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The media ing ole o anxie y and dep ession be ween academic
sa is ac ion and academic pe o mance among bachelo 's and
mas e 's nu sing s uden s
Pa in Yadollahi1, Mahdi Salmanpou 2, Ma yam Shaygan3* , Zah a Jahandideh4
1Depa men o Midwi e y, Ma e nal-Fe al Medicine Resea ch Cen e . School o Nu sing and Midwi e y, Shi az Uni e si y o Medical
Sciences, Shi az, I an
2Depa men o S a is ics, College o Ma hema ical Sciences, Uni e si y o Kashan, Kashan, I an
3Depa men o Nu sing, Communi y Based Psychia ic Ca e Resea ch Cen e , School o Nu sing and Midwi e y, Shi az Uni e si y o
Medical Sciences, Shi az, I an
4Fasa Uni e si y o Medical Sciences, Fasa, I an
A icle in o Abs ac
In oduc ion
One o he mos signi ican and s ess ul pe iods in a
nu sing s uden 's li e is en e ing uni e si y and acing
clinical p ac ices, inal exams, and he po en ial impac
on hei men al heal h [3, 4]. This s ess is exace ba ed
by he loss o suppo om amilies, inancial
obliga ions, and pe sonal esponsibili ies, which in u n
a ec s uden sa is ac ion le els [1, 2]. The deg ee o
which s uden s eel sa is ied wi h hei uni e si y
expe iences and whe he hei expec a ions o lea ning
a e me du ing hei ime a an academic ins i u ion is
known as s uden sa is ac ion. Nu sing s uden s'
sa is ac ion can signi ican ly in luence hei academic
achie emen s, abili y o con inue hei s udies, and
o e all well-being, leading o inc eased engagemen and
mo i a ion [5]. In con as , discon en can esul in
educed educa ional mo i a ion and po en ially e en
educa ional a i ion [6]. The e has been an inc easing
in e es in s udying he elemen s ha in luence academic
A icle his o y:
Recei ed 12 Jan. 2025
Accep ed 17 Jun. 2025
Published 13 Jul. 2025
Yadollahi e al. J Med Edu De . 2025; 18(2): 55-64 Jou nal o Medical Educa ion De elopmen
Backg ound & Objec i e: Men al dis ess, such as anxie y and dep ession, a e impo an
componen s ha a ec educa ional achie emen . This s udy aimed o examine he media ing
ole o anxie y and dep ession in he ela ionship be ween academic sa is ac ion and academic
pe o mance among bachelo 's and mas e 's nu sing s uden s.
Ma e ials & Me hods: This is a c oss-sec ional s udy ha u ilized a s uc u al equa ion model.
Sampling was conduc ed using a wo-s age clus e sampling me hod, conside ing he inclusion
and exclusion c i e ia o 1,695 bachelo 's and mas e 's nu sing s uden s om Feb ua y 11 o
No embe 30, 2019. Da a we e collec ed using ou ques ionnai es, namely a demog aphics
su ey, he Spielbe ge S a e-T ai Anxie y In en o y (STAI), he Pa ien Heal h Ques ionnai e-
9 (PHQ-9), and he Academic Sa is ac ion Scale. Da a analysis was conduc ed using SPSS 26.0
and he mac o PROCESS model 6 o e alua e he media ing e ec s o dep ession and anxie y
simul aneously. A p- alue o less han 0.05 was conside ed s a is ically signi ican .
Resul s: This s udy demons a ed ha he di ec e ec o nu sing s uden s' academic
sa is ac ion signi ican ly co ela ed wi h hei academic pe o mance. Addi ionally, he
ela ionship be ween nu sing s uden s' academic sa is ac ion and academic pe o mance was
signi ican ly media ed, bo h sepa a ely and simul aneously, by hei le els o dep ession and
anxie y (β = 0.0005, CI = 0.0001 o 0.001).
Conclusion: Conside ing he impo ance o academic sa is ac ion and pe o mance o nu sing
s uden s, as well as he ad e se e ec s o anxie y and dep ession on hese a iables, he
implica ion o sui able s a egies is essen ial o p e en ing academic bu nou . The e o e,
educa ional sys em au ho i ies a e ad ised o p io i ize s uden s' well-being o p e en u u e
nega i e consequences, especially in hei p o essional oles.
Keywo ds: dep ession, anxie y, academic sa is ac ion, academic pe o mance, bachelo and
mas e s uden s
*Co esponding au ho :
Ma yam Shaygan, Depa men o
Nu sing, Communi y Based
Psychia ic Ca e Resea ch Cen e ,
School o Nu sing and Midwi e y,
Shi az Uni e si y o Medical
Sciences, Shi az, I an
Email: [email protected]
O iginal A icle
How o ci e his a icle:
Yadollahi P, Salmanpou M, Shaygan
M, Jahandideh Z. The media ing ole
o anxie y and dep ession be ween
academic sa is ac ion and academic
pe o mance among bachelo 's and
mas e 's nu sing s uden s. J Med Edu
De . 2025; 18(2): 55-64.
[ DOI: 10.61882/edcj.18.2.55 ] [ Downloaded om edujou nal.zums.ac.i on 2025-10-03 ]
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: Rela ion anxie y and dep ession wi h academic sa is ac ion and academic pe o mance
56 Jou nal o Medical Educa ion De elopmen ¦ Volume 18 ¦ Issue 2 ¦ 2025
sa is ac ion and success in ecen yea s. Resea che s
ha e examined se e al aspec s, including he indi idual
a ibu es o nu sing s uden s, such as age, gende ,
pe sonali y, he ins i u ional en i onmen , and ac o s
ha a ec s uden s' men al heal h, such as dep ession and
anxie y. These ac o s a e emo ional s a es ha a ise in
eac ion o di icul ci cums ances, and nu sing s uden s
a e mo e p one o su e ing in ense, p olonged dis ess
and e en dep ession compa ed o o he demog aphic
g oups [7, 8]. In his line, Beck's cogni i e heo y o
dep ession sugges s ha in achie emen -o ien ed
en i onmen s like uni e si y, indi iduals wi h
dep essi e symp oms a e p one o eeling inadequa e,
ha ing nega i e sel -pe cep ions, and ha ing low sel -
es eem when hey ecei e low g ades. This issue leads o
educed academic sa is ac ion [9].
Addi ional esea ch has sugges ed ha s uden s may
ha e unde pe o mance, no due o a de iciency in hei
capabili ies bu a he as a esul o hei anxie y- ela ed
si ua ion [10]. Based on pas s udies, academic
dissa is ac ion can igge eelings o ne ousness,
anxie y, i i abili y, impa ience, a lack o in e es , and
demo i a ion ela ed o cou sewo k, which may be
e lec ed in dec eased class a endance. The e o e,
dis inguishing he ac o s ha a ec his issue is c ucial
[11, 12]. Howe e , i 's c ucial o no e ha he ela ionship
be ween hese ac o s and academic achie emen is
me ely co ela ional, and co ela ion does no imply
causa ion. Gi en he nega i e e ec s o psychological
dis ess on academic sa is ac ion and pe o mance
among nu sing s uden s, as well as he con o e sial da a
su ounding his issue, his s udy aims o in es iga e he
ela ionship be ween academic sa is ac ion and academic
pe o mance among bachelo 's and mas e 's nu sing
s uden s while conside ing he media ing oles o anxie y
and dep ession.
Ma e ials & Me hods
Design and se ing(s)
This s udy is a c oss-sec ional analysis based on a
s uc u al equa ion model o examine nu sing s uden s a
medical sciences uni e si ies in I an. The s udy was done
om 11 Feb ua y o 30 No embe 2019. The se ing o
his s udy was he nu sing colleges in I an. The Bachelo
o Nu sing p og am in I an has a du a ion o ou yea s,
which is di ided in o eigh semes e s. Du ing his pe iod,
s uden s mus ul ill he obliga ion o ea ning 130 c edi s.
S a ing om he second semes e , nu sing s uden s a e
allowed o en oll in cou ses ha in ol e p ac ical
aining in clinical se ings. The mas e 's nu sing
p og am has a du a ion o wo yea s, consis ing o ou
semes e s. Du ing his ime, s uden s mus ul ill a o al
o 32 c edi s. Pos g adua e s uden s begin clinical
aining s a ing wi h he i s semes e .
Pa icipan s and sampling
To calcula e he sample size o he s uc u al equa ion
model [13], we used he guideline o 20 subjec s pe
obse able a iable. In ou s udy, 72 obse able
a iables (i ems and dimensions om ques ionnai es on
academic pe o mance, academic sa is ac ion, anxie y,
and dep ession) we e iden i ied, esul ing in an es ima ed
sample size o 1,440 nu sing s uden s. Conside ing a
20% d opou a e, he inal sample size was de e mined
o be 1,728 subjec s. Du ing he da a collec ion and
analysis p ocess, da a om 1,695 pa icipan s we e
ul ima ely analyzed.
The sampling me hod used was a mul is age app oach.
Nu sing colleges in I an we e o iginally ca ego ized in o
i e dis inc geog aphic egions: No h, Sou h, Eas ,
Wes , and Cen e . Each egion was hen classi ied in o a
ca ego y, wi h egions ha ing a highe pe cen age o
s uden s assigned a la ge numbe o pa icipan s. A wo-
s age clus e sampling me hod was used o selec wo
p o inces om each a ea andomly, and om hose wo
p o inces, h ee nu sing colleges we e andomly
selec ed. Each college was andomly sampled o
s uden s. The esea che s ob ained a os e o s uden s'
names om he educa ion depa men o each school.
They selec ed indi iduals who me he inclusion c i e ia
by using a able o andom numbe s gene a ed by
SPSS e sion 26.0.
The inclusion c i e ia o he s udy we e s uden s
pu suing unde g adua e s udies om Semes e 2 o
Semes e 8 o pos g adua e s udies om Semes e 1 o
Semes e 4. The exclusion c i e ia included s uden s who
we e no willing o pa icipa e in he s udy, hose who
had ans e ed om ano he school, had been absen o
on a b eak a he ime o sampling, had a se e e men al
o physiological diso de du ing he s udy, o had a
his o y o using psychoac i e d ugs o seda i es.
Tools/Ins umen s
The demog aphic o m included in he collec ed da a
we e he s uden s' age, gende , ma i al s a us, educa ion
le el, pa en s' educa ion le el, place o esidence, and
G ade Poin A e age (GPA). Addi ional ins umen s
used in his s udy we e adap ed om he a icle by
Shaygan e al. [14].
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Jou nal o Medical Educa ion De elopmen ¦ Volume 18 ¦ Issue 2 ¦ 2025 57
The Spielbe ge S a e-T ai Anxie y In en o y
(STAI), a commonly used ins umen in psychological
esea ch, comp ises sepa a e sel -assessmen scales o
measu ing s a e and ai anxie y. The s a e anxie y
subscale consis s o 20 i ems ha assess he esponden 's
eelings a he momen hey a e answe ing. Each
s a emen is a ed on a 4-poin Like scale anging om
(1) no a all, (2) somewha , (3) mode a ely, and (4) e y
much. The i ems measu ing anxie y le els a e sco ed
om 1 o 4, while ques ions ha indica e a lack o
anxiousness a e anked in e e se o de , om 4 o 1. A
sco e o 4 on he anxie y scale sugges s a signi ican le el
o anxie y; speci ically, his sco e is assigned o 10 i ems
om he s a e anxie y scale and 11 i ems om he ai
anxie y scale. In con as , a high sco e on he o he i ems
indica es an absence o wo y. In his con ex , he e a e
en i ems speci ically add essing s a e anxie y and nine
i ems add essing ai anxie y. To calcula e a
esponden 's sco e o each o he wo subscales, ce ain
i ems a e sco ed in he opposi e di ec ion. The
esea che s hen calcula e he o al sum o he 20 i ems in
each subscale. The sco es o each subscale ange om
20 o 80. The scale demons a ed a high le el o in e nal
consis ency, wi h a ange o 0.86 o 0.95, as epo ed by
Spielbe ge e al. The es - e es eliabili y o he scale
was assessed o e 2 mon hs, yielding a ange o 0.65 o
0.75. The cons uc alidi y o he scale was deemed
sa is ac o y [15]. Abdoli e al. (2020) assessed he
eliabili y and alidi y o he Pe sian e sion o he
Spielbe ge S a e-T ai Anxie y In en o y (STAI) using
a g oup o 492 s uden s. The scale demons a ed s ong
in e nal consis ency, wi h C onbach's alpha coe icien s
o 0.88 o ai anxie y and 0.84 o s a e anxie y. To
e alua e he cons uc alidi y, we conduc ed a
compa a i e analysis be ween he STAI and he Beck
Anxie y In en o y. The compa ison esul ed in
C onbach's alpha coe icien s o 0.64 o bo h ai and
s a e anxie y [16]. The s udy assessed he eliabili y o
he scale, esul ing in a coe icien o 0.89.
Pa ien Heal h Ques ionnai e-9 (PHQ-9) con ains nine
i ems, each o which add esses one o he symp oms o
dep es-sion acco ding o DSM c i e ia [Diagnos ic and
S a is i-cal Manual o Men al Diso de s]. One o he
mos eliable ools o disco e ing dep ession in ch onic
diseases is PHQ-9. The i ems a e sco ed on a 3-poin
Like scale, anging om always [3] o ne e [0]. The
o al sco es ange be ween 0 and 27. A sco e o unde 5
indica es he absence o dep ession; mild dep ession is
ep esen ed by sco es anging om 5 o 9; mode a e
dep ession co esponds o sco es om 10 o 14; and
se e e dep ession is iden i ied by sco es abo e 15.
Cons uc alidi y o PHQ-9 has been con i med by
Zui ho e al. The eliabili y o his scale is suppo ed by
an ICC o 0.88 and a es - e es co ela ion o = 0.94
[17].
Addi ionally, he alidi y and eliabili y o he Pe sian
e sion o PHQ-9 ha e been con i med by Dad a e al.
The o al sco e o his e sion anges om 0 o 27. To
ensu e he eliabili y o he scale, In aclass Co ela ion
Coe icien (ICC) and es - e es analyses we e
conduc ed, esul ing in alues o 0.88 and 0.79,
espec i ely. E alua ion o he con e gen alidi y o he
ques ionnai e esul ed in 0.7 wi h he b ie e sion o he
Beck Dep ession In en o y-13 (BDI-13) and −0.35 wi h
he Wo ld Heal h O ganiza ion Well-Being Index
(WHO5). Con i ma o y ac o analysis p o ed he good
i o he da a: CFI=-0.94, TLF = 0.93, and RMSEA =
0.069 [18]. The eliabili y o he scale was ob ained a
0.84 in he p esen s udy. Academic sa is ac ion scale
was de eloped by A ashka e al. [19] in I an. I consis s
o 20 i ems ha ho oughly e alua e s uden s'
pe cep ions ega ding hei mo i es o selec ing hei
majo , as well as hei academic, p o essional, and
inancial p ospec s. The i ems a e sco ed wi h a i e-
poin Like scale, anging om 1 o 5. The o al sco e
on his scale anges om 20 o 100 poin s. Fi e expe s
con i med he con en alidi y o he ques ionnai e.
Finally, he Con en Validi y Ra io (CVR) was
de e mined o be 0.87, while he con en alidi y index
(CVI) was measu ed a 0.88. The scale was ound o be
eliable, wi h a C onbach's alpha coe icien o 0.89 [19].
Addi ionally, he esea che s adminis e ed he scale o a
sample o 30 s uden s o assess i s eliabili y, yielding a
C onbach's alpha coe icien o 0.84.
Da a collec ion me hods
A e ob aining pe mission om he dean o each nu sing
school, he esea che wen o he educa ion depa men
a he espec i e ins i u ions. The e, a comp ehensi e lis
o all unde g adua e s uden s om Semes e 2 o
Semes e 8, as well as pos g adua e s uden s om
Semes e 1 o Semes e 4, was ob ained. Following his,
a subse o s uden s who me he speci ied c i e ia was
andomly selec ed using a able o numbe s gene a ed by
SPSS. The selec ed s uden s we e gi en an en elope
con aining in o ma ion abou he s udy's objec i es, an
in o med consen o m, and sel - epo ques ionnai es.
In addi ion, he s uden s we e in o med ace- o- ace
abou he s udy's goals and asked o comple e he
ques ionnai es i hey we e willing o pa icipa e
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58 Jou nal o Medical Educa ion De elopmen ¦ Volume 18 ¦ Issue 2 ¦ 2025
manually. The su eys we e dis ibu ed and collec ed
manually. This s udy was ca ied ou on a na ional le el
and ecei ed app o al om he I anian Biomedical
E hics Commi ee.
Addi ionally, all necessa y pe missions om he ele an
uni e si y we e ob ained. Be o e dis ibu ing he su eys
manually, we ensu ed ha he deans o each nu sing
school secu ed he app op ia e pe mi s.
To main ain he eliabili y and accu acy o he da a, he
co esea che was gi en explici ins uc ions o adhe e
s ic ly o a s anda dized me hodology du ing bo h he
da a collec ion and he andom sampling p ocesses.
Fu he mo e, o minimize he isk o social desi abili y
bias, pa icipan s we e in o med abou he s udy's
objec i es and assu ed ha hei esponses would emain
anonymous, wi h all da a kep con iden ial h oughou
he s udy.
Da a analysis
The da a analysis was pe o med using SPSS e sion
26.0. F equencies and means we e epo ed o
summa ize he da a.
The ela ionships among he a iables we e assessed
using Pea son co ela ion coe icien s. The - alues we e
in e p e ed as ollows: an - alue o 0 indica ed no
co ela ion, alues be ween 0 and 0.4 ep esen ed weak
co ela ion, alues be ween 0.4 and 0.8 indica ed
mode a e co ela ion, and alues om 0.8 o 1 showed a
s ong linea co ela ion.
The media ion analysis was conduc ed using he
PROCESS mac o ( e sion 4.2) de eloped by Hayes.
Model 4 was u ilized o assess he indi idual media ing
e ec o each psychological a iable (anxie y and
dep ession), while Model 6 was employed o e alua e he
sequen ial (se ial) media ion e ec s when bo h media o s
we e analyzed simul aneously.
S a is ical signi icance was es ablished a a h eshold o
p < 0.05.
Resul s
In his s udy, 1695 nu sing s uden s pa icipa ed. The
mean age o he nu sing s uden s was 22.41 yea s (SD =
2.98). Mos o he subjec s we e emale (n = 1046,
61.7%), and he o he s we e male. In addi ion, 1476
(87.1%) nu sing s uden s we e single, and he o he s
(12.9%) we e ma ied. O he cha ac e is ics a e indica ed
in Table 1.
The mean sco es o academic pe o mance and
sa is ac ion in nu sing s uden s we e 16.02 (SD = 1.19)
and 53.24 (SD = 7.47), espec i ely.
Table 1. Demog aphic and academic cha ac e is ics o
nu sing s uden s
Va iables
n (%)
Gende
Female
1046 (61.7)
Male
649 (38.3)
Ma i al s a us
Single
1476 (87.1)
Ge ma ied
219 (12.9)
Fa he ’s educa ion
Academic educa ion
500 (29.5)
High school and diploma
786 (46.4)
Seconda y and p ima y School
345 (20.4)
illi e a e
64 (3.7)
Mo he ’s educa ion
Academic educa ion
455 (26.8)
High school and diploma
727 (42.9)
Seconda y and p ima y school
398 (23.5)
illi e a e
115 (6.8)
Li ing place
Do mi o y
986 (58.2)
Li ing wi h amily
672 (39.6)
Indi idual house
37 (2.2)
Abb e ia ions: n, numbe o pa icipan s; %, pe cen age.
The mean sco es o nu sing s uden s' dep ession and
anxie y we e 8.74 (SD = 4.71) and 88.63 (SD = 17.00),
espec i ely. The mean sco es o s a e and ai anxie y
we e 44.37 (SD = 8.74) and 44.25 (SD = 8.99),
espec i ely. As Figu es 1 and 2 show, app oxima ely
hal o nu sing s uden s epo ed mode a e le els o s a e
and ai anxie y. Table 2 displays a signi ican , posi i e,
and weak associa ion be ween he mean sco e o nu sing
s uden s' academic pe o mance and academic
sa is ac ion ( = 0.11, p < 0.001). Fu he mo e, a
signi ican , nega i e, and weak associa ion was
iden i ied be ween he mean sco es o nu sing s uden s'
academic pe o mance and hei le els o dep ession ( =
-0.09, p < 0.001) as well as anxie y ( = - 0.10, p < 0.001).
Acco ding o Table 3, he di ec e ec o nu sing
s uden s' academic sa is ac ion signi ican ly co ela ed
wi h hei academic pe o mance (b = 0.01, - alue =
4.26, p- alue <0.001). The nu sing s uden s's uden s'
dep ession co ela ed signi ican ly wi h hei academic
pe o mance (b = - 0.02, - alue = - 3.27, p- alue =
0.001). The indi ec e ec o nu sing s uden s' academic
sa is ac ion on academic pe o mance by dep ession was
signi ican (E ec = 0.001, Boo SE = 0.0006, 95% CI:
0.0005 o 0.002). This model showed ha nu sing
s uden s' academic sa is ac ion and dep ession accoun ed
o 1.8% o he a iance in academic pe o mance (R =
0.13, R² = 0.018, MSE = 1.39, F = 16.27, p- alue <
0.001).
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: Rela ion anxie y and dep ession wi h academic sa is ac ion and academic pe o mance
Jou nal o Medical Educa ion De elopmen ¦ Volume 18 ¦ Issue 2 ¦ 2025 59
Figu es 1. The pe cen age o s a e anxie y in nu sing s uden s
Figu es 2. The pe cen age o ai anxie y in nu sing s uden s
Table 2. The associa ion among nu sing s uden s’ academic pe o mance, sa is ac ion, dep ession, and anxie y
Va iables
Academic pe o mance
Academic sa is ac ion
Dep ession
Anxie y
Academic pe o mance
Pea son Co ela ion
1
Sig. (2- ailed)
Academic sa is ac ion
Pea son Co ela ion
0.11**
1
Sig. (2- ailed)
< 0.001
Dep ession
Pea son Co ela ion
- 0.09**
- 0.11**
1
Sig. (2- ailed)
< 0.001
< 0.001
Anxie y
Pea son Co ela ion
- 0.10**
- 0.15**
0.43**
1
Sig. (2- ailed)
< 0.001
< 0.001
< 0.001
No e: Pea son co ela ion coe icien was used o assess he linea ela ionship be ween a iables.
Abb e ia ions: Sig, s a is ical signi icance; p, p obabili y alue.
**. Co ela ion is signi ican a he 0.01 le el (2- ailed)
No, o Less
6.2%
Mild
33.0%
Mode a e
49.0%
Se e e
11.7%
Nu sing s uden s s a e anxie y
No, o Less
13.7%
Mild
35.4%
Mode a e
45.0%
Se e e
5.8%
Nu sing s uden s ai anxie y
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60 Jou nal o Medical Educa ion De elopmen ¦ Volume 18 ¦ Issue 2 ¦ 2025
Table 3. The media ing e ec o nu sing s uden s’ dep ession in he ela ionship be ween academic sa is ac ion and pe o mance
E ec ()
SE
S a is ics
P-Values
95% CI
Di ec e ec
Academic sa is ac ion Academic pe o mance
0.01
0.003
4.26
< 0.001
0.008 o 0.02
Dep ession  Academic pe o mance
- 0.02
0.006
- 3.27
0.001
- 0.03 o - 0.008
Academic sa is ac ion  Dep ession
- 0.07
0.01
- 4.83
< 0.001
0.10 o - 0.04
Indi ec e ec s
Academic sa is ac ion  Dep ession  Academic
pe o mance
0.001
0.0006 a
----
----
0.0005 o 0.002
No e: -s a is ic was used o assess he a io be ween he de ia ion o an es ima ed alue om i s hypo hesized alue and i s s anda d e o .
Abb e ia ions: β, s anda dized eg ession coe icien ; SE, S anda d E o ; a Boo s apping S anda d E o ; Sig, s a is ical signi icance; p, p obabili y- alue; 95% CI, A
95% Con idence In e al.
Acco ding o Table 4, nu sing s uden s' academic
sa is ac ion signi ican ly co ela ed wi h hei academic
pe o mance (b = 0.01, - alue = 4.05, p- alue = 0.0001).
The s uden s's uden s' anxie y signi ican ly co ela ed
wi h hei academic pe o mance (b = -0.006, - alue = -
3.70, p- alue = 0.002). The indi ec e ec o nu sing
s uden s' academic sa is ac ion on academic pe o mance
by anxie y was signi ican (E ec = 0.002, Boo SE =
0.008, 95% CI 0.0009 o 0.003). This model indica ed
ha nu sing s uden s' academic sa is ac ion and anxie y
accoun ed o 2% o hei academic pe o mance (R =
0.14, R2 = 0.02, MSE = 1.39, F = 17.82, p- alue <
0.001). The e o e, based on he indings, nu sing
s uden s's uden s' anxie y media es he ela ionship
be ween academic sa is ac ion and pe o mance.
The esul s o his s udy showed = 0.15, squa e = 0.02,
MSE = 1.39, F = 13.07, and p < 0.001. As Table
5 shows, nu sing s uden s' academic sa is ac ion
signi ican ly co ela ed wi h academic pe o mance (b =
0.01, = 3.94, p = 0.0001). Dep ession was co ela ed
wi h nu sing s uden s's uden s' academic pe o mance (b
= -0.01, = -1.88, p = 0.04). Mo eo e , anxie y was
co ela ed wi h nu sing s uden s's uden s' academic
pe o mance (b = -0.004, = -2.56, p = 0.01).
As Table 4 displays, he ela ionship be ween nu sing
s uden s' academic sa is ac ion and academic
pe o mance was signi ican ly media ed by dep ession (b
= 0.002, CI = 0.001 o 0.004). In addi ion, he
ela ionship be ween nu sing s uden s' academic
sa is ac ion and academic pe o mance was signi ican ly
media ed by hei anxie y (b=0.0009, CI = 0.00001 o
0.002). Mo eo e , as can be seen in Table 4, he
ela ionship be ween nu sing s uden s' academic
sa is ac ion and academic pe o mance was signi ican ly
media ed by hei dep ession and anxie y (b = 0.0005, CI
= 0.0001 o 0.001).
Table 4. The media ing e ec o nu sing s uden s’ anxie y in he ela ionship be ween academic sa is ac ion and pe o mance
E ec ()
SE
S a is ics
P-Values
95% CI
Di ec e ec
Academic sa is ac ion  academic
pe o mance
0.01
0.003
4.05
0.0001
0.008 o 0.02
Anxie y  Academic pe o mance
- 0.006
0.001
- 3.70
0.002
- 0.009 o - 0.003
Academic sa is ac ion  Anxie y
- 0.34
0.05
- 6.40
< 0.001
- 0.45 o - 0.24
Indi ec e ec s
Academic sa is ac ion  Anxie y 
Academic pe o mance
0.002
0.0008 a
----
----
0.0009 o 0.003
No e: -s a is ic was used o assess he a io be ween he de ia ion o an es ima ed alue om i s hypo hesized alue and i s s anda d e o .
Abb e ia ions: β, s anda dized eg ession coe icien ; SE, S anda d E o ; a Boo s apping S anda d E o ; Sig, s a is ical signi icance; p, p obabili y- alue; 95% CI, A
95% Con idence In e al.
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Yadollahi e al
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Jou nal o Medical Educa ion De elopmen ¦ Volume 18 ¦ Issue 2 ¦ 2025 61
Table 5. The media ing e ec o nu sing s uden s’ dep ession and anxie y in he ela ionship be ween academic sa is ac ion and
pe o mance
E ec ()
SE
S a is ics
P-Values
95% CI
Di ec e ec
Academic sa is ac ion  Academic
pe o mance
0.01
0.003
3.94
0.0001
0.007 o 0.02
Dep ession  Academic
pe o mance
- 0.01
0.006
- 1.88
0.04
0.00001 o 0.0005
Anxie y  Academic pe o mance
- 0.004
0.001
- 2.56
0.01
- 0.008 o -0.001
Academic sa is ac ion 
Dep ession
- 0.07
0.01
- 4.83
< 0.001
- 0.10 o -0.04
Academic sa is ac ion  Anxie y
- 0.23
0.04
- 4.76
< 0.001
- 0.33 o -0.13
Dep ession  Anxie y
1.52
0.07
19.26
< 0.001
1.36 o 1.67
Indi ec e ec s
Academic sa is ac ion 
Dep ession  Academic
pe o mance
0.002
0.0008 a
----
----
0.001 o 0.004
Academic sa is ac ion  Anxie y
 Academic pe o mance
0.0009
0.0005 a
----
----
0.0001 o 0.002
Academic sa is ac ion 
Dep ession  Anxie y 
Academic pe o mance
0.0005
0.0003 a
----
----
0.0001 o 0.001
No e: -s a is ic was used o assess he a io be ween he de ia ion o an es ima ed alue om i s hypo hesized alue and i s s anda d e o .
Abb e ia ions: β, s anda dized eg ession coe icien ; SE, s anda d e o ; a, boo s apping s anda d e o ; Sig, s a is ical signi icance; p, p obabili y alue; 95% CI, a
95% con idence in e al.
Discussion
In he p esen s udy, 1965 nu sing s uden s pa icipa ed.
They had mild dep ession, and app oxima ely hal o
hem had mode a e le els o s a e and ai anxie y. In
line wi h his s udy, Jamil e al. showed hal o he
nu sing s uden s who pa icipa ed in his s udy had
anxie y and dep ession[20]. Howe e , Alou i e al. Based
on a sys ema ic e iew o 44 s udies epo ed a
s a is ically signi ican educ ion in he s ess, anxie y, o
dep ession expe ienced by nu sing s uden s. This inding
can be in luenced by a ious ac o s, including
indi idual, socio-cul u al, and psychological ac o s, as
well as hei ela ionship wi h p o esso s [21].
O he indings o his s udy showed nu sing s uden s'
academic sa is ac ion signi ican ly co ela ed wi h hei
academic pe o mance. In o he wo ds, a high sco e in
academic sa is ac ion assis ed wi h a high sco e in
academic pe o mance, while Mahda i e al. indica ed
s uden s' sa is ac ion and achie emen we e no
signi ican ly co ela ed [22]. Di e en easons, including
cul u al di e ences among s uden s, he quali y o
uni e si y se ices, in e ac ion wi h acul y, and he
o ganiza ion o cou ses, can con ibu e o his
dissa is ac ion. Despi e his inding, academic
sa is ac ion and us in he sys em a e c ucial ac o s ha
adminis a o s mus no o e look. The p esen s udy
e ealed a signi ican media o ole o dep ession
be ween academic sa is ac ion and pe o mance. In o he
wo ds, high dep ession sco es in nu sing s uden s led o
a nega i e ela ionship be ween academic sa is ac ion
and hei pe o mance. The esul s o se e al s udies
align wi h his issue. Ha ison e al. indica ed ha
dep ession symp oms signi ican ly p edic ed academic
p og ession delay [23]. Addi ionally, he indings o
Vishakha e al.'s esea ch, which aimed o de e mine he
impac o men al heal h on academic pe o mance,
highligh ed ha while some s uden s e ec i ely cope
wi h s ess and challenges, o he s may s uggle,
ul ima ely nega i ely a ec ing hei academic
pe o mance, in some cases, leading o in e up ions in
hei s udies [24]. Since men al heal h dis u bances lead
o dissa is ac ion and disachie emen in educa ional
se ings, iden i ying he cogni i e ac o s ha induce his
discom o and add essing hem can be e ec i e in
assessing academic achie emen . In his s udy, i was
ound ha nu sing s uden s' anxie y media ed he
ela ionship be ween academic sa is ac ion and
pe o mance. This inding aligns wi h Lisnyj e al.'s
esul s, which epo ha anxie y nega i ely impac s
s uden s' educa ional ou comes, including poo academic
pe o mance and s uden a i ion [25]. Nume ous
in e nal and ex e nal ac o s induce anxie y. E idence
indica es ha anxie y can lead o subpa pe o mance,
while a his o y o inadequa e pe o mance may cause
anxie y. These wo pa ame e s exhibi a bidi ec ional
link o syne gis ic e ec [20]. Iden i ying and managing
hese ac o s can help educe anxie y, leading o
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Yadollahi e al
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: Rela ion anxie y and dep ession wi h academic sa is ac ion and academic pe o mance
62 Jou nal o Medical Educa ion De elopmen ¦ Volume 18 ¦ Issue 2 ¦ 2025
imp o ed academic pe o mance. The main inding o
his s udy was he signi ican media o ole o nu sing
s uden s' dep ession and anxie y in academic sa is ac ion
and pe o mance. The e o e, high sco es in bo h
dep ession and anxie y o nu sing s uden s a e associa ed
wi h low sco es in academic sa is ac ion and
pe o mance. In line wi h his inding, Ha ison e al. and
Jamil e al. indica ed ha como bid psychological
dis ess such as anxie y and dep ession would esul in
inc eased le els o incompe ence in academic asks han
hose who ha e only one o hem [20‚23]. Some
esea che s belie e ha academic dissa is ac ion in
nu sing s uden s can in luence no only hei pe sonal
well-being and academic pe o mance bu also hei
communica ion wi h pa ien s du ing clinical placemen
and he quali y and sa e y o he heal hca e hey deli e
[12]. I seems ha he c ea ion o an educa ional
en i onmen cha ac e ized by hope, happiness, a en ion
o s uden 's expec a ions and needs, p o essional
quali ica ions, inno a ion, and he app op ia eness o
educa ional cu icula o he p o essional p ac ice
en i onmen leads o a educ ion in dis ess beha io s,
such as dep ession and anxie y, and ul ima ely imp o es
academic sa is ac ion and academic pe o mance. Some
s udies ha e indica ed ha academic dissa is ac ion and
poo pe o mance can lead o academic bu nou ,
esul ing in a loss o con idence and emo ional p oblems,
such as academic exhaus ion. In he u u e, his issue will
likely in e e e wi h job p epa a ion, he ans e o
p o essional oles, socializa ion, and job sa is ac ion
[26].One o he limi a ions o he p esen s udy was he
pe sonal, amilial, cul u al, and social di e ences
be ween he nu sing s uden s, which may ha e a ec ed
he s udy's esul s. Addi ionally, ac o s such as si ing
ime, main aining p ope pos u e while si ing, academic
semes e , and he use o assis i e de ices du ing eading
a he uni e si y we e no conside ed in he p esen s udy.
Since co ela ional designs don' de e mine he cause and
e ec o a iables, longi udinal o in e en ional s udies
should in es iga e he e ec o anxie y and dep ession on
academic pe o mance in nu sing s uden s. Addi ionally,
esea ch should be conduc ed using quali a i e me hods
o gain a deepe unde s anding o he ac o s ha
in luence academic pe o mance.
Conclusion
This s udy indica es ha nu sing s uden s' dep ession and
anxie y ha e a cen al ole in he ela ionship be ween
academic sa is ac ion and academic pe o mance. While
some s udies indica ed ha s uden s' sa is ac ion and
achie emen we e no signi ican ly co ela ed, o he
indings, as well as he p esen esea ch, co obo a e
e idence o he ela ion be ween hese a iables.
The e o e, i is possible o enhance academic sa is ac ion
and pe o mance by iden i ying and add essing ac o s
ha con ibu e o anxie y and dep ession. Addi ionally,
p o iding e ec i e eaching me hods, ensu ing
p o essional quali ica ions, os e ing inno a ion, and
aligning educa ional cu icula wi h he p o essional
p ac ice en i onmen can s imula e s uden s o be c i ical
and e lec i e hinke s. I is necessa y o emphasize he
impo ance o men al heal h suppo in academic
se ings. The e o e, adminis a o s need o con inuously
examine quali a i e and quan i a i e e alua ion
p ocesses h ough obse a ion, eedback, and e lec ion
and de elop p ope in e ac ion wi h nu sing s uden s o
imp o e educa ional ou comes.
E hical conside a ions
The p esen s udy has been app o ed by he E hics
Commi ee o Shi az Uni e si y o Medical Sciences
(IR.SUMS.REC.1397.52), and ele an guidelines and
egula ions pe o med all me hods. In o med consen
was aken om pa icipan s be o e pa icipa ion. All he
nu sing s uden s we e in o med abou he objec i es o
he s udy and subsequen ly asked o ill ou he in o med
consen o m. The s uden s we e assu ed o anonymi y
and con iden iali y ega ding hei in o ma ion. The
s udy p ocedu es adhe ed o he p inciples ou lined in he
Decla a ion o Helsinki.
A i icial in elligence u iliza ion o a icle
w i ing
The u iliza ion o a i icial in elligence in he p ocess o
a icle edi ing was ca ied ou wi h s ic adhe ence o
e hical p inciples and guidelines, ensu ing anspa ency,
in eg i y, and he p ese a ion o o iginal hough .
Acknowledgmen
This a icle is he esul o a esea ch p ojec egis e ed
a Shi az Uni e si y o Medical Sciences, Shi az, I an
(no. 13666). The au ho s would like o exp ess hei
g a i ude o all he nu sing s uden s who pa icipa ed in
his s udy.
Con lic o in e es s a emen
The au ho (s) decla ed no po en ial con lic s o in e es
o he esea ch, au ho ship, and/o publica ion o his
a icle.
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Yadollahi e al
.
: Rela ion anxie y and dep ession wi h academic sa is ac ion and academic pe o mance
Jou nal o Medical Educa ion De elopmen ¦ Volume 18 ¦ Issue 2 ¦ 2025 63
Au ho con ibu ions
PY and M SH a e esponsible o he s udy design and
in e p e a ion o da a, d a ing and e ising he a icle
c i ically, and app o ing he e sion o be
published.MS aided in da a analysis da a, and ZJ aided
in c i ical e ision o he inal manusc ip . All au ho s
ead and app o ed he inal manusc ip .
Funding
The au ho (s) ecei ed no inancial suppo o he
esea ch, au ho ship, and publica ion o his a icle.
Da a a ailabili y s a emen
All da a gene a ed o analyzed du ing his s udy a e
included in his published a icle.
Re e ences
1. Awadalla S, Da ies EB, Glazeb ook C. A longi udinal
coho s udy o explo e he ela ionship be ween
dep ession, anxie y and academic pe o mance among
Emi a i uni e si y s uden s. BMC Psychia y.
2020;20:1-10. [h ps://doi.o g/10.1186/s12888-020-
02854-z]
2. Campos JN. S ess expe iences and ou comes in
di e se college s uden s: applying he s ess p ocess
model [disse a ion]. Cali o nia S a e Uni e si y,
Sac amen o; 2022.
[h ps://hdl.handle.ne /20.500.12741/ ep:2777]
3. Li W, Zhao Z, Chen D, Peng Y, Lu Z. P e alence and
associa ed ac o s o dep ession and anxie y symp oms
among college s uden s: a sys ema ic e iew and me a
analysis. Jou nal o Child Psychology and Psychia y.
2022;63(11):1222-30.
[h ps://doi.o g/10.1111/jcpp.13606]
4. Zheng Yx, Jiao JR, Hao WN. P e alence o s ess
among nu sing s uden s: a p o ocol o sys ema ic e iew
and me a-analysis. Medicine. 2022;101(31):e29293.
[h ps://doi.o g/10.1097/MD.0000000000029293]
5. Naeem I, Apa icio-Ting FE, Dyju P. S uden s ess
and academic sa is ac ion: a mixed me hods explo a o y
s udy. In e na ional Jou nal o Inno a ion and Business
S a egy. 2020;6:388-95.
[h ps://doi.o g/10.20533/ijibs.2046.3626.2020.0050]
6. Junaid M, Au AI, Shaikh K, Khan N, Abdel ahim SA.
Co ela ion be ween academic pe o mance and anxie y
in medical s uden s o Majmaah uni e si y–KSA.
Jou nal o he Pakis an Medical Associa ion.
2020;70(5):865-8.
[h ps://doi.o g/10.5455/JPMA.19099]
7. Mohammadi B, Jamshidi K, Ami i SM, Pou sabe i R.
The in luen ial ac o s in s uden s' sa is ac ion wi h
Ke manshah uni e si y o medical sciences, I an (2015-
2016). Educa ional Resea ch in Medical Sciences.
2021;10(1). [h ps://doi.o g/10.5812/e ms.115893]
8. Gao L, Xie Y, Jia C, Wang W. P e alence o
dep ession among Chinese uni e si y s uden s: a
sys ema ic e iew and me a-analysis. Scien i ic Repo s.
2020;10(1):15897. [h ps://doi.o g/10.1038/s41598-020-
72998-1]
9. Abela JZ, D’Alessand o DU. Beck’s cogni i e heo y
o dep ession: a es o he dia hesis-s ess and causal
media ion componen s. B i ish Jou nal o Clinical
Psychology. 2002;41:111-28.
[h ps://doi.o g/10.1348/014466502163912]
10. Wunsch K, Fiedle J, Bache P, Woll A. The
idi ec ional ela ionship among physical ac i i y,
s ess, and academic pe o mance in uni e si y s uden s:
a sys ema ic e iew and me a-analysis. In e na ional
Jou nal o En i onmen al Resea ch and Public Heal h.
2021;18(2):739.
[h ps://doi.o g/10.3390/ije ph18020739]
11. Jamil H, Alakka i M, Al-Mahini MS, Alsayid M, Al
Jandali O. The impac o anxie y and dep ession on
academic pe o mance: a c oss-sec ional s udy among
medical s uden s in Sy ia. A icenna Jou nal o
Medicine. 2022;12(3):111-9. [h ps://doi.o g/10.1055/s-
0042-1755181]
12. Ba is a RS, San os MD, Melo EC, Mo ei a RC,
Ma ins JT, Galdino MQ. Bu nou and academic
sa is ac ion o nu sing s uden s in adi ional and
in eg a ed cu icula. Jou nal o School o Nu sing –
Uni e si y o São Paulo. 2021;9(55):3713.
[h ps://doi.o g/10.1590/S1980-220X2020002003713]
13. Gus a sson JE, Ma enson R. Hands-on app oach o
s uc u al equa ion modeling. PsycCRITIQUES.
2002;47(4). [h ps://doi.o g/10.1515/9783110687279-
004]
14. Shaygan M, Teh aninesha B, Teshnizi SH,
Mohammadi A. The p edic ing ac o s o ch onic pain
among nu sing s uden s: a na ional s udy in I an. BMC
Psychology. 2024;12(1):297.
[h ps://doi.o g/10.1186/s40359-024-01803-9]
15. Spielbe ge CD. S a e ai anxie y in en o y o
adul s: sample se : manual, es , sco ing key; [ o m Y];
STAIS-AD. Mind Ga den; 1983.
[h ps://doi.o g/10.1037/ 06496-000]
16. Abdoli N, Fa nia V, Salemi S, e al. Reliabili y and
alidi y o Pe sian e sion o s a e- ai anxie y in en o y
among high school s uden s. Eas Asian A chi es o
Psychia y. 2020;30(2):44-7.
[h ps://doi.o g/10.12809/eaap1870]
17. Zui ho NP, e al. The Pa ien Heal h Ques ionnai e-
9 o de ec ion o majo dep essi e diso de in p ima y
ca e: consequences o cu en h esholds in a c oss-
sec ional s udy. BMC Family P ac ice. 2010;11:1–7.
[h ps://doi.o g/10.1186/1471-2296-11-98]
18. Dad a M, Kaliba se a Z, Les e D. Con iabilidade e
alidade da e são pe sa do pa ien heal h ques ionnai e-
9 (PHQ-9) em pacien es psiquiá icos ambula o iais
i anianos. T ends Psychia y Psycho he . 2018;40:144-
51. [h ps://doi.o g/10.1590/2237-6089-2017-0116]
[ DOI: 10.61882/edcj.18.2.55 ] [ Downloaded om edujou nal.zums.ac.i on 2025-10-03 ]
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