Dimensions of reality shock, anxiety, and depression among nursing students: a structural equation model of the mediating roles of self-esteem and resilience

Transitioning from school education to professional nursing is a crucial phase in students’ lives, requiring them to adapt to a demanding healthcare environment, acquire new skills, and provide care in real-world settings. High levels of resilience and self-esteem can help nursing students effectively cope with anxiety and other psychological challenges. This study evaluated a structural equation model examining the associations between dimensions of reality shock and psychological distress, modeled as combined anxiety/depression symptoms using a modified PHQ-4 construct, with self-esteem and resilience tested as potential mediators. A cross-sectional survey was conducted among 1,257 BSc Nursing students (Years I-IV) at nursing institutions in India. Data were collected using the Reality Shock Scale for Nursing Students (RSS-NS), Rosenberg Self-Esteem Scale (RSES), Patient Health Questionnaire-4 (PHQ-4), and the 10-item Connor-Davidson Resilience Scale (CD-RISC-10). Psychological distress was analyzed as a combined latent construct based on three retained PHQ-4 indicators after one item was removed because of low outer loading. Data were analyzed using Partial Least Squares Structural Equation Modeling (PLS-SEM) to examine direct and indirect associations. Poorer clinical staff relations (β = -0.103, p = 0.003) and lower self-esteem (β = -0.107, p = 0.001) were significantly associated with higher psychological distress. Higher professional commitment was also significantly associated with increased psychological distress (β = 0.134, p = 0.001). Mediation analysis showed that self-esteem significantly partially mediated the associations between selected reality shock dimensions and psychological distress: 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). 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. Self-esteem was a salient mediator in the association between reality shock and psychological distress. Nursing curricula should prioritize structured mentorship and supportive clinical environments to strengthen students’ self-worth and may thereby reduce vulnerability to psychological distress during professional role transition.