In the UK, five generations of nurses are registered with the Nursing and Midwifery Council (NMC) (2022): the Silent Generation, Baby Boomers, Generation X, Generation Y/Millennials and Generation Z/Post-Millennials (Jones et al, 2015). Generational characteristics, shaped by life experiences and world events, vary significantly (Shorey et al, 2021).
Although generalising traits across a generation can obscure individual differences (Hampton and Keys, 2017), recognising these generational variances in preferences, work habits and attitudes is particularly important (Stutzer, 2019).
Generation Z's (Gen Z) traits are particularly shaped by technology (Chicca and Shellenbarger, 2018; Allen, 2021). Born into a world connected by the internet (Seemiller and Grace, 2017), they are often referred to as ‘digital natives’ (Hernandez-de-Menendez et al, 2020). Twenge (2017) noted their emotional vulnerability, attributing it to delayed adolescence, increased social isolation, anxiety and depression, often stemming from virtual communication, which leads to underdeveloped social and relational skills. The American Psychological Association (2018) reported that Gen Z students are more likely to acknowledge mental health challenges and seek assistance. Consequently, more students with pre-existing mental health conditions are entering university (McLafferty et al, 2017), a setting already associated with heightened mental health risks (Jenkins et al, 2021).
Before the COVID-19 pandemic, studies indicated that nursing students' anxiety levels were higher than those of typical university students, impacting learning and clinical performance (Turner and McCarthy, 2017). UK nursing programmes are split equally between academic study and clinical practice, and the clinical environment is a known source of student anxiety, directly affecting clinical performance (Moscaritolo, 2009). Simpson and Sawatzky (2020) highlighted that clinical placements are particularly anxiety-inducing. This may be due to fears of making mistakes or harming patients (Shaban et al, 2012; Moots, 2023).
During the pandemic, US nursing students were removed from clinical settings (Dickel, 2021), causing uncertainty and missed learning opportunities. Conversely, the UK allowed senior students to continue their placements while initially withdrawing first-year students (NMC, 2020). Rohde et al (2022) found that first-year students were most affected, struggling with social aspects of learning and concerned about completing their courses due to changing restrictions. Moots (2023) noted that missing patient interaction opportunities may have impacted students' communication skills and practical abilities.
Aims
This study aimed to assess self-reported anxiety levels in first-year undergraduate nursing students prior to or at the start of their first post-pandemic placement.
Design and methods
This study investigated the impact of anxiety on Gen Z nursing students' experiences. A cross-sectional design was used, with the Generalized Anxiety Disorder-7 (GAD-7) questionnaire used to assess students' anxiety severity (Spitzer et al, 2006). Participant demographics included gender, age (with past studies indicating higher anxiety among females and younger individuals (Twenge, 2017; BlackDeer et al, 2023)), field of nursing, and ethnicity, acknowledging the under-researched nature of mental health issues in minority groups (Lipson et al, 2018). Previous healthcare experience was also considered, as Rodrigues et al (2021) found no link between anxiety and clinical experience. However, exposure to simulated clinical experiences is thought to reduce student anxiety (Stunden et al, 2015). The study did not address students' pre-existing mental health concerns, as students may be reluctant to disclose such information, fearing it could impact their nursing journey (Devereux et al, 2012).
Ethical considerations
Ethical approval for this study was obtained from the university's Research Ethics Committee. Participants received detailed information about the study's aims and objectives, emphasising voluntary participation and the right to withdraw at any time. Additionally, resources offering support services were made available to the students.
Sample
The study recruited a post-pandemic purposive sample of nursing students from a university in North East England. Inclusion criteria required potential participants (n=462) to be enrolled in the first year of an undergraduate nursing programme (all fields) and to be prior to or just commencing their first clinical placement. Exclusion criteria applied to second or third-year nursing students and those who had completed one or more clinical placements.
Generalized Anxiety Disorder-7 Questionnaire
The GAD-7, a seven-question self-rating scale developed by Spitzer et al (2006), screens for generalised anxiety symptoms such as nervousness and worrying over a 2-week period. It employs a 4-point Likert scale ranging from 0 (not at all) to 3 (nearly every day), with total scores ranging from 0 to 21, indicating the severity of generalised anxiety (Rutter and Brown, 2017). Spitzer et al (2006) defined severity cut-off points as 5 (mild), 10 (moderate) and 15 (severe). The GAD-7's reliability and validity have been confirmed in various populations, including the general population (Löwe et al, 2008) and Portuguese college students (Bártolo et al, 2017).
Data collection
Students were invited to participate through an email distributed via the university's electronic learning platform, which included a consent form, information leaflet, aftercare support, and a link to the GAD-7 questionnaire with accompanying demographic questions.
Generational birth-date ranges vary and therefore this study adopted the following dates for generational demographics: Gen X (1965-1980), Gen Y (1981-1995) and Gen Z (1996-2010) (Eldridge, 2024).
Statistical analysis
Statistical analysis was conducted using IBM SPSS version 28.0 (2021). Mean scores for generational groups' GAD-7 items and total scores were calculated. The Mann-Whitney U test was used to compare mean scores for significance determination.
Demographics of respondents
The survey was sent to 462 students, with 24 completing the questionnaire – the response rate was 5.2% (Table 1). This low rate may be attributed to concerns over disclosure or the timing of the data collection coinciding with preparation for their first placement. The cohort was divided into fields of nursing: Adult (n=15), Mental Health (n=6), Children's (n=2), and Learning Disabilities (n=1), representing approximately 5% of each field. Generational representation was as follows: Gen X (n=1, 4%), Gen Y (n=11, 46%), and Gen Z (n=12, 50%).
Table 1. Demographical overview of participants
| Generation | N | % | ||
|---|---|---|---|---|
| Gender | X (1965–1980) | Female | 1 | 100.0% |
| Y (1981–1995) | Female | 10 | 90.9% | |
| Male | 1 | 9.1% | ||
| Z (1996–2010) | Female | 11 | 91.7% | |
| Male | 1 | 8.3% | ||
| Previous experience of healthcare | X (1965–1980) | Yes | 1 | 100.0% |
| Y (1981–1995) | No | 6 | 54.5% | |
| Yes | 5 | 45.5% | ||
| Z (1996–2010) | No | 8 | 66.7% | |
| Yes | 4 | 33.3% | ||
| Duration of previous healthcare experience | X (1965–1980) | Over 16 years | 1 | 100.0% |
| Y (1981–1995) | 11–15 years | 1 | 9.1% | |
| 5–10 years | 1 | 9.1% | ||
| 1–4 years | 1 | 9.1% | ||
| Less than 1 year | 3 | 27.3% | ||
| Not applicable | 5 | 45.5% | ||
| Z (1996–2010) | 1–4 years | 3 | 25.0% | |
| Less than 1 year | 1 | 8.3% | ||
| Not applicable | 8 | 66.7% | ||
| Course studied | X (1965–1980) | Mental Health nursing | 1 | 100.0% |
| Y (1981–1995) | Adult nursing | 7 | 63.6% | |
| Children's nursing | 1 | 9.1% | ||
| Learning Disabilities nursing | 1 | 9.1% | ||
| Mental Health nursing | 2 | 18.2% | ||
| Z (1996–2010) | Adult nursing | 8 | 66.7% | |
| Children's nursing | 1 | 8.3% | ||
| Mental Health nursing | 3 | 25.0% | ||
| Ethnicity | X (1965–1980) | White | 1 | 100.0% |
| Y (1981–1995) | Other ethnic background | 1 | 9.1% | |
| White | 10 | 90.9% | ||
| Z (1996–2010) | Arab | 1 | 8.3% | |
| Asian or Asian British – Pakistani | 2 | 16.7% | ||
| Black or Black British – African | 1 | 8.3% | ||
| Other Asian background | 1 | 8.3% | ||
| Other White Background | 2 | 16.7% | ||
| White | 5 | 41.7% | ||
Results
The percentage categorisation of the sample's GAD scores is as follows: 20.8% reported minimal anxiety (n=5); 25% reported mild anxiety (n=6); 29.2% (n=7) reported moderate anxiety; and 25% (n=6) reported severe anxiety.
Further analysis involved dividing responses into generational groups: 1981–1995 (Gen Y) and 1996–2010 (Gen Z). The lone participant born prior to these ranges was excluded from this part of the analysis due to the lack of significant insight a single data point could provide.
The mean GAD-7 score for Gen Y (10.27) was not significantly different from that of Gen Z (10.75), as confirmed by the Mann-Whitney U test (exact significance 0.833). However, Gen Z's results showed a higher standard deviation (6.524 compared to 5.293). Applying the GAD-7 classification to these scores revealed that Gen Z students experienced both higher levels of severe and minimal anxiety, while most Gen Y students fell into the intermediate categories. This polarisation among Gen Z students is notable, although the small sample size limits the conclusions that can be drawn (Figure 1).
Subsequent analysis sorted the data by nursing field, considering means and standard deviations (see Table 2). The analysis included students in all fields, including the single Learning Disabilities and two Children's Nursing students. This was to provide context rather than expect statistically significant comparisons. It is interesting that Mental Health Nursing students had lower mean scores on all GAD-7 items compared to other fields. The comparison of Mental Health students to Adult Nursing students using the Mann-Whitney U test showed no significant differences. However, the distinct lower scores of Mental Health students suggest a possible resilience unique to this group. When the other three fields were combined into ‘Other fields’, the Mann-Whitney U test still found no significant differences in total scores (exact significance=0.119).
Table 2. Field of nursing study GAD-7 mean total scores
| Adult | Children's | Learning disabilities | Mental health | |||||
|---|---|---|---|---|---|---|---|---|
| Mean | SD | Mean | SD | Mean | SD* | Mean | SD | |
| Total score | 10.80 | 6.144 | 13.50 | 4.950 | 13.00 | − | 6.83 | 6.014 |
SD=standard deviation;
* No standard deviation data due to sample size of 1Lastly, a simple count of GAD-7 classifications by nursing field was conducted (see Figure 2).
It is notable that most Mental Health Nursing students fell into the lower classifications of anxiety, with only one notable outlier. In contrast, a significant number of Adult Nursing students were categorised within the higher anxiety classifications. This trend was also observed among all representatives from Children's and Learning Disabilities Nursing. This distribution suggests a discernible difference in anxiety levels between the fields, with Mental Health Nursing students generally exhibiting lower levels of anxiety compared to their counterparts in other nursing specialties.
Discussion
This modest study aimed to assess the anxiety levels of first-year nursing students post-COVID-19 lockdowns, just before or after beginning their first clinical placement. It explored self-reported anxiety levels, prevalence, generational differences, and field-of-study comparisons.
The prevalence of moderate to severe anxiety (GAD-7 score of 10 or more) was reported by 54.2% of participants. This is comparable to findings in a Spanish study (Martinez-Vázquez et al, 2023), although drawing broader conclusions is challenging due to the sample size. Savitsky et al (2021) and Kells and Jennings Mathis (2023) reported varying rates, while Comparcini et al (2022) observed a notably higher prevalence.
The recent pandemic's influence on the sample's anxiety levels cannot be definitively established. However, the participants' school or college experiences during the UK's pandemic lockdowns likely contributed to heightened anxiety levels. This period was marked by disrupted education and an increased risk of poor mental health (Cowie and Myers, 2021; McKinlay et al, 2022). More than a third of university students exhibit symptoms of common mental conditions at the start of their courses (Osborn et al, 2022), and the transition to university life, compounded by pandemic experiences, could have contributed to the higher GAD scores observed.
Gen Z students reported higher levels of anxiety prior to their placement, in line with findings that first placements often induce anticipatory excitement or anxiety (MacDonald et al, 2016). Various factors influence this anxiety, such as self-doubt, role models' attitudes, and pre-placement experiences (Eick et al, 2012; Jonsén et al, 2013; Levett-Jones et al, 2015; Alshahrani et al, 2018). Middleton et al (2021) observed higher anxiety levels in Gen Z students, correlating with decreased quality of life and academic performance. This aligns with Jia et al's (2020) findings, who identified increased stress and anxiety in younger students and Twenge (2017), who noted a higher propensity for anxiety in Gen Z females.
Mental Health Nursing students reported intermediate levels of anxiety, challenging the findings of Galvin et al (2015) and McLafferty et al (2022), who suggested there were higher psychological challenges in this group. This study contributes to the limited research on nursing and anxiety across different fields (Lipson et al, 2016).
Regardless of field of nursing or generation, a supportive approach to any student suffering from mental health challenges is required, therefore equipping staff with the requisite skills is paramount. Adopting the 3R's approach would accelerate early support interventions, and universities should consider expansion of mental wellbeing support resources. The 3Rs are (Universities UK, 2022):
- Recognise early
- Respond to student concern
- Refer onto relevant services.
Prior to their first placement, nursing students should be enabled to explore anxiety-provoking situations in a safe environment (Simpson and Flynn, 2024). Incorporation of mental health wellbeing strategies into pre-placement preparation sessions is advisable (Universities UK, 2022), as well as introducing these concepts into any practice assessor/supervisor workshop/updates. DiMattio and Hudacek (2020) suggested involving students in decision-making and providing feedback and support to enhance placement satisfaction.
For further recommendations on reducing placement anxiety and improving satisfaction among Gen Z students, refer to Turner and McCarthy (2017), Alshahrani et al (2018), Aloufi et al (2021), and Universities UK (2022).
Limitations
This study has several limitations. It captured only the numerical aspect of participants' anxiety levels, missing the opportunity to gather qualitative data on the causes of anxiety during the GAD-7 completion period. A recommendation is to repeat the study with a future nursing cohort, including qualitative data collection, and aiming for a higher response rate for a more comprehensive understanding.
Another limitation is the focus on a single university in one geographical area of England. The small sample size also limits the generalisability of findings across different nursing fields. However, these results can initiate discussions on how nurse educators can adapt to support Gen Z students. Further research, including longitudinal studies on generational responses to mental health challenges and their impact on student attrition rates, is necessary.
Conclusion
Although increased anxiety levels in nursing students are not new, Gen Z students are navigating a unique set of challenges. Universities and placement providers must therefore evolve their support strategies to meet these needs. This involves developing staff to understand and address the specific concerns of Gen Z students in all learning environments. A holistic approach is necessary, one that not only acknowledges but actively caters to the distinct wants, needs, and emotional wellbeing of these students. Such measures are crucial for fostering the long-term sustainability of their careers in nursing.
As Gen Z will be part of the workforce until at least 2078, there is a pressing need for more focused research on this demographic within the nursing field. This understanding is vital for effective strategies in recruitment and retention within nursing programmes, ensuring a resilient nursing workforce for the future.
KEY POINTS
- Generation Z (Gen Z) nursing students exhibit significant anxiety levels post-pandemic, necessitating targeted support systems in academic and clinical settings to address their unique mental health challenges
- The study reveals a polarisation in anxiety levels among Gen Z students compared to other generational groups, with Mental Health Nursing students reporting lower levels of anxiety
- Holistic approaches in universities and placement settings are essential to foster the emotional wellbeing and long-term resilience of nursing students, particularly in adapting to the evolving challenges of a post-pandemic world
CPD reflective questions
- How do the findings about Generation Z (Gen Z) nursing students' anxiety levels in the post-pandemic context challenge or affirm your current understanding or practices in nursing education and mental health support?
- Reflect on the varied anxiety levels reported across different fields of nursing as highlighted in the study. What implications do these findings have for the design and implementation of mental health support systems in nursing education?
- Considering the study's emphasis on holistic approaches to support nursing students' emotional wellbeing, what strategies or changes could be implemented in your practice or institution to better support the mental health and resilience of nursing students, especially those from Gen Z?