI-Ed; Cronbach’s α - 0.877), which is specifically adapted to the field of education ( Gil-Monte et al., 2010 ). The scale consists of consists of 20 items, which are divided into four subscales: (1) enthusiasm for work (5 items) - the individual’s desire to achieve goals at work as a source of personal pleasure; (2) psychological exhaustion (5 items) - the manifestation of emotional and physical exhaustion due to the daily interaction with problematic people at work; (3) indolence (6 items) - the emergence of negative attitudes and indifference to the individual; and (4) guilt (4 items), which arise from the emergence of negative attitudes and attitudes toward others. Items were scored on a five-point Likert-type scale ranging from 0 (‘never’) to 4 (‘very often: every day’).

Coping strategies were assessed by analyzing participants’ behavior when they felt depressed, low in mood, anxious, or stressed, including communication with family and friends, contact with mental health professionals, prayer, physical activity and hobbies, harmful habits (e.g., smoking, alcohol, etc.), problem-solving and ignoring, feelings of guilt (blaming oneself, others, and fate), and self-isolation. Respondents’ answers were marked on a scale ranging from “never” to “almost always.”

Statistical analysis

A descriptive statistical analysis was performed for all study variables, as well as correlation and mean comparison analyses. The distribution of variables in each group was calculated using frequency-distribution tests. The missing data ranged from 0.6 to 1.5 percent for different variables. Due to that small proportion, imputation procedure was excluded, instead those few participants were excluded from the certain calculations where those variables were included. The relationships between the variables were calculated using Spearman’s correlations. Hierarchical regression analysis was used to explain the relationship between one scale dependent variable and independent variables. Enter method was used. The internal consistency of the scales was assessed using Cronbach’s alpha (>0.7). All analyses were performed using the statistical package SPSS 24.0 (SPSS Inc., Chicago, IL, USA).

The findings indicated that the mental health or psychosomatic symptoms of teachers were not associated with their teaching experience or their duration of service in the workplace ( p  > 0.05). Teachers’ work location in cities or suburbs of different sizes, as well as their marital status, did not indicate a relationship between teachers’ mental health or psychosomatic symptoms ( p  > 0.05) ( Table 2 ). More than half (56.9%) of the teaching staff had good psychological well-being, almost a third (31.1%) had moderate well-being, and 12% of the teaching staff were at risk of depression. Almost one-third of the teachers (32.2%) showed signs of high psychological distress. It was found that teachers’ enthusiasm was above average (3.7 ± 0.74), indolence at work (1.99 ± 0.63), and guilt at work (1.89 ± 0.54) were at low levels. However, teachers’ psychological exhaustion was quite high, with a mean score of (2.81 ± 0.83) in the sample.

Table 2 . Indicators of teachers’ mental health and the psychological climate of their working environment.

The analysis of coping strategies showed that when teachers felt depressed, low in mood, anxious, or stressed, the majority of teachers tended to use problem-solving (68.9%), talk with family and/or friends (67.6%), and engage in hobbies (64.9%), and that 20–25% of the participants sometimes used these strategies. 35.2% participated in sports, and 31.5% sometimes participated in sports ( Figure 1 ).

Figure 1 . Teachers’ cooping strategies.

Meanwhile, 9% of the respondents ignored these problems. Some respondents noted that they drank alcohol (2.4%), smoked (5.8%), or took other addictive substances (0.5%). 10–20% tend to blame themselves, 11.1% of teachers tended to isolate themselves (24.0% did this sometimes), and 20.3% blamed themselves (30.1% did this sometimes). Only a small proportion of teachers (4.7%) self-referred to mental health specialists.

The correlation analysis revealed that teachers’ psychological well-being and enthusiasm for work are positively correlated with sports and exercising ( r  = 0.103–0.216; p  < 0.001), hobby ( r  = 0.250–0.324, p  < 0.001), and problem-solving ( r  = 0.252–0.268; p  < 0.001). Meanwhile, teachers’ psychological distress, psychological exhaustion, indolence, and guilt were associated with ignoring problems ( r  = 0.152–0.297; p  < 0.001), doing less sports ( r  = −0.145–0.195; p  < 0.001), and less time spent on hobbies ( r  = −0.135–0.219; p  < 0.001). In addition, teachers’ psychological exhaustion, indolence, and guilt were positively related to alcohol consumption and other addictive substances ( r  = 0.147–0.241; p  < 0.001) and ignoring problems ( r  = 0.152–0.297; p < 0.001). Teachers’ self-isolation, blaming others, blaming destiny, and blaming themselves were also significantly negatively related to teachers’ well-being, psychological distress, and enthusiasm for work ( Table 3 ).

Table 3 . Bivariate correlations among study variables.

Hierarchical regression analysis was performed. Model 1 in each regression included sociodemographic variables. Model 1 indicated the percentage of variance they covered and revealed the unique importance of sociodemographic variables for psychological health. They also served as covariates in Model 2 which disclose the controlled for covariates relationships of stress coping strategies with psychological health variables. Results presented in Table 4 indicate that sociodemographic indicators in Model 1 predict only 3.3 percent of the variance of enthusiasm at work. Among them only financial status was significant – the higher the financial status in the family the more enthusiasm the schoolteachers experience at work. The financial status remained significant in Model 2. Among stress coping strategies in Model 2 engaging in a hobby and problem solving were positively related to higher enthusiasm at work, while blaming others and self-isolation predicted lower work-related enthusiasm. Altogether stress coping indicators explained 21.6 percent of the variance of enthusiasm.

Table 4 . Sociodemographic and stress coping factors of enthusiasm at work, psychological exhaustion, inactivity and guilt (Std β).

Similar results were found when analyzing the prediction of sociodemographic variables for the prevention of psychological exhaustion - financial status and engaging in a hobby are also significant. Consuming alcohol, blaming others and oneself predict greater psychological exhaustion. Stress coping indicators explained 24.8 percent of the variance in psychological exhaustion.

Indolence was positively associated with male gender in Model 1, alcohol consumption, ignoring problems, blaming others, and self-isolation in Model 2. 26.1 percent of the variance in indolence was explained by stress coping indicators.

Alcohol consumption, use of other addictive substances, blaming others and oneself, as well as blaming fate, are predictors of guilt. The stress coping indicators in this model explain almost a third of the variance (31.3 percent).

The aim of this study was to assess the relationship between teachers’ emotional health and stress coping. Although previous studies have already analyzed the consequences of stress and burnout syndrome experienced by teachers, we have gone beyond the study of these negative effects to include factors that will allow us to predict the direction of improvement of teachers’ emotional health and thus contribute to the overall well-being of schools.

Some research suggests that teachers’ ability to cope with or remain in school in the face of high job uncertainty, job stress, policy changes, and career challenges is most difficult at the beginning of their careers when they are prone to burnout and leaving the profession (e.g., Schaefer, 2013 ). However, in the case of our study, teachers’ age did not affect the stress experienced by teachers or their well-being. Additionally, teachers’ mental health and psychosomatic symptoms were not related to the size of the city in which they worked, marital status, or length of time in the same job.

While most of the teachers in the study had good well-being and did not experience significant psychological exhaustion, some teachers were at risk of depression, and one-third of the study participants experienced psychological distress. However, despite these indicators, the teachers in this study had high levels of enthusiasm, moderate levels of psychological exhaustion, and relatively low levels of indolence and guilt. This study showed that teachers’ psychological exhaustion, sluggishness, guilt at work, and psychosomatic indicators were not related to their financial situation. However, the study showed that teachers’ financial situation and hobbies are related to their psychological well-being and enthusiasm at work. The results of our study are in line with other studies on the relationship between financial satisfaction and subjective well-being ( Ngamaba et al., 2020 ), which showed that financial satisfaction is moderately and positively related to subjective well-being. The authors note that this relationship is higher and stronger in developing countries when multiple items rather than single-item measures are used. Thus, the results of our study imply that teachers’ financial well-being can positively affect their enthusiasm and reduce psychological exhaustion. However, financial status was not related to teacher burnout. This means that improving teachers’ financial status alone does not prevent negative mental health outcomes. It should be noted that improving teachers’ mental health is essential for improving their working conditions and increasing job satisfaction ( Peng et al., 2022 ).

Teachers’ enthusiasm emerged as an important dimension of the study, and was not only influenced by the financial situation. Teachers’ psychological well-being and enthusiasm are related to social, emotional, and instrumental support as well as to the support of their manager, administration, and colleagues. Enthusiasm is described as constructive emotional satisfaction that includes interest ( Kunter and Holzberger, 2014 ). The enthusiasm of each teacher is a key factor in effective teaching, determining teachers’ well-being and behavior, and students’ cognitive, emotional, and motivational outcomes ( Burić and Moe, 2020 ). Demonstrating enthusiasm is indicative of an individual’s invigorating and energetic nature ( Keller et al., 2016 ). It should be noted that teachers’ enthusiasm is important for their personal well-being, quality of teaching, and engagement of students in the teaching process, as well as for the constructive impact and inspiration of students ( Keller et al., 2016 ). Additionally, enthusiasm is significant for an individual’s participation in career development ( Hakanen et al., 2006 ).

The results of this study broaden the understanding of teachers’ emotional health by highlighting the link between well-being and stress management strategies. This study highlights a number of stress coping strategies that teachers use when faced with challenges, such as timely problem solving, sports and exercise, and hobbies. Interestingly, talking to family and friends was one of the most common strategies used by teachers. Correlation analysis showed that this coping strategy had an impact on teachers’ enthusiasm; however, it was not related to their well-being. It is likely that talking to relatives improves emotional well-being during the interview but does not affect emotional health. Thus, for emotional health problems, it is appropriate to seek professional advice from specialists who can accurately diagnose the problem and suggest appropriate treatment ( Soklaridis et al., 2020 ). In addition, the study showed that teachers’ self-isolation was a significant predictor of emotional health problems. This suggests that avoidance of communication and social relationships can lead to emotional health problems.

The study did not find any association between addressing mental health professionals and teachers’ well-being, enthusiasm, psychological distress, enthusiasm for work, psychological exhaustion, indolence, or guilt. Although there is evidence that specialist support can be effective in addressing emotional health problems, it is likely that these findings were obtained because only a small minority of professionals in the study mentioned that they were addressing mental health specialists. In addition, some teachers showed signs of psychological distress, a symptom of emotional health problems, indicating the need to address their mental health issues.

While some teachers managed their stress independently, some participants noted that they had resorted to harmful behaviors such as smoking, drinking alcohol, or using other addictive substances. In addition, some teachers showed signs of psychological distress, which is a sign of emotional health problems. Given that teachers’ well-being influences teaching effectiveness and students’ mental well-being, safety, and academic performance ( Harding et al., 2019 ; Frenzel et al., 2021 ; Granziera et al., 2023 ), emotional health support and support for teachers is a valuable way to both improve the well-being of the teachers themselves and contribute to better learning conditions for students. Supporting teachers’ well-being and fostering teacher-student relationships is an important part of creating a healthy school climate ( López et al., 2017 ). Therefore, providing psychological support to teachers is an untapped opportunity to improve educational practices. This insight is important because it shifts the focus from simply addressing stressors and reducing burnout to strengthening teachers’ psychosocial resources. Organizational support and teacher well-being are closely linked ( Viac and Fraser, 2020 ), and teacher well-being is important for the optimal functioning of schools and educational systems ( Hascher and Waber, 2021 ).

The results of our study demonstrate the importance of addressing teachers’ personal well-being. Improving subjective well-being is a top priority for many governments around the world ( Ngamaba et al., 2020 ); therefore, identifying the key factors that influence teachers’ well-being is crucial for government policymaking. The findings are important for education managers and policymakers when designing interventions to improve teachers’ emotional health and well-being and to address work-life balance issues through preventative leisure activities. To reduce teacher burnout and attrition and improve the effectiveness and quality of education, it is recommended that education policy makers and institutions implement measures to enhance teachers’ emotional health. It is important to give priority to measures that promote teachers’ enthusiasm and enjoyment of leisure time, improving the work-life balance. Developing a culture of psychological support in schools is crucial to ensuring that teachers can seek professional help when they face emotional difficulties. By prioritising teachers’ well-being, policy makers can have a positive impact on the whole education system. Supporting and enhancing teachers’ emotional health and creating a supportive working environment can increase teaching effectiveness, reduce teacher burnout and turnover, and improve student outcomes.

The study has its strengths and limitations. Given the nested sampling, the wide range of teachers were involved including teachers in urban and rural areas, also those teaching in primary and secondary schools. Although, male gender was underrepresented. Meanwhile in the country among all teachers, male teachers cover 15 percent ( Eurostat, 2021 ) in comparison with 9 percent in our study. This study used recognized and validated measures of psychological well-being, psychological distress, and burnout to ensure the reliability and validity of the results. This provides an opportunity for scientific dialogue on teachers’ well-being at the international level. Although the study analyzed different coping strategies, it did not assess and analyze the actual impact and effectiveness of coping strategies in improving teachers’ mental health. Therefore, assessing the impact of specific coping strategies could be a future research perspective that provides more practical insights based on empirical research.

The study shows that teachers are very enthusiastic about their work, and most feel good about themselves. However, one-third of the participants have high levels of psychological distress and 11.9 per cent show signs of depression. Teachers’ age, length of service in the same school, size of settlement, and marital status are not related to their emotional health. Teachers’ psychological exhaustion and psychosomatic indicators are not related to their financial situation, but their financial situation and hobbies are positively related to teachers’ enthusiasm.

The most common coping strategies used by teachers are problem solving, talking to family/friends, sports and exercise, hobbies, praying, and blaming themselves; however, only problem solving, sports and exercise, and hobbies are positively related to emotional health. Ignoring problems, self-isolation, blame, and alcohol use are significantly related to greater psychological distress, psychological exhaustion, indolence, and guilt and predict a decline in well-being and enthusiasm at work.

Data availability statement

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Ethics statement

The studies involving humans were approved by Ethics Committee of the Department of Nursing, Vilnius University, Faculty of Medicine. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.

Author contributions

AE: Conceptualization, Data curation, Formal analysis, Funding acquisition, Methodology, Project administration, Resources, Supervision, Validation, Writing – review & editing, Investigation. SS: Formal analysis, Visualization, Writing – original draft, Investigation, Methodology, Writing – review & editing, Data curation, Validation. BM: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Resources, Software, Supervision, Validation, Writing – review & editing. NI: Conceptualization, Methodology, Supervision, Writing – review & editing, Funding acquisition, Resources, Validation.

The author(s) declare financial support was received for the research, authorship, and/or publication of this article. This research was part of the research project “Emotional well-being of school teaching staff,” was funded by the Public Health Enhancement Fund and administered by the Ministry of Health (Nr. (1.78 MR) SU-1565/S-162).

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher’s note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

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Data for missing values

Table 2. Indicators of teachers’ mental health and the psychological climate of their working environment.

Well-being: WHO scale:

Psychological distress: Kessler Psychological Distress Scale (K6):

Keywords: teachers, emotional health, well-being, psychological distress, burnout, stress coping

Citation: Emeljanovas A, Sabaliauskas S, Mežienė B and Istomina N (2023) The relationships between teachers’ emotional health and stress coping. Front. Psychol . 14:1276431. doi: 10.3389/fpsyg.2023.1276431

Received: 14 August 2023; Accepted: 31 October 2023; Published: 20 November 2023.

Reviewed by:

Copyright © 2023 Emeljanovas, Sabaliauskas, Mežienė and Istomina. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Stanislav Sabaliauskas, [email protected]

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Impact of Implementing New Technology Into K-12 Classrooms on Teacher Well-Being During the COVID-19 Pandemic

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• Published: 15 April 2024

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• Madeline Dunfee   ORCID: orcid.org/0000-0003-2134-8105 1 ,
• Heather Bush 1 ,
• Kate A. Leger 2 ,
• Timothy J. Hilbert 3 ,
• Candace Brancato 1 &
• Erin N. Haynes 1  

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At the start of the COVID-19 pandemic, K-12 teachers rapidly implemented new technologies to provide remote education, often with limited technological training and support. We tested whether teachers’ satisfaction with their technology training was associated with their perceived stress, depression, anxiety, well-being and sleep. The School Staff Health and Wellness Study has surveyed school staff about their experiences throughout the COVID-19 pandemic. A priori analyses included comparisons of well-being scores among teachers who were satisfied with their technology training, dissatisfied with their technology training and those who had not received technology training. We also explore qualitatively what additional technology-related responsibilities teachers had throughout Fall 2020. Participants included 5,873 K-12 teachers who identified predominately as female, White and Non-Hispanic. Most K-12 teachers (88%) had to learn new technology, and 54% reported being “not at all” or only “a little bit” satisfied with the technology training they received. Teachers who were satisfied with their training in new technology were less anxious, depressed, stressed, scored lower on measures of sleep disturbance and higher on measures of well-being compared to other groups. Understanding the association between training in new technology and teachers’ well-being will help school leaders support teachers amid future challenging circumstances.

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Acknowledgements

Thank you to all participants for their time and contributions. Thank you also to our School Staff Advisory Board for their valuable insights and assistance.

This research was supported by the Center for Clinical Translational Science and the NIH National Center for Advancing Translational Sciences through grant number 5TL1TR001997. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.

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Conceptualization, M.D., E.H. and H.B.; methodology, M.D., E.H. and H.B.; formal analysis, M.D.; resources, M.D., E.H. and H.B.; data curation C.B. and M.D.; writing—original draft preparation M.D.; writing—review and editing, E.H., H.B., C. B., T.H., and K.L.; supervision, E.H.; project administration, C.B.; funding acquisition, E.H. and H.B. All authors have read and agreed to the final version of the manuscript.

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Dunfee, M., Bush, H., Leger, K.A. et al. Impact of Implementing New Technology Into K-12 Classrooms on Teacher Well-Being During the COVID-19 Pandemic. TechTrends (2024). https://doi.org/10.1007/s11528-024-00957-y

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• Published: 17 April 2024

Deciphering the influence: academic stress and its role in shaping learning approaches among nursing students: a cross-sectional study

• Rawhia Salah Dogham 1 ,
• Heba Fakieh Mansy Ali 1 ,
• Asmaa Saber Ghaly 3 ,
• Nermine M. Elcokany 2 ,
• Mohamed Mahmoud Seweid 4 &
• Ayman Mohamed El-Ashry   ORCID: orcid.org/0000-0001-7718-4942 5  

BMC Nursing volume  23 , Article number:  249 ( 2024 ) Cite this article

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Nursing education presents unique challenges, including high levels of academic stress and varied learning approaches among students. Understanding the relationship between academic stress and learning approaches is crucial for enhancing nursing education effectiveness and student well-being.

This study aimed to investigate the prevalence of academic stress and its correlation with learning approaches among nursing students.

Design and Method

A cross-sectional descriptive correlation research design was employed. A convenient sample of 1010 nursing students participated, completing socio-demographic data, the Perceived Stress Scale (PSS), and the Revised Study Process Questionnaire (R-SPQ-2 F).

Most nursing students experienced moderate academic stress (56.3%) and exhibited moderate levels of deep learning approaches (55.0%). Stress from a lack of professional knowledge and skills negatively correlates with deep learning approaches (r = -0.392) and positively correlates with surface learning approaches (r = 0.365). Female students showed higher deep learning approach scores, while male students exhibited higher surface learning approach scores. Age, gender, educational level, and academic stress significantly influenced learning approaches.

Academic stress significantly impacts learning approaches among nursing students. Strategies addressing stressors and promoting healthy learning approaches are essential for enhancing nursing education and student well-being.

Nursing implication

Understanding academic stress’s impact on nursing students’ learning approaches enables tailored interventions. Recognizing stressors informs strategies for promoting adaptive coping, fostering deep learning, and creating supportive environments. Integrating stress management, mentorship, and counseling enhances student well-being and nursing education quality.

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Introduction

Nursing education is a demanding field that requires students to acquire extensive knowledge and skills to provide competent and compassionate care. Nursing education curriculum involves high-stress environments that can significantly impact students’ learning approaches and academic performance [ 1 , 2 ]. Numerous studies have investigated learning approaches in nursing education, highlighting the importance of identifying individual students’ preferred approaches. The most studied learning approaches include deep, surface, and strategic approaches. Deep learning approaches involve students actively seeking meaning, making connections, and critically analyzing information. Surface learning approaches focus on memorization and reproducing information without a more profound understanding. Strategic learning approaches aim to achieve high grades by adopting specific strategies, such as memorization techniques or time management skills [ 3 , 4 , 5 ].

Nursing education stands out due to its focus on practical training, where the blend of academic and clinical coursework becomes a significant stressor for students, despite academic stress being shared among all university students [ 6 , 7 , 8 ]. Consequently, nursing students are recognized as prone to high-stress levels. Stress is the physiological and psychological response that occurs when a biological control system identifies a deviation between the desired (target) state and the actual state of a fitness-critical variable, whether that discrepancy arises internally or externally to the human [ 9 ]. Stress levels can vary from objective threats to subjective appraisals, making it a highly personalized response to circumstances. Failure to manage these demands leads to stress imbalance [ 10 ].

Nursing students face three primary stressors during their education: academic, clinical, and personal/social stress. Academic stress is caused by the fear of failure in exams, assessments, and training, as well as workload concerns [ 11 ]. Clinical stress, on the other hand, arises from work-related difficulties such as coping with death, fear of failure, and interpersonal dynamics within the organization. Personal and social stressors are caused by an imbalance between home and school, financial hardships, and other factors. Throughout their education, nursing students have to deal with heavy workloads, time constraints, clinical placements, and high academic expectations. Multiple studies have shown that nursing students experience higher stress levels compared to students in other fields [ 12 , 13 , 14 ].

Research has examined the relationship between academic stress and coping strategies among nursing students, but no studies focus specifically on the learning approach and academic stress. However, existing literature suggests that students interested in nursing tend to experience lower levels of academic stress [ 7 ]. Therefore, interest in nursing can lead to deep learning approaches, which promote a comprehensive understanding of the subject matter, allowing students to feel more confident and less overwhelmed by coursework and exams. Conversely, students employing surface learning approaches may experience higher stress levels due to the reliance on memorization [ 3 ].

Understanding the interplay between academic stress and learning approaches among nursing students is essential for designing effective educational interventions. Nursing educators can foster deep learning approaches by incorporating active learning strategies, critical thinking exercises, and reflection activities into the curriculum [ 15 ]. Creating supportive learning environments encouraging collaboration, self-care, and stress management techniques can help alleviate academic stress. Additionally, providing mentorship and counselling services tailored to nursing students’ unique challenges can contribute to their overall well-being and academic success [ 16 , 17 , 18 ].

Despite the scarcity of research focusing on the link between academic stress and learning methods in nursing students, it’s crucial to identify the unique stressors they encounter. The intensity of these stressors can be connected to the learning strategies employed by these students. Academic stress and learning approach are intertwined aspects of the student experience. While academic stress can influence learning approaches, the choice of learning approach can also impact the level of academic stress experienced. By understanding this relationship and implementing strategies to promote healthy learning approaches and manage academic stress, educators and institutions can foster an environment conducive to deep learning and student well-being.

Hence, this study aims to investigate the correlation between academic stress and learning approaches experienced by nursing students.

Study objectives

Assess the levels of academic stress among nursing students.

Assess the learning approaches among nursing students.

Identify the relationship between academic stress and learning approach among nursing students.

Identify the effect of academic stress and related factors on learning approach and among nursing students.

Materials and methods

Research design.

A cross-sectional descriptive correlation research design adhering to the STROBE guidelines was used for this study.

A research project was conducted at Alexandria Nursing College, situated in Egypt. The college adheres to the national standards for nursing education and functions under the jurisdiction of the Egyptian Ministry of Higher Education. Alexandria Nursing College comprises nine specialized nursing departments that offer various nursing specializations. These departments include Nursing Administration, Community Health Nursing, Gerontological Nursing, Medical-Surgical Nursing, Critical Care Nursing, Pediatric Nursing, Obstetric and Gynecological Nursing, Nursing Education, and Psychiatric Nursing and Mental Health. The credit hour system is the fundamental basis of both undergraduate and graduate programs. This framework guarantees a thorough evaluation of academic outcomes by providing an organized structure for tracking academic progress and conducting analyses.

Participants and sample size calculation

The researchers used the Epi Info 7 program to calculate the sample size. The calculations were based on specific parameters such as a population size of 9886 students for the academic year 2022–2023, an expected frequency of 50%, a maximum margin of error of 5%, and a confidence coefficient of 99.9%. Based on these parameters, the program indicated that a minimum sample size of 976 students was required. As a result, the researchers recruited a convenient sample of 1010 nursing students from different academic levels during the 2022–2023 academic year [ 19 ]. This sample size was larger than the minimum required, which could help to increase the accuracy and reliability of the study results. Participation in the study required enrollment in a nursing program and voluntary agreement to take part. The exclusion criteria included individuals with mental illnesses based on their response and those who failed to complete the questionnaires.

socio-demographic data that include students’ age, sex, educational level, hours of sleep at night, hours spent studying, and GPA from the previous semester.

Tool two: the perceived stress scale (PSS)

It was initially created by Sheu et al. (1997) to gauge the level and nature of stress perceived by nursing students attending Taiwanese universities [ 20 ]. It comprises 29 items rated on a 5-point Likert scale, where (0 = never, 1 = rarely, 2 = sometimes, 3 = reasonably often, and 4 = very often), with a total score ranging from 0 to 116. The cut-off points of levels of perceived stress scale according to score percentage were low < 33.33%, moderate 33.33–66.66%, and high more than 66.66%. Higher scores indicate higher stress levels. The items are categorized into six subscales reflecting different sources of stress. The first subscale assesses “stress stemming from lack of professional knowledge and skills” and includes 3 items. The second subscale evaluates “stress from caring for patients” with 8 items. The third subscale measures “stress from assignments and workload” with 5 items. The fourth subscale focuses on “stress from interactions with teachers and nursing staff” with 6 items. The fifth subscale gauges “stress from the clinical environment” with 3 items. The sixth subscale addresses “stress from peers and daily life” with 4 items. El-Ashry et al. (2022) reported an excellent internal consistency reliability of 0.83 [ 21 ]. Two bilingual translators translated the English version of the scale into Arabic and then back-translated it into English by two other independent translators to verify its accuracy. The suitability of the translated version was confirmed through a confirmatory factor analysis (CFA), which yielded goodness-of-fit indices such as a comparative fit index (CFI) of 0.712, a Tucker-Lewis index (TLI) of 0.812, and a root mean square error of approximation (RMSEA) of 0.100.

Tool three: revised study process questionnaire (R-SPQ-2 F)

It was developed by Biggs et al. (2001). It examines deep and surface learning approaches using only 20 questions; each subscale contains 10 questions [ 22 ]. On a 5-point Likert scale ranging from 0 (never or only rarely true of me) to 4 (always or almost always accurate of me). The total score ranged from 0 to 80, with a higher score reflecting more deep or surface learning approaches. The cut-off points of levels of revised study process questionnaire according to score percentage were low < 33%, moderate 33–66%, and high more than 66%. Biggs et al. (2001) found that Cronbach alpha value was 0.73 for deep learning approach and 0.64 for the surface learning approach, which was considered acceptable. Two translators fluent in English and Arabic initially translated a scale from English to Arabic. To ensure the accuracy of the translation, they translated it back into English. The translated version’s appropriateness was evaluated using a confirmatory factor analysis (CFA). The CFA produced several goodness-of-fit indices, including a Comparative Fit Index (CFI) of 0.790, a Tucker-Lewis Index (TLI) of 0.912, and a Root Mean Square Error of Approximation (RMSEA) of 0.100. Comparative Fit Index (CFI) of 0.790, a Tucker-Lewis Index (TLI) of 0.912, and a Root Mean Square Error of Approximation (RMSEA) of 0.100.

Ethical considerations

The Alexandria University College of Nursing’s Research Ethics Committee provided ethical permission before the study’s implementation. Furthermore, pertinent authorities acquired ethical approval at participating nursing institutions. The vice deans of the participating institutions provided written informed consent attesting to institutional support and authority. By giving written informed consent, participants confirmed they were taking part voluntarily. Strict protocols were followed to protect participants’ privacy during the whole investigation. The obtained personal data was kept private and available only to the study team. Ensuring participants’ privacy and anonymity was of utmost importance.

Tools validity

The researchers created tool one after reviewing pertinent literature. Two bilingual translators independently translated the English version into Arabic to evaluate the applicability of the academic stress and learning approach tools for Arabic-speaking populations. To assure accuracy, two additional impartial translators back-translated the translation into English. They were also assessed by a five-person jury of professionals from the education and psychiatric nursing departments. The scales were found to have sufficiently evaluated the intended structures by the jury.

Pilot study

A preliminary investigation involved 100 nursing student applicants, distinct from the final sample, to gauge the efficacy, clarity, and potential obstacles in utilizing the research instruments. The pilot findings indicated that the instruments were accurate, comprehensible, and suitable for the target demographic. Additionally, Cronbach’s Alpha was utilized to further assess the instruments’ reliability, demonstrating internal solid consistency for both the learning approaches and academic stress tools, with values of 0.91 and 0.85, respectively.

Data collection

The researchers convened with each qualified student in a relaxed, unoccupied classroom in their respective college settings. Following a briefing on the study’s objectives, the students filled out the datasheet. The interviews typically lasted 15 to 20 min.

Data analysis

The data collected were analyzed using IBM SPSS software version 26.0. Following data entry, a thorough examination and verification were undertaken to ensure accuracy. The normality of quantitative data distributions was assessed using Kolmogorov-Smirnov tests. Cronbach’s Alpha was employed to evaluate the reliability and internal consistency of the study instruments. Descriptive statistics, including means (M), standard deviations (SD), and frequencies/percentages, were computed to summarize academic stress and learning approaches for categorical data. Student’s t-tests compared scores between two groups for normally distributed variables, while One-way ANOVA compared scores across more than two categories of a categorical variable. Pearson’s correlation coefficient determined the strength and direction of associations between customarily distributed quantitative variables. Hierarchical regression analysis identified the primary independent factors influencing learning approaches. Statistical significance was determined at the 5% (p < 0.05).

Table  1 presents socio-demographic data for a group of 1010 nursing students. The age distribution shows that 38.8% of the students were between 18 and 21 years old, 32.9% were between 21 and 24 years old, and 28.3% were between 24 and 28 years old, with an average age of approximately 22.79. Regarding gender, most of the students were female (77%), while 23% were male. The students were distributed across different educational years, a majority of 34.4% in the second year, followed by 29.4% in the fourth year. The students’ hours spent studying were found to be approximately two-thirds (67%) of the students who studied between 3 and 6 h. Similarly, sleep patterns differ among the students; more than three-quarters (77.3%) of students sleep between 5- to more than 7 h, and only 2.4% sleep less than 2 h per night. Finally, the student’s Grade Point Average (GPA) from the previous semester was also provided. 21% of the students had a GPA between 2 and 2.5, 40.9% had a GPA between 2.5 and 3, and 38.1% had a GPA between 3 and 3.5.

Figure  1 provides the learning approach level among nursing students. In terms of learning approach, most students (55.0%) exhibited a moderate level of deep learning approach, followed by 25.9% with a high level and 19.1% with a low level. The surface learning approach was more prevalent, with 47.8% of students showing a moderate level, 41.7% showing a low level, and only 10.5% exhibiting a high level.

Nursing students? levels of learning approach (N=1010)

Figure  2 provides the types of academic stress levels among nursing students. Among nursing students, various stressors significantly impact their academic experiences. Foremost among these stressors are the pressure and demands associated with academic assignments and workload, with 30.8% of students attributing their high stress levels to these factors. Challenges within the clinical environment are closely behind, contributing significantly to high stress levels among 25.7% of nursing students. Interactions with peers and daily life stressors also weigh heavily on students, ranking third among sources of high stress, with 21.5% of students citing this as a significant factor. Similarly, interaction with teachers and nursing staff closely follow, contributing to high-stress levels for 20.3% of nursing students. While still significant, stress from taking care of patients ranks slightly lower, with 16.7% of students reporting it as a significant factor contributing to their academic stress. At the lowest end of the ranking, but still notable, is stress from a perceived lack of professional knowledge and skills, with 15.9% of students experiencing high stress in this area.

Nursing students? levels of academic stress subtypes (N=1010)

Figure  3 provides the total levels of academic stress among nursing students. The majority of students experienced moderate academic stress (56.3%), followed by those experiencing low academic stress (29.9%), and a minority experienced high academic stress (13.8%).

Nursing students? levels of total academic stress (N=1010)

Table  2 displays the correlation between academic stress subscales and deep and surface learning approaches among 1010 nursing students. All stress subscales exhibited a negative correlation regarding the deep learning approach, indicating that the inclination toward deep learning decreases with increasing stress levels. The most significant negative correlation was observed with stress stemming from the lack of professional knowledge and skills (r=-0.392, p < 0.001), followed by stress from the clinical environment (r=-0.109, p = 0.001), stress from assignments and workload (r=-0.103, p = 0.001), stress from peers and daily life (r=-0.095, p = 0.002), and stress from patient care responsibilities (r=-0.093, p = 0.003). The weakest negative correlation was found with stress from interactions with teachers and nursing staff (r=-0.083, p = 0.009). Conversely, concerning the surface learning approach, all stress subscales displayed a positive correlation, indicating that heightened stress levels corresponded with an increased tendency toward superficial learning. The most substantial positive correlation was observed with stress related to the lack of professional knowledge and skills (r = 0.365, p < 0.001), followed by stress from patient care responsibilities (r = 0.334, p < 0.001), overall stress (r = 0.355, p < 0.001), stress from interactions with teachers and nursing staff (r = 0.262, p < 0.001), stress from assignments and workload (r = 0.262, p < 0.001), and stress from the clinical environment (r = 0.254, p < 0.001). The weakest positive correlation was noted with stress stemming from peers and daily life (r = 0.186, p < 0.001).

Table  3 outlines the association between the socio-demographic characteristics of nursing students and their deep and surface learning approaches. Concerning age, statistically significant differences were observed in deep and surface learning approaches (F = 3.661, p = 0.003 and F = 7.983, p < 0.001, respectively). Gender also demonstrated significant differences in deep and surface learning approaches (t = 3.290, p = 0.001 and t = 8.638, p < 0.001, respectively). Female students exhibited higher scores in the deep learning approach (31.59 ± 8.28) compared to male students (29.59 ± 7.73), while male students had higher scores in the surface learning approach (29.97 ± 7.36) compared to female students (24.90 ± 7.97). Educational level exhibited statistically significant differences in deep and surface learning approaches (F = 5.599, p = 0.001 and F = 17.284, p < 0.001, respectively). Both deep and surface learning approach scores increased with higher educational levels. The duration of study hours demonstrated significant differences only in the surface learning approach (F = 3.550, p = 0.014), with scores increasing as study hours increased. However, no significant difference was observed in the deep learning approach (F = 0.861, p = 0.461). Hours of sleep per night and GPA from the previous semester did not exhibit statistically significant differences in deep or surface learning approaches.

Table  4 presents a multivariate linear regression analysis examining the factors influencing the learning approach among 1110 nursing students. The deep learning approach was positively influenced by age, gender (being female), educational year level, and stress from teachers and nursing staff, as indicated by their positive coefficients and significant p-values (p < 0.05). However, it was negatively influenced by stress from a lack of professional knowledge and skills. The other factors do not significantly influence the deep learning approach. On the other hand, the surface learning approach was positively influenced by gender (being female), educational year level, stress from lack of professional knowledge and skills, stress from assignments and workload, and stress from taking care of patients, as indicated by their positive coefficients and significant p-values (p < 0.05). However, it was negatively influenced by gender (being male). The other factors do not significantly influence the surface learning approach. The adjusted R-squared values indicated that the variables in the model explain 17.8% of the variance in the deep learning approach and 25.5% in the surface learning approach. Both models were statistically significant (p < 0.001).

Nursing students’ academic stress and learning approaches are essential to planning for effective and efficient learning. Nursing education also aims to develop knowledgeable and competent students with problem-solving and critical-thinking skills.

The study’s findings highlight the significant presence of stress among nursing students, with a majority experiencing moderate to severe levels of academic stress. This aligns with previous research indicating that academic stress is prevalent among nursing students. For instance, Zheng et al. (2022) observed moderated stress levels in nursing students during clinical placements [ 23 ], while El-Ashry et al. (2022) found that nearly all first-year nursing students in Egypt experienced severe academic stress [ 21 ]. Conversely, Ali and El-Sherbini (2018) reported that over three-quarters of nursing students faced high academic stress. The complexity of the nursing program likely contributes to these stress levels [ 24 ].

The current study revealed that nursing students identified the highest sources of academic stress as workload from assignments and the stress of caring for patients. This aligns with Banu et al.‘s (2015) findings, where academic demands, assignments, examinations, high workload, and combining clinical work with patient interaction were cited as everyday stressors [ 25 ]. Additionally, Anaman-Torgbor et al. (2021) identified lectures, assignments, and examinations as predictors of academic stress through logistic regression analysis. These stressors may stem from nursing programs emphasizing the development of highly qualified graduates who acquire knowledge, values, and skills through classroom and clinical experiences [ 26 ].

The results regarding learning approaches indicate that most nursing students predominantly employed the deep learning approach. Despite acknowledging a surface learning approach among the participants in the present study, the prevalence of deep learning was higher. This inclination toward the deep learning approach is anticipated in nursing students due to their engagement with advanced courses, requiring retention, integration, and transfer of information at elevated levels. The deep learning approach correlates with a gratifying learning experience and contributes to higher academic achievements [ 3 ]. Moreover, the nursing program’s emphasis on active learning strategies fosters critical thinking, problem-solving, and decision-making skills. These findings align with Mahmoud et al.‘s (2019) study, reporting a significant presence (83.31%) of the deep learning approach among undergraduate nursing students at King Khalid University’s Faculty of Nursing [ 27 ]. Additionally, Mohamed &Morsi (2019) found that most nursing students at Benha University’s Faculty of Nursing embraced the deep learning approach (65.4%) compared to the surface learning approach [ 28 ].

The study observed a negative correlation between the deep learning approach and the overall mean stress score, contrasting with a positive correlation between surface learning approaches and overall stress levels. Elevated academic stress levels may diminish motivation and engagement in the learning process, potentially leading students to feel overwhelmed, disinterested, or burned out, prompting a shift toward a surface learning approach. This finding resonates with previous research indicating that nursing students who actively seek positive academic support strategies during academic stress have better prospects for success than those who do not [ 29 ]. Nebhinani et al. (2020) identified interface concerns and academic workload as significant stress-related factors. Notably, only an interest in nursing demonstrated a significant association with stress levels, with participants interested in nursing primarily employing adaptive coping strategies compared to non-interested students.

The current research reveals a statistically significant inverse relationship between different dimensions of academic stress and adopting the deep learning approach. The most substantial negative correlation was observed with stress arising from a lack of professional knowledge and skills, succeeded by stress associated with the clinical environment, assignments, and workload. Nursing students encounter diverse stressors, including delivering patient care, handling assignments and workloads, navigating challenging interactions with staff and faculty, perceived inadequacies in clinical proficiency, and facing examinations [ 30 ].

In the current study, the multivariate linear regression analysis reveals that various factors positively influence the deep learning approach, including age, female gender, educational year level, and stress from teachers and nursing staff. In contrast, stress from a lack of professional knowledge and skills exert a negative influence. Conversely, the surface learning approach is positively influenced by female gender, educational year level, stress from lack of professional knowledge and skills, stress from assignments and workload, and stress from taking care of patients, but negatively affected by male gender. The models explain 17.8% and 25.5% of the variance in the deep and surface learning approaches, respectively, and both are statistically significant. These findings underscore the intricate interplay of demographic and stress-related factors in shaping nursing students’ learning approaches. High workloads and patient care responsibilities may compel students to prioritize completing tasks over deep comprehension. This pressure could lead to a surface learning approach as students focus on meeting immediate demands rather than engaging deeply with course material. This observation aligns with the findings of Alsayed et al. (2021), who identified age, gender, and study year as significant factors influencing students’ learning approaches.

Deep learners often demonstrate better self-regulation skills, such as effective time management, goal setting, and seeking support when needed. These skills can help manage academic stress and maintain a balanced learning approach. These are supported by studies that studied the effect of coping strategies on stress levels [ 6 , 31 , 32 ]. On the contrary, Pacheco-Castillo et al. study (2021) found a strong significant relationship between academic stressors and students’ level of performance. That study also proved that the more academic stress a student faces, the lower their academic achievement.

Strengths and limitations of the study

This study has lots of advantages. It provides insightful information about the educational experiences of Egyptian nursing students, a demographic that has yet to receive much research. The study’s limited generalizability to other people or nations stems from its concentration on this particular group. This might be addressed in future studies by using a more varied sample. Another drawback is the dependence on self-reported metrics, which may contain biases and mistakes. Although the cross-sectional design offers a moment-in-time view of the problem, it cannot determine causation or evaluate changes over time. To address this, longitudinal research may be carried out.

Notwithstanding these drawbacks, the study substantially contributes to the expanding knowledge of academic stress and nursing students’ learning styles. Additional research is needed to determine teaching strategies that improve deep-learning approaches among nursing students. A qualitative study is required to analyze learning approaches and factors that may influence nursing students’ selection of learning approaches.

According to the present study’s findings, nursing students encounter considerable academic stress, primarily stemming from heavy assignments and workload, as well as interactions with teachers and nursing staff. Additionally, it was observed that students who experience lower levels of academic stress typically adopt a deep learning approach, whereas those facing higher stress levels tend to resort to a surface learning approach. Demographic factors such as age, gender, and educational level influence nursing students’ choice of learning approach. Specifically, female students are more inclined towards deep learning, whereas male students prefer surface learning. Moreover, deep and surface learning approach scores show an upward trend with increasing educational levels and study hours. Academic stress emerges as a significant determinant shaping the adoption of learning approaches among nursing students.

Implications in nursing practice

Nursing programs should consider integrating stress management techniques into their curriculum. Providing students with resources and skills to cope with academic stress can improve their well-being and academic performance. Educators can incorporate teaching strategies that promote deep learning approaches, such as problem-based learning, critical thinking exercises, and active learning methods. These approaches help students engage more deeply with course material and reduce reliance on surface learning techniques. Recognizing the gender differences in learning approaches, nursing programs can offer gender-specific support services and resources. For example, providing targeted workshops or counseling services that address male and female nursing students’ unique stressors and learning needs. Implementing mentorship programs and peer support groups can create a supportive environment where students can share experiences, seek advice, and receive encouragement from their peers and faculty members. Encouraging students to reflect on their learning processes and identify effective study strategies can help them develop metacognitive skills and become more self-directed learners. Faculty members can facilitate this process by incorporating reflective exercises into the curriculum. Nursing faculty and staff should receive training on recognizing signs of academic stress among students and providing appropriate support and resources. Additionally, professional development opportunities can help educators stay updated on evidence-based teaching strategies and practical interventions for addressing student stress.

Data availability

The datasets generated and/or analysed during the current study are not publicly available due to restrictions imposed by the institutional review board to protect participant confidentiality, but are available from the corresponding author on reasonable request.

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Acknowledgements

Our sincere thanks go to all the nursing students in the study. We also want to thank Dr/ Rasha Badry for their statistical analysis help and contribution to this study.

The research was not funded by public, commercial, or non-profit organizations.

Open access funding provided by The Science, Technology & Innovation Funding Authority (STDF) in cooperation with The Egyptian Knowledge Bank (EKB).

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Critical Care & Emergency Nursing, Faculty of Nursing, Alexandria University, Alexandria, Egypt

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Asmaa Saber Ghaly

Faculty of Nursing, Beni-Suef University, Beni-Suef, Egypt

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Ayman M. El-Ashry & Rawhia S. Dogham: conceptualization, preparation, and data collection; methodology; investigation; formal analysis; data analysis; writing-original draft; writing-manuscript; and editing. Heba F. Mansy Ali & Asmaa S. Ghaly: conceptualization, preparation, methodology, investigation, writing-original draft, writing-review, and editing. Nermine M. Elcokany & Mohamed M. Seweid: Methodology, investigation, formal analysis, data collection, writing-manuscript & editing. All authors reviewed the manuscript and accept for publication.

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Dogham, R.S., Ali, H.F.M., Ghaly, A.S. et al. Deciphering the influence: academic stress and its role in shaping learning approaches among nursing students: a cross-sectional study. BMC Nurs 23 , 249 (2024). https://doi.org/10.1186/s12912-024-01885-1

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• v.8(Spec Iss 4); 2015

A review of the effectiveness of stress management skills training on academic vitality and psychological well-being of college students

P alborzkouh.

* Exceptional Children Psychology, Islamic Azad University, Central Tehran Branch, Iran

** General Psychology, Islamic Azad University, South Tehran Branch, Iran

*** General Psychology, Humanities and Social Sciences Faculty, Paradise University, Gillan Branch, Iran

**** General Psychology, Islamic Azad University, Science and Research Branch, Tehran, Iran

F Shahgholy Ghahfarokhi

***** Clinical Psychology, Islamic Azad University, Science and Research Branch Branch, Isfahan, Iran

Objective: Carrying out the appropriate psychological interventions to improve vitality and mental well-being is critical. The study was carried out to review the effectiveness of stress management training on the academic life and mental well-being of the students of Shahed University.

Methodology: The method used was quasi-experimental with a pretest-posttest plan and control group. Therefore, a total of 40 students of Shahed University of Tehran were selected by a convenience sampling method and were organized into two groups: experimental and control group. Both groups were pretested by using an academic vitality inventory and an 84-question psychological well-being inventory. Then, the experimental group received stress management skills training for ten sessions, and the control group did not receive any intervention. Next, both groups were post-tested, and the data were analyzed with SPSS-21 software by using descriptive and inferential statistical methods.

Findings: The findings showed that the stress management skills training significantly contributed to promoting the academic vitality and psychological well-being of students (p < 0.001).

Conclusions: It was concluded from this research that teaching the methods for dealing with stress was an effective strategy to help students exposed to high stress and pressure, and this was due to its high efficiency, especially when it was held in groups, had a small cost, and it was accepted by the individuals.

Introduction

Challenges during education create sources of stress for students, and put their health at risk, in a way that affects their learning abilities [ 1 ]. Therefore, paying attention to the factors that could have a positive impact on the agreeableness and could increase the positive psychological states, and as a result, the physical and psychological health of the students was of great importance.

Among the important factors that affect people’s ability to adapt to the stresses of studying era is academic vitality [ 2 ]. Academic vitality means an adaptive response to various challenges and barriers experienced during education [ 3 ]. When a person does things spontaneously, does not feel not only frustrated and tired, but also constantly feels the strength and increased energy, and overall has a sense of inner vitality [ 2 ]. Therefore, the academic life has a relationship with the individual’s adaptation to the various situations of the academic period, feelings of self-efficacy and empowerment in the face of challenges, experiencing less anxiety and depression, a sense of responsibility in dealing with the academic tasks and better academic success [ 3 ]. Despite the high importance of academic vitality in the successful confrontation with the challenging academic period, the literature review of the studies managed in Iran showed that few studies were performed on the factors promoting this important variable. Therefore, an attempt to address this research gap increased the need for the current study.

Another important positive psychological state in students is the psychological well-being. The psychological well-being factor is defined as a person’s real talents growth and has six components that are the purpose in life, positive relations with others, personal growth, self-acceptance, autonomy, and environmental mastery [ 4 ]. The purpose in life means having a purpose and direction in life and pursuing them [ 5 ]. Positive relations with the others mean having warm, satisfactory relations along with confidence and empathy [ 6 ]. Personal growth means having a sense of continuous growth and the capacity for it and having an increased sense of efficacy and wisdom [ 4 ]. Self-acceptance means having a positive attitude towards oneself and accepting the various aspects of oneself [ 6 ]. Autonomy means the feeling of self-determination, independence, and self-assessment against personal criteria [ 4 ]. Moreover, environmental mastery means a sense of competence and the ability to manage the complex environment around [ 5 ].

However, one of the most significant parts affecting the psychological health and well-being of individuals is life skills training [ 7 ]. Life skills’ training is critical for students, in a way that on this basis, many universities have started to teach life skills and stress management skills to improve the physical and psychological health of their students in the recent years [ 8 ]. The main objective of the World Health Organization regarding the creation of a life skills plan is in the field of psychological health. Therefore, different societies throughout the world try to promote the implementation and evaluation of the programs training in life skills. It focuses on the growth of mental abilities such as problem-solving, coping with emotions, self-awareness, social harmony, and stress management among children, teenagers, and even adults [ 9 ]. From the life skills, training in stress management skills is critical, because students need to deal effectively with stressful issues and factors. Accordingly, it was thought that teaching stress management skills is very efficient in improving the students’ positive psychological states, in particular, their vitality and mental well-being. Therefore, this study examined the effectiveness of the stress management skills training on the academic life and psychological well-being among Shahed University students.

Methodology

The study was quasi-experimental with a pretest-posttest. The analytical community of the study included all the students of Shahed University of Tehran in the fall of 2015, who were selected with a convenience method. For the calculation of the sample size, the appropriate sample size in experimental studies was of 15 people for each group [ 10 ]. At first, the sample size of 15 individuals was selected for each group. Then, to increase the statistical power and to manage the possible decrease in the number of participants, the sample size of 20 individuals (n = 20) was considered for each group. The sampling was voluntary non-random from among all the students studying at Shahed University. The inclusion criteria included an informed consent and the willingness to participate in the research, the ability to take part in the sessions and to collaborate in carrying out assignments, willingness to cooperate in completing the instruments, and the age range of 18 to 35 years. The exclusion criteria included the lack of desire to participate in the sessions and the absence to more than three courses in the preparation method, the lack of the ability to participate in the sessions, lack of cooperation in carrying out assignments, and receiving any training or psychological therapy that was not part of the program of this research.

The procedure of the study was that from all the students studying at Shahed University, a number was non-randomly and voluntarily selected, and if they met the inclusion criteria, they were randomly assigned to two groups: experimental and control. At the beginning and before starting the study, an informed consent was obtained from all of them to uphold moral considerations, through informing them of the aim of the study and the impact of such studies in improving their psychological status. Then, all the information of the participants were collected, and they were assured that the information would remain confidential by the researcher. Then, the experimental group received group stress management training for ten sessions, and the control group did not receive any intervention. In the end, both groups were post-tested. The protocol of stress management training sessions is presented in Table 1 .

Protocol of stress management skills training sessions

The instruments used in the study included a demographic sample page, an academic vitality questionnaire, and a psychological well-being scale (PWBS-18).

Demographic sample page: The demographic sample page included age, gender, educational level, and marital status. The sample page was prepared and evaluated by the researchers of the study.

Academic vitality questionnaire: This questionnaire was developed by Dehqanizadeh MH, Hosseinchari M (2012) [ 3 ], based on the academic vitality scale of Martin AJ, Marsh HW (2006) [ 15 ], which had four items. After various implementations of the items of the questionnaire, the final version was rewritten, and the result was that the revised version had ten items. Then the items above were again examined in a preliminary study on a sample including 186 high school students, who were chosen by using a cluster random sampling, and their psychometric properties were examined. The results of the examination showed that the obtained Cronbach’s alpha coefficient, by removing [ 3 ] item number 8, was 0.80 and the retest coefficient was 0.73. Also, the range of correlation of the elements with the total score was between 0.51 and 0.68. These results indicated that the items had a satisfactory internal consistency and stability.

Psychological well-being scale (SPWB): Riffe’s mental well-being scale [ 11 ] was made up of 84 questions in Likert’s 7-degree scale (from “strongly disagree” to “agree strongly”). It was a self-report questionnaire, which measured six components of the psychological well-being, including purpose in life, positive relations with others, personal growth, self-acceptance, autonomy, and environmental mastery. The internal consistency coefficients for the components of this questionnaire were obtained from 0.83 to 0.91. In Mohammadpour and Joshanloo research (2014) [ 6 ], the reliability coefficient of this scale with Cronbach’s alpha method for the psychological well-being scale obtained was 0.81. Also, for the subscales of the test including self-compliance, environmental mastery, personal growth and development, link with others, the goal in life, and self-acceptance were obtained at 0.60, 0.64, 0.54, 0.58, 0.65, and 0.61, respectively. A study performed by Kafka and Kozma (2002) was conducted to verify the validity of the items of the Riffe’s psychological well-being scale. The findings showed that there was a high correlation between this scale and the subjective well-being scale (SWB) and the satisfaction with life scale (SWLS). In the present study, the reliability coefficient with Cronbach’s alpha method for the psychological well-being scale obtained was 0.81. Also, for the subscales of the test, including self-compliance, environmental mastery, personal growth and development, relations with others, the goal in life, and self-acceptance were obtained at 0.60, 0.64, 0.54, 0.58, 0.65, and 0.61, respectively.

The SPSS-20 software was used for data analysis. The statistical method used for the data analysis of the research on the level of descriptive statistics was mean, standard deviation, frequency, and frequency percentage indexes, and on the inferential statistics, univariate and multivariate analysis of covariance model were used.

Findings of the research

The demographic properties of the sample present in the study are presented in Table 2 .

Demographic characteristics of the subjects

As presented in Table 1 , the largest frequency of participation belonged to the participants in the age range of 21 to 25 with 14 individuals (35%) and the lowest frequency of individuals in the range of 18 to 20 years, with six individuals (15%). In addition, the mean age of the participants was 24.85, and the standard deviation was 4.41. The other information about the demographic properties of the present sample is provided in Table 2

As shown in Table 3 , the mean scores of purpose in life, positive relations with others, personal growth, self-acceptance, autonomy, environmental mastery, total score of psychological well-being, and academic vitality of posttest were increased in the test group as associated with the control group.

Descriptive stats of academic vitality and psychological well-being scores of the two groups divided by the pretest and posttest

As shown in Table 4 , the null hypothesis of the equality of variances of the two groups in the academic vitality and psychological well-being with all its components was confirmed. It meant that the variances of the two clusters in the population were equal and had no significant difference for the academic vitality and the psychological well-being variable with all its components. Thus, given the compliance with the Levene assumption, the analysis of covariance of the results of the hypothesis of the research were permitted.

Results of Levene test for the examination of the consistency of variances of academic vitality and psychological well-being variables with its components in the posttest stage

As shown in Table 5 , the significance level of all the tests (p < 0.001) indicated that there was a significant difference between the two groups at least in one of the dependent variables (academic vitality and psychological well-being with its components). And, according to the eta square, 0.89 percent of the differences observed among individuals were associated with the effect of the independent variable, which was the intervention method (stress management skills training). On the other hand, given that the statistical power was 0.95, which was higher than 0.80, the sample size was acceptable for the research. The results related to significant differences in any of the dependent variables are listed below.

Results of multivariate analysis of covariance on the scores of posttest with the control of pretest in the academic vitality and psychological well-being variable with its components

According to Table 6 , the significance level was p < 0.001, the hypothesis of the difference between the academic vitality and the psychological well-being with its components in the two groups was confirmed. It stated that 0.54, 0.25, 0.52, 0.64, 0.60, 0.59, 0.45 and 0.81 percent change in the academic vitality, individuals’ purpose in life, positive relations with others, personal growth, self-acceptance, autonomy, environmental mastery, and psychological well-being scores were due to the independent variable (stress management skills training). Therefore, it could be said that stress management skills training increased the academic vitality and the psychological well-being and all of its components.

The results of multivariate analysis of covariance to assess the impact of stress management skills training on the level of psychological well-being and its components in the posttest stage

Discussion and conclusions

Given the aim of this study, which was to examine the effectiveness of stress management skills training on the academic vitality and psychological well-being of the students of Shahed University, the results of the univariate and multivariate analysis of covariance showed that stress management skills training had a significant impact on increasing the academic vitality and psychological well-being. The findings indicated that the stress management skills training had a major impact on increasing the academic life. It was consistent with different studies of Habibi M (2015), Pakdaman A, Ganji K, Ahmadzadeh M (2012), Shirbim Z, Sudani M, Shafi-Abadi A (2008) [ 12 - 14 ].

In explaining their similar finding, Pakdaman A, Ganji K, Ahmadzadeh M (2012) [ 13 ] also stated that life skills training helped in the improvement of the academic conditions of the subjects. In addition, this was because of this training, with growing different skills of the students, helping the students know their strengths and weaknesses, and overall, help the individuals move from weaknesses and skill deficits to capable and strong skills. Therefore, this could provide the students with better educational conditions [ 14 ]. In explaining their similar finding, Shafi-Abadi (2008) stated that teaching life skills, including stress management skills, are one of the ways to improve the mental health of the individuals of the community and to prevent harms. In fact, these teachings protected the health and mental hygiene of the society and protected it against diseases, disabilities, and disturbances in human relations. As a result, the feeling of security and solidarity increased among the members of the society, and then their senses of happiness, vitality, and health increased.

The findings showed that stress management skills’ training has a significant impact on the psychological well-being. It was consistent with the multiple studies of Qadiri-Bahramabadi F, Mikaeli-Manee F (2015), Qanbari N, Habibi M, Shams-Aldini S (2013), Alavi-Arjmand N, Kashaninia Z, Hosseini MA, Reza-Soltani P (2012), Chubforushzadeh A, Kalantari M, Molavi H (2009) [ 16 - 19 ].

In explaining their similar findings, Qadiri-Bahramabadi F, Mikaeli-Manee F (2015) [ 16 ] stated that facing numerous stresses required teaching and learning of appropriate stress management skills. In other words, during stress, individuals must know the necessary coping skills to reduce the effects of stress, and if the pressure was managed and the effective coping skills were applied, the person would be able to get along better with the needs and challenges of his/ her life. Therefore, the intervention of stress management led to the formation of good feelings about oneself, as well as a positive performance in the stable world. It created interest and motivation in people’s lives as well as increasing the self-confidence of the individuals. As a result, it increased the psychological well-being.

In explaining their similar finding, Qanbari N, Habibi M, Shams-Aldini S (2013) [ 17 ] stated that with the help of multiple strategies to manage stress such as relaxation, and muscular relaxation, stress and anxiety could be reduced. The individuals identified the somatic symptoms, and with mastering the ways to acquire relaxation, which was inconsistent with stress, reduced their anxiety and unpleasant feelings, thus increasing the psychological well-being. Also, in explaining their similar finding, Chubforushzadeh A, Kalantari M, Molavi H (2009) [ 19 ], stated that stress management treatments make multiple changes in the individual’s beliefs, feelings, and behaviors. Therefore, improving the individual’s evaluations and coping skills, and the provided practices to integrate the learned separations with real life situations could lead to a decrease in the perceived stress and an increase in the psychological well-being.

Acknowledgement

The authors would like to thank the venerable authorities of Shahed University of Tehran for their assistance. Also, the authors would like to thank all the participants in the study.