Nursing students in India who reported poorer relationships with clinical staff and lower self-esteem also reported higher levels of combined anxiety and depression symptoms, according to a cross-sectional survey of 1,257 Bachelor of Science Nursing students published in BMC Medical Education. The study used structural equation modeling to test how different dimensions of the so-called reality shock—the disorienting transition from classroom learning to professional practice—relate to psychological distress, and whether self-esteem and resilience mediate that relationship.
The researchers surveyed students in Years I through IV at nursing institutions in India, using four validated instruments: the Reality Shock Scale for Nursing Students, the Rosenberg Self-Esteem Scale, the Patient Health Questionnaire-4, and the 10-item Connor-Davidson Resilience Scale. Psychological distress was modeled as a combined latent construct built from three retained PHQ-4 indicators, after one item was removed because of a low outer loading in the measurement model.
The results showed that poorer clinical staff relations were significantly associated with higher psychological distress (β = -0.103, p = 0.003), as was lower self-esteem (β = -0.107, p = 0.001).
The mediation analysis revealed a clear pattern: self-esteem significantly and partially mediated the associations between selected reality shock dimensions and psychological distress. Specifically, self-esteem carried part of the effect for professional commitment (β = 0.025, p = 0.004), role burden and psychosocial outcomes (β = 0.021, p = 0.008), and perceived professional adequacy (β = 0.013, p = 0.024).
Resilience told a different story. Although reality shock dimensions were associated with resilience levels, resilience itself did not emerge as a significant mediator of the relationship between reality shock and psychological distress.
The study’s authors conclude that self-esteem was the salient mediator in the association between reality shock and psychological distress. They suggest that nursing curricula should prioritize structured mentorship and supportive clinical environments to strengthen students’ self-worth, which may in turn reduce vulnerability to psychological distress during professional role transition.
The findings come with important caveats. As a cross-sectional survey, the study captures a single point in time and cannot establish causal direction—whether low self-esteem drives distress, distress erodes self-esteem, or both. The sample was limited to BSc Nursing students in India, so generalization to other countries, educational systems, or degree pathways remains untested. The removal of one PHQ-4 item also means the distress construct differs from the standard four-item version of the instrument.
Subject of Research: Associations between reality shock dimensions and psychological distress among Indian nursing students, with self-esteem and resilience tested as mediators
Article Title: Dimensions of reality shock, anxiety, and depression among nursing students: a structural equation model of the mediating roles of self-esteem and resilience
Article References: Kumar, R., Hassan, Y. S. A., Charan, G. S., Kalia, R., Beniwal, K., & Patil, H. (2026). Dimensions of reality shock, anxiety, and depression among nursing students: a structural equation model of the mediating roles of self-esteem and resilience. BMC Medical Education. https://doi.org/10.1186/s12909-026-10407-3
Image Credits: AI Generated
DOI: 10.1186/s12909-026-10407-3
Keywords: nursing students, reality shock, psychological distress, self-esteem, resilience, PLS-SEM, cross-sectional survey, anxiety, depression, clinical staff relations, professional commitment, India
News Source: Glenn Wilkins. (October 28, 2026). Reality shock hits nursing students, but self-esteem may soften the blow. Scienmag.
