Intervention Strategies Regarding Perceived Anxiety and Health Complaints among Newly Admitted Nursing Students

Background Anxiety is an important construct today, especially in the lives of students, as it affects their mental, physical and social wellbeing. This study aimed to evaluate the effect of intervention strategies regarding perceived anxiety and health complaints among newly admitted nursing students. Design: A quasi-experimental design was utilized to achieve the aim of the study. Setting: The study was carried out at the Faculty of Nursing, Benha University. Sample: -A systematic random sample was chosen as one every fifth. It included 100 students from the total number (500) of firstgrade nursing students enrolled in the academic year 2019-2020. Tool of Data Collection: The tool was divided into three tools: Tool one: -A structured interviewing questionnaire. Tool two: Health Complaints Questionnaire. Tool three: Anxiety scale for undergraduate students. The main findings of the study: More than two-thirds of the studied sample has mild total health complaints and decrease the level of anxiety of them postintervention strategies. Positive correlation between total anxiety scale, its dimensions and total health complaints pre and post-interventions strategies. Conclusion: Based on the findings of the present study, it was concluded that intervention strategies had a positive effect regarding perceived anxiety and health complaints among newly admitted nursing students. Recommendation: A comparison of anxiety among newly admitted nursing students and other students in various other colleges.


INTRODUCTION
Professional experience among newly admitted nursing students often lays the foundation for what will hopefully be long-term professional satisfaction. The transition to professional practice can be exciting and challenging, it can also be a time of high anxiety; especially when the realities of work do not meet existing expectations and feelings of fatigue or isolation have set in (Afolayan et al., 2018).
Duchscher, (2019)has conducted extensive research surrounding the role and transition shock in nursing, describing it as the person "jumped into the deep end of the pool" while not being prepared for the reality of the transition's effects on their personal and professional selfconcepts. Feelings of shock at new-found and unexpected realities can have negative implications on aspects of physical well-being, social development, intellectual capabilities and psychological response.
Anxiety is a set of responses that includes a complex combination of the feeling of fear excessive worry, depression, nervousness and irrelevant thinking, to a class of stimuli from an individual's experience of assessment and outcome. Excessive anxiety occurs in response to an actual or anticipated situation or as a pathological state. Adolescence is more vulnerable to anxiety, especially students. Nursing students experience a variety of stresses during their nursing education program which in turn ignites anxiety in them (Mohamed & Youssef, 2014).
According to DSM-1V, approximately 3% of people will develop an anxiety disorder during a given year and 5% of people will have anxiety at some point in their life. A college environment proved to produce anxiety in some individuals. First-year of the baccalaureate nursing program is proved to be a period of stressors and anxiety as they face a situation of being new in the nursing profession well as facing excessive anxiety in their initial clinical posting. Persistence of anxiety for a prolonged time can adversely affect the self-esteem levels (Stuart, 2017).
Common sources of anxiety students most often mention first experiences at anew clinical site, fear of making mistakes, concerns about performing clinical skills and using hospital equipment, angst about faculty evaluating skills, and lack of support of nursing personal. Students also find it difficult to close the gap from theory to practice. Anxiety can increase if there is a theory gap which is defined as an inconsistency between what is taught in the classroom and what is practiced in the clinical setting (Moscaritolo, 2018).
Clark &Zeldow (2016)reported in their study that, anxiety is often accompanied by health complaints such as palpitations, chest pain and/or shortness of breath. In a moderate level, anxiety stimulates anticipatory and adaptive responses to challenging and stressful events. It's also accompanied bya number of unexplained, nonspecific gastrointestinal symptoms such as nausea, abdominal pain, bloating, excess gas, cramping, dyspepsia, or other stomach or upper GI discomfort (Tricia,2017).
University students feel a wide assortment of symptoms, referred to as self-reported symptoms, health complaints, psychosomatic symptoms, or health strains or burdens. Such complaints include back pains and shoulder pains, various headaches, many gastrointestinal symptoms, psychological symptoms, psychiatric episode(s) and mental health issues including depression and anxiety, sleep disturbances, and circulatory/breathing complaints (e.g., dyspnoeic symptoms, tachycardia, excessive perspiration, and menstruation disorders) as manifestations of anxiety (Lee et al., 2014).
Nursing education requires placement in a variety of clinical settings to gain hands-on experience and to apply theory to practice. Preparation for practice entails more than developing skills in the on-campus lab. It requires developing an ability to provide safe and effective care to other human beings in various clinical settings. This aspect of developing expertise as a student nurse can be very stressful to nursing students and create anxiety. High levels of anxiety can affect student's learning, performance and in some cases retention within a nursing program (Moscaritolo,2018).
So, the negative impact of anxiety may be reduced when faculty acknowledges anxiety and provide a supportive learning environment for nursing students where mistakes are accepted as a part of the learning process. Educating nursing faculty regarding teaching strategies that decrease anxiety will both promote a positive and safe learning environment for students and build trusting relationships between faculty and students (Purfeerst, 2017).

SIGNIFICANT OF THE STUDY
Many people in the population may experience transient symptoms of anxiety or state anxiety, but do not meet diagnostic criteria for an anxiety disorder. By measuring anxious mood state, found a significant positive correlation between anxiety disorders and health complaints such as abdominal problems, headache, sleep problems, backache and circulatory /breathing complaints (Harter et al., 2018).
It is important for clinical nursing faculty to be aware of the heightened sense of anxiety students may experience during their clinical rotations. Strategies found in the literature to help reduce anxiety in nursing students include providing consistent clinical placement, peer mentoring, counselling, faculty role modelling, and developing positive student and staff relationships (Bell,2019).

Aim of the study:
This study aimed to evaluate the effect of intervention strategies regarding perceived anxiety and health complaints among newly admitted nursing students. It was achieved through: 1. Assessing the anxiety and health complaints for newly admitted nursing students. 2. Designing; implementing and evaluating the effect of intervention strategies regarding perceived anxiety and health complaints among newly admitted nursing students.

Research hypothesis:
To fulfil the aim of this study the following research hypothesis were formulated: H1: Nursing students who undertake the interventions strategy will exhibit a reduced level of anxiety and health complaints.
H2: There will be a positive correlation between anxiety and health complaints among nursing students.

Research design:
A quasi-experimental design was utilized to achieve the aim of the study.

Setting:
The study was carried out at the Faculty of Nursing, Benha University.

Sample type & size:
A systematic random sample was chosen as one every Fifth. It included 100 students from the total number (500) of firstgrade nursing students enrolled in the academic year 2019-2020 at the Faculty of Nursing, Benha University was the target of this study.

Tools of Data Collection:
The following three tools were used for data collection. Arabic translation of all the tools by the researcher and retranslation into English and tested for their translation. Headaches. This tool used pre and post-implementation of the intervention strategies. Tool (3):-Anxiety scale for undergraduate students was adopted by Singhal, (2015):A scale to measure anxiety status among newly admitted students. It consists of 50 items, each item provided Strongly Disagree, Disagree, Undecided, Agree and Strongly Agree, as alternatives for responding. This tool used pre and post-implementation of the intervention strategies. The scoring was as follows for the positive items:  Strongly Disagree 1  Disagree 2  Undecided 3  Agree 4  Strongly Agree 5 Negative items were scored in the reverse: These groups of items were framed into four dimensions or factors were defined as follows: 1. Competitive Environment (12 items)means the anxiety due to the competition for jobs, career, studies, rising population and increasingly competitive environment. (13 items)was the anxiety due to pressure of society in friendship with the opposite sex, desire for modern luxuries, to be in fashion, about one's appearance, of trying to do multitasking ( many things at the same time). 3. Worry about the Future (10 items)was the anxiety due to being insecure about the future, future outcome of events and the anxiety of being unsuccessful.

Psychological Manifestations (15 items)
-The resulting physical and mental manifestations of anxiety, through psychological symptoms like anger, irritation, loneliness and purely physical symptoms like crying, shouting and not sleeping.

Content Validity:
The tools were tested for content validity by a jury of five experts in the field of Psychiatric and Mental Health Nursing speciality to ascertain relevance and comprehensiveness. The tools proved to be valid.

Reliability of the tools:
Reliability was applied by the researcher for testing the internal consistency of the tool, by the administration of the same tools to the same sample under similar conditions on one or more occasions. Answers from repeated testing were compared (Test-re-test reliability).

Administrative Approval:
The researchers have obtained permissions from the Dean of Faculty of Nursing, Benha University to conduct the study. The objectives and the nature of the study were explained and then it was possible to carry out the study with minimum resistance.

Ethical considerations:
Before conducting the study, students were assured that the data will be collected from the questionnaires will remain confidential and that no personal identification was needed by any means. Students were informed that they could refuse to participate in this study, or withdraw from it at any time and then acceptance of the student to participate in the study was taken.

Pilot study:
A pilot study was conducted on 10 students (10% of the sample) to test by the designed assessment tool and its applicability on the sample and in order to estimate the time needed to fill in the sheets and to identify obstacles or problems in data collection and accordingly necessary modifications were done. Subjects who shared in the pilot study were included in the study sample.

Fieldwork:
 The researchers have obtained permissions from the Dean of Faculty of Nursing, Benha University to conduct the study.  The aim and the nature of the study were explained and then it was possible to carry out the study with minimum resistance.
 The researchers collected all students to be acquainted with them, explained to them the objectives of the study and its expected outcomes.  The researchers met each student after introducing their selves and explained to them the purpose of the study to seek participants' cooperation and emphasizing that all collected information is strictly confidential to obtain oral consent from them.  The study was carried out from the beginning of October 2019 to the end of December 2019 for two days/week.  The study was carried out at the Faculty of Nursing, Benha University.  Systematic random samples of 100 students were included in the study.

Procedures:
The intervention strategies comprised of the following phases: A-Assessment Phase:  A comfortable, private place was chosen for the interviewers. Orientation was done about the researcher's name, purpose, significance, content of the study. Samples were interviewed where the assessment was done using socio-demographic characteristic, health complaints questionnaire and Anxiety scale for undergraduate students.  The researchers completed the questionnaire (preintervention) from students for two days a week. This process took one month (October 2019). Data was collected using the interview and observational method. The sheet was filled individually by the researchers for each student. This interview took about 15 to 20 minutes.

B-Implementation phase:
The general objective of the study was to evaluate the effect of the intervention strategies regarding perceived anxiety and health complaints among newly admitted nursing students.
The specific objectives of the intervention strategies include the following:  Define of anxiety, causes, levels and its symptoms of the anxiety such as psychological and somatic symptoms.  Teaching the methods about how to control anxiety.  Training on relaxation exercises strategy.  Apply yoga exercises strategy for students.  Training about how to take care of your health.  Training the students on a strategy of problem-solving skills.
Content of the intervention strategies was designed by the researchers according to the previously mentioned objectives. The theoretical content of the intervention strategies included the definition of anxiety, causes, levels and its symptoms; Teaching the methods about how to control anxiety.
The practical content of the intervention strategies was included: Training on relaxation exercises strategy; Apply yoga exercises strategy for students; training about how to take care of your health; Training the students on a strategy of problem-solving skills.
The intervention strategies /theoretical and practical training included six sessions two for theory and four for practices. The sessions were carried out from (Beginning of November to end December 2019). Students were classified into 5 groups; each group consists of 20 students. The contents were repeated for each group by the researchers. Each session takes from 20-30 minutes for theory and 30-40minutes for practical. The teaching methods used were lectures and discussions as teaching methods for theory, however, role play, demonstration and re-demonstration, Data show, video were used as practical skills. As regards the teaching media used, they were booklet. At the end of every session, students were discussed to correct any misunderstanding, which has happened this through making conclusion and taking feedback from students about the content of the session and orienting them about the content of the next session.

C-Evaluation Phase:
Immediately after implementation of the intervention strategies, each student in the study was asked to evaluate health complaints questionnaire and Anxiety scale for undergraduate student(post-test). The results were compared to the pre-test results.

Statistical analysis:
The calculated data for this study were analyzed and the collected data was organized, coded, computerized and tabulated and analyzed by using (SSPS) programs version 20. Data analysis was accomplished by the use of the number, percentage distribution, mean and standard division, Paired "t" test was used to test the significance of some variance, and correlation coefficient was used determine statistically significance relations significant p < 0.05.

Figure (1):
Portrays that, more than two thirds (72.0%) have mild total health complaints post -intervention strategies.    Table (6): Clarifies that, positive correlation between total anxiety scale, its dimensions and total health complaints preintervention strategies. : Clarifies that, positive correlation between total anxiety scale, its dimensions and total health complaints postintervention strategies.

DISCUSSION
Anxiety is a psychological and physiological state characterized by physical, emotional, cognitive, and behavioral components. It is considered to be a normal response to stress. It may help an individual to cope with the demands of life but in excess it may be considered as anxiety disorder (National Institution of Mental Health, 2015).
Newly admitted students are moving into and through a major developmental period of transition. As they grapple with increased academic, personal, social, and moral pressures in their lives, these stressors may lead to increased anxiety, depression, headaches, sleep disturbances, gastrointestinal symptoms and sometimes suicidal ideations. Health anxiety is also an important aspect that affects college students' lives and studies. With regards to nursing students, the literature regarding mental health distress has focused on academic and personal sources of stress and coping efforts, with an emphasis on the stress and anxiety associated with clinical practice (Zhang et al., 2014).
Therefore, the aim of the present study was to evaluate the effect of the intervention strategies regarding perceived anxiety and health complaints among newly admitted nursing students. This aim was achieved throughout the study findings and the research hypothesis was accepted.
The result of the present study revealed that More than twothirds of the studied subjects were 18 years old and their mean age was18.34±0.58 years this is because it is the normal age for entering university on Egypt and more than half were male, majority of studied subjects were living in rural areas. This is might be due to the geographical location of benha university it is near from the rural areas and majority of them had residence with family during study this is might be due to the rural community maintains its children by living close to their families and not far from them. These findings were similar to the study done by Prabhuswami et al., (2016) found that the demographic data of maximum students belong to the age of 18 years; the majority of them from a rural area and staying with their families. Also, this result in agreement with Mohamed & Youssef , (2014) their results revealed that the age of nearly half of the students ranged between 18 years and the meanage was (19.34 ± 1.54) years. The majority of students were singles; two-thirds of them were residing in rural areas and living with their families.
Regarding the health status of the studied subjects, the findings of the current study showed that the majority of them were no smoking and no chronic illness. More than half of them had good general health status. This may be due to the majority of studied subjects were live with their families as the rural culture prevents them from smoking, keeps their sons and cares for their health and takes care of them so they had good general health. This results supported by Ramadan & Ahmed, (2015) they found the majority of students were no smoking and with good general health status. Furthermore, this result was consistent with Cheung et al.,(2016) only five respondents were current smokers. Most respondents perceived their physical and mental health as good.
The result of the present study revealed that there was statistically and highly statistically significant differences between pre and post-intervention strategies related to all items regarding to health complaints. This result indicated the efficacy of the Intervention Strategies in reducing health complaints among nursing students. These findings were similar to the study done by Ilankoon&Warnakulasooriya, (2015)they found that there was an association between anxiety and the physical wellbeing factors: feeling tired easily, getting nervous, poor sleep and chest tightness, loss of appetite, reduced or increased psychomotor speed, weight changes and loss of libido. And relieving these health complaints after implementation nursing program contains of deep breathing exercises.
Also, the result of the current study clarified that there were no statistically significant differences between pre and postnursing intervention strategies related to Nightmares, Trembling, Speech impediment and Breathing difficulties. This might be due to limitation of the session time and the students need more sessions these findings were similar to the study done by Singh et al., (2016) they found no improvement on some items of physical health after implementation of coping strategies used by nursing interns.
Apparently, the current study finding indicated that there was a highly statistically significant difference of Anxiety scale dimensions means score pre and post -intervention strategies. This may be due to College nursing students have additional stressors other college students do not have to face. In addition to the intense theoretical learning encompassed in a nursing program, nursing students are required to perform clinical and critical thinking skills. Nursing students are thrust into the professional environment while still developing their knowledge base, which can be a great source of anxiety and after the implementation of the nursing intervention strategies, the level of anxiety decreased. This finding was consistent with Riet et al., (2015) who revealed that using stress management and mindfulness program had significant effects on all Anxiety scale dimensions including environmental, Societal Pressure and Psychological Manifestations The present study illustrated that decrease the level of anxiety of the studied sample post -intervention strategies. This indicated that the provided intervention strategies were effective. This finding was supported by Manpreet & Maheshwari, (2015) they found a decreased level of depression, anxiety and stress among postgraduate nursing students after implementation of psycho-educational program. Also, this result supported by Behrozian & Nematpour, (2017) they found that stress management training based on the meditation could significantly reduce the anxiety level of the nursing students in the intervention group compared to before the intervention.
Furthermore this study showed that, there are a positive correlation between total anxiety scale and total health complaints pre-and post-intervention strategies. From researchers' points of view this is may be due to anxiety is often accompanied by health complaints such as palpitations, chest pain and/or shortness of breath, diarrhea, constipation, abdominal problems, back pain, neck pain, fatigue and others symptom's. The less anxiety a student has the less physical symptoms they will complain about. These findings were in accordance with Malinski&Todaro-Franceschi, (2017)reported in their study that, anxiety is often accompanied by health complaints and these complaints decreased after Exploring co-meditation as a means of reducing anxiety and facilitating relaxation in a nursing school. Also this result in agreement with Davazdahemami et al.,(2019) who found that positive correlation between anxiety and symptom of hyper and hypo thyroidism pre-and post-stress management training.

ACKNOWLEDGEMENT
We are grateful for all the respondents participated in this study.

CONCLUSION
Based on the findings of the present study, it is concluded that intervention strategies had a positive effect regarding perceived anxiety and health complaints among newly admitted nursing students.

RECOMMENDATIONS
In the light of the findings of the current research, the following recommendations are suggested:  A comparison of anxiety among newly admitted nursing students and other students in various other colleges.  Planning of effective interventions and policies are very important to limit the psychological health issues among nursing students.  Early recognition of anxiety and related problems are essential, and initiation of stress management programs expanding counseling activities for nursing students are warranted.  Longitudinal studies are warranted to observe timeseries changes in mental health aspects among nursing students.