Coping strategies and factors of post-pandemic suicidal ideation among nursing students

Estrategias de afrontamiento y factores de la ideación suicida pospandémica en estudiantes de enfermería

ABSTRACT

Objectives:  to analyze the association between sociodemographic factors, professional future prospects, academic performance, workload overload, non-suicidal self-harm, depression, coping strategies, and suicidal ideation post-COVID-19 pandemic among nursing students.

Methods:  a cross-sectional study conducted with 120 nursing students from a Brazilian public university. Poisson regression with robust and adjusted variance was used.

Results:  LGBTQIAPN+ students were three times more likely (OR=2.98) to have suicidal ideation; students who did not perceive changes in academic performance after the pandemic were 16 times more likely (OR=15.68) to have suicidal ideation; and students who did not experience non-suicidal self-harm were five times more likely (OR=5.31) to have suicidal ideation.

Conclusions:  LGBTQIAPN+ nursing students who did not perceive the impact of the pandemic on academic performance and did not experience non-suicidal self-harm were more vulnerable to suicidal ideation.

Descriptors:
Mental Health; Nursing Students; COVID-19; Suicidal Ideation; Coping Strategies

RESUMO

Objetivos:  analisar a associação entre fatores sociodemográficos, perspectiva de futuro profissional, rendimento acadêmico, sobrecarga da rotina, autolesão não suicida, depressão, estratégias de enfrentamento e ideação suicida pós-pandemia de COVID-19 em estudantes de enfermagem.

Métodos:  estudo transversal realizado com 120 estudantes de enfermagem de universidade pública brasileira. Empregou-se a regressão de Poisson com variância robusta e ajustada.

Resultados:  estudantes LGBTQIAPN+ apresentaram três vezes mais chance (OR=2,98) de ter ideação suicida; estudantes que não perceberam mudanças do rendimento escolar após a pandemia apresentaram 16 vezes mais chance (OR=15,68) de ter ideação suicida; e estudantes que não tinham autolesão não suicida apresentaram cinco vezes mais chance (OR=5,31) de ter ideação suicida.

Conclusões:  os estudantes de enfermagem LGBTQIAPN+ que não perceberam o impacto da pandemia no rendimento escolar e não tiveram autolesão não suicida apresentaram maior vulnerabilidade para a presença de ideação suicida.

Descritores:
Saúde Mental; Estudantes de Enfermagem; COVID-19; Ideação Suicida; Estratégias de Coping

RESUMEN

Objetivos:  analizar la asociación entre factores sociodemográficos, perspectivas profesionales futuras, rendimiento académico, sobrecarga de trabajo, autolesiones no suicidas, depresión, estrategias de afrontamiento e ideación suicida tras la pandemia de COVID-19 en estudiantes de enfermería.

Métodos:  estudio transversal realizado con 120 estudiantes de enfermería de una universidad pública brasileña. Se utilizó una regresión de Poisson con varianza robusta y ajustada.

Resultados:  el alumnado LGBTQIAPN+ tuvo tres veces más probabilidades (OR=2,98) de tener ideación suicida; el alumnado que no percibió cambios en su rendimiento académico tras la pandemia tuvo 16 veces más probabilidades (OR=15,68) de tener ideación suicida; y el alumnado que no experimentó autolesiones no suicidas tuvo cinco veces más probabilidades (OR=5,31) de tener ideación suicida.

Conclusiones:  el alumnado de enfermería LGBTQIAPN+ que no percibió el impacto de la pandemia en su rendimiento académico ni experimentó autolesiones no suicidas fue más vulnerable a la ideación suicida.

Descriptores:
Salud Mental; Estudiantes de Enfermería; COVID-19; Ideación Suicida; Estrategias de Afrontamiento

INTRODUCTION

The COVID-19 pandemic, caused by the SARS-CoV-2 coronavirus, brought global challenges to public health, including financial and psychosocial implications, with a focus on mental health and well-being in the post-COVID era(¹). This study examines nursing students’ mental health, specifically, the phenomenon of suicidal ideation and the possible repercussions of the pandemic, because this population is considered at risk for suicidal behavior(²,³). In this context, coping strategies become essential for nursing students to adapt to the academic, social, and emotional changes intensified by the pandemic.

Coping strategies act as mediators in the relationship between core competencies and academic frustration(⁴). Students with effective coping strategies experience lower levels of academic frustration; however, those with ineffective strategies tend to deal with their problems by lowering their expectations and self-limiting, which weakens their resilience, increases the use of inadequate resources to handle stressors, and impacts their mental health(⁴).

A meta-analysis focusing on various mental health conditions among nursing students worldwide found that depression was the most prevalent mental health issue in this population(⁵). A study involving Chinese university students identified that 7.7% exhibited emotional distress, and although suicide literacy reduced suicide stigma among health sciences students, it did not improve rates of seeking professional help(⁶). Attitudes toward suicide among Korean students indirectly affected non-suicidal self-injury (NSSI) behavior through depression(⁷).

In general, the prevalence of suicidal ideation among young university students ranges from 26% to 72%, with higher associations observed among LGBTQIAPN+ individuals and females(²,³,⁸). High levels of psychological pain and hopelessness have been linked to suicide risk among students in England(²).

The findings of this study may contribute new and relevant insights into the phenomenon of suicidal ideation among university students in Latin America. The knowledge generated can support suicide prevention programs in university educational environments, given the urgent need to promote safe spaces for mental health care among nursing students—who will become future nurses and work directly in the frontline of care for the Brazilian population, often facing situations that may worsen mental health and increase suicide risk.

Given the rapid overview presented, this study hypothesizes that: (1) the effects of the two years following the period of greatest social restriction during the pandemic have impacted students’ perception of routine overload, academic underperformance, and negative professional prospects, which directly influence the presence of suicidal ideation among nursing students; and (2) the presence of NSSI, depression, and emotion-focused coping strategies are directly associated with the presence of suicidal ideation among nursing students.

OBJECTIVES

To analyze the association between sociodemographic factors, professional future prospects, academic performance, routine overload, NSSI, depression, coping strategies, and suicidal ideation after the COVID-19 pandemic among nursing students at a public higher education institution in São Paulo, Brazil.

METHODS

Ethical aspects

The study was approved by the Higher Education Institution’s Research Ethics Committee. Ethical guidelines and procedures outlined in Resolution 466/12 of the Brazilian National Health Council were followed. All participants provided Informed Consent Form (ICF) through a digital signature. At the end of the electronic form, information was provided on how to seek help from mental health services available 24 hours a day.

Study design and place

The Federal Higher Education Institution selected as the setting for this study is located in São Paulo, Brazil. During the data collection period, from March to May 2023, it offered the following health-related programs: nursing, speech therapy, medicine, biomedicine, and health technology. The institution was chosen due to its historical significance, the quality of its education, and its contribution to Brazilian nursing.

Study protocol

This is a quantitative, cross-sectional study guided by the STrengthening the Reporting of OBservational studies in Epidemiology and Checklist for Reporting Results of Internet E-Surveys guidelines(⁹). Data collection included a sociodemographic characterization script and the Depression, Anxiety, and Stress Scale-21 (DASS-21) to assess students’ levels of depression, anxiety, and stress. The reliability of this instrument in Brazilian university students was α ≥ 0.70(¹⁰), and the Coping Strategies Inventory was used to assess the strategies used by participants. The psychometric properties of this instrument in Brazilian university students are excellent, with Cronbach’s alpha (α = 0.89)(¹¹), using the Columbia Suicide Risk Assessment Scale to assess aspects related to suicidal behavior. The reliability of this instrument is Cronbach’s alpha (α = 0.81)(¹²).

The study population included 282 university students. For the sample size calculation, a 95% confidence level, a 5% margin of error, and an estimated prevalence of suicidal ideation of 9.9%(¹³) were used, resulting in a sample size of 120 students. A convenience sampling method was applied. Inclusion criteria comprised being enrolled in a nursing program, being over 18 years of age, signing the ICF, and completing the questionnaire in full. Exclusion criteria comprised students who were absent from academic activities due to family/illness reasons or on institutional exchanges, and those who did not complete the questionnaire in full. No pre-test was administered.

Participants were invited through social media (WhatsApp^® and Instagram^®) and emails sent to classes through class representatives. Additionally, posters with QR codes were posted throughout the university’s physical facilities to provide access to the electronic form (created on the Google Forms^® platform), ensuring that academic activities were not disrupted. The mean time to complete the form was ten minutes.

Data analysis and statistics

Descriptive analysis was performed using mean and standard deviation, median, count, and percentage. Bivariate analyses used Fisher’s exact test or chi-square test for qualitative variables, in addition to the two-tailed unpaired Student’s t-test and the Mann-Whitney test. In cases where a statistically significant difference was observed, post-hoc analysis was performed with the z-test. The Statistical Package for the Social Sciences version 26.0 was used.

Suicidal ideation was considered the dependent variable. The following independent variables were included in the crude analyses: age; sex; sexual orientation; gender identity; marital status; race/ethnicity; living arrangement; employment status; student financial aid; personal income; family income; religion; mental disorder diagnosis during the pandemic; professional future prospects; academic performance; academic overload; NSSI; depressive symptom items from the DASS-21; and coping strategies with a p-value < 0.20.

In adjusted analysis 1, variables with p-values <0.15 were retained, and in adjusted analysis 2, only those with p-values <0.05 were included. The significance level adopted was 5%. In the multivariate analysis, using logistic regression, it was possible to simultaneously analyze multiple variables with all those that presented p-values <0.05 to list which ones would comprise the regression model. Thus, Poisson regression with robust and adjusted variance was used, estimating the Odds Ratio and its 95% Confidence Intervals.

To assess the quality of the regression model, multicollinearity indicators were verified through linear regression procedures using tolerance values and variance inflation factor (VIF). No multicollinearity was detected, as tolerance values were above 0.1 and VIF values were below 5, indicating model adequacy.

RESULTS

The majority of participants (65.83%) were between 21 and 30 years old, female (86.67%), heterosexual (66.67%), single (90%), living with their families (76.67%), with a monthly household income of two to four minimum wages (40.83%), without personal income (41.67%), and reported having a religion (64.17%). Noteworthy among the participants were those who identified as non-binary (0.9%), non-white (30.83%), employed (25%), and those receiving student financial aid (19.17%). These results highlight the need for mental health interventions targeting young adult women, who make up the majority of the program and are recognized as more vulnerable to suicidal ideation.

Concerning the association between sociodemographic factors and suicidal ideation among nursing students, a significant relationship was found between suicidal ideation and participants identifying as homosexual as well as those reporting a religion (Table 1).

Table 1
Differences in the association of suicidal ideation and sociodemographic factors among nursing students, São Paulo, São Paulo, Brazil, 2025

Variable	Category	Suicide ideation				p value
		Yes		No
		n	%	n	%
Sex	Female	59	56.73	45	43.27	0.424
	Male	11	68.75	5	31.25
Sexual orientation	Heterosexual	54	72.97	20	27.03	< 0.001 *
	Homosexual	16	34.78	30	65.22
Gender identity	Cisgender man	12	75.00	4	25.00	0.136
	Cisgender woman	58	56.31	45	43.69
	Nonbinary	0	0.00	1	100.00
Marital status	Single	62	57.41	46	42.59	> 0.999
	Married	4	66.67	2	33.33
	Divorced	1	100.00	0	0.00
	Others	3	60.00	2	40.00
Race	White	48	57.83	35	42.17	> 0.999
	Nonwhite	22	59.46	15	40.54
Who do you live with?	Family	56	60.87	36	39.13	0.727
	Student co-op	5	50.00	5	50.00
	Alone	5	55.56	4	44.44
	Others	4	44.44	5	55.56
Work	Yes	18	60.00	12	40.00	> 0.999
	No	52	57.78	38	42.22
Do you receive student aid?	Yes	12	52.17	11	47.83	0.639
	No	58	59.79	39	40.21
Personal income	Undergraduate research scholarship	13	56.52	10	43.48	0.484
	Extension scholarship	8	72.73	3	27.27
	Student assistance grant	3	33.33	6	66.67
	Others	15	55.56	12	44.44
	Without	31	62.00	19	38.00
Religion	Without religion	17	39.53	26	60.47	0.002 *
	With religion	53	68.83	24	31.17
Age	18 to 20	16	44.44	20	55.56	0.087
	21 to 30	51	64.56	28	35.44
	31 to 40	1	50.00	1	50.00
	41 to 50	1	50.00	1	50.00
	> 50	1	100.00	0	0.00
Family income	Until 1 MW	6	46.15	7	53.85	0.916
	From 2 to 4 MWs	32	65.31	17	34.69
	From 4 to 6 MWs	14	48.28	15	51.72
	From 6 to 8 MWs	10	66.67	5	33.33
	> 8 MWs	8	57.14	6	42.86
Were you diagnosed with a mental disorder?	Yes	23	32.86	24	48.00	0.129
	No	47	67.14	26	52.00

• Note: Fisher’s exact test.
• ^*
  Statistically significant value at the 5% level (≤ 0.05); MW – minimum wage.

With regard to academic aspects, a significant association was observed between the perception of no change in academic performance and suicidal ideation (p = 0.039). This result may suggest a pre-existing perception of low performance, not attributed to the pandemic (Table 2).

Table 2
Differences between the association between suicidal ideation and academic aspects after the COVID-19 pandemic, São Paulo, São Paulo, Brazil, 2025

Academic aspect	Pandemic impact	Suicide ideation				p value
		Yes		No
		n	%	n	%
Professional future perspective	No	13	50.00	13	50.00	0.587
	Yes, for better	27	62.79	16	37.21
	Yes, for worse	30	58.82	21	41.18
Academic performance	No	12	85.71	2	14.29	0.039 *
	Yes, for better	7	41.18	10	58.82
	Yes, for worse	51	57.30	38	42.70
Routine burden	No	17	62.96	10	37.04	0.688
	Yes, for better	5	71.43	2	28.57
	Yes, for worse	48	55.81	38	44.19

• Note: Fisher’s exact test.
• ^*
  Statistically significant value at the 5% level (≤ 0.05).

Nursing students with NSSI showed a lower association with suicidal ideation, while moderate levels of depression were associated with the presence of suicidal ideation in the past 30 days. As for NSSI, the counterintuitive finding that students without NSSI were more likely to present suicidal ideation (p < 0.001) suggests that the absence of visible self-injurious behaviors does not imply the absence of psychological distress (Table 3).

Table 3
Differences in the association between suicidal ideation, self-harm, and depression, São Paulo, São Paulo, Brazil, 2025

Behavior	Category	Suicide ideation				p value
		Yes		No
		n	%	n	%
Self-harm	Yes	11	15.71	28	56.00	<0.001 *
	No	59	84.29	22	44.00
Depression	Regular	47	67.14	24	48.00	0.017 * w
	Mild	8	11.43	7	14.00
	Moderate	15	21.43	16	32.00
	Severe/extremely severe	0	0.00	3	6.00

• Note: Fisher’s exact test.
• ^*
  Statistically significant value at the 5% level (≤ 0.05); w - calculated with Welch’s correction for heteroskedasticity.

Furthermore, students with moderate levels of depression showed a higher prevalence of suicidal ideation (p = 0.017). These findings reinforce the need for institutional strategies focused on the early identification of depressive symptoms, even at moderate stages (Table 3).

With regard to coping strategies, domains such as distancing (p = 0.001), acceptance of responsibility (p = 0.003), escape/avoidance (p = 0.002), and positive reappraisal (p = 0.035) showed a significant association with suicidal ideation. The lack of adaptive strategies, such as problem-solving and seeking social support, reduces the ability to cope with academic and personal stressors (Table 4).

Table 4
Differences in the association between suicidal ideation and coping strategies, São Paulo, São Paulo, Brazil, 2025

Domain	Suicide ideation	n	Mean	SD	Median	Min.	Max.	p value	ES
Confrontation	Yes	70	3.81	2.10	4.00	0.00	9.00	0.310	0.182
	No	50	4.18	1.86	4.00	0.00	9.00
Withdrawal	Yes	70	4.41	2.82	4.00	0.00	11.00	0.001 *	0.668
	No	50	6.30	2.83	6.50	0.00	11.00
Self-control	Yes	70	7.30	2.76	7.00	1.00	12.00	0.120	0.290
	No	50	8.08	2.59	8.00	3.00	12.00
Social support	Yes	70	7.04	4.64	6.00	0.00	18.00	0.501	0.125
	No	50	6.46	4.67	6.50	0.00	16.00
Acceptance of responsibility	Yes	70	3.03	1.64	3.00	0.00	6.00	0.003 * w	0.411
	No	50	3.64	1.24	4.00	0.00	6.00
Avoidance	Yes	70	3.60	2.05	4.00	0.00	6.00	0.002 *	0.578
	No	50	4.74	1.86	6.00	0.00	6.00
Problem-solving	Yes	70	1.34	1.09	1.00	0.00	3.00	0.116	0.297
	No	50	1.66	1.04	2.00	0.00	3.00
Positive reappraisal	Yes	70	10.11	5.68	11.00	0.00	23.00	0.035 *	0.390
	No	50	7.94	5.44	7.00	0.00	20.00

• Note: Student’s t-test for independent samples. SD - standard deviation; Min - minimum; Max - maximum; ES - effect size; w - calculated with Welch’s correction for heteroskedasticity;
• ^*
  Statistically significant value at the 5% level (p ≤ 0.05).

Multivariate analysis confirmed a higher likelihood of suicidal ideation among LGBTQIAPN+ students (OR = 2.98), those who did not perceive changes in academic performance (OR = 15.68), and those who did not report NSSI (OR = 5.31). These findings reinforce the central role of universities in formulating policies that include affirmative actions and psychosocial support strategies, with a focus on coping strategies (Table 5).

Table 5
Final adjusted model of the association between suicidal ideation and sexual orientation, religion, perception of academic performance after the pandemic, self-harm behaviors, depression level, and usage of coping strategies such as avoidance, acceptance of responsibility, escape/avoidance, and positive reassessment, São Paulo, São Paulo, Brazil, 2025

Variable	Tested category	Reference category	Parameters
			b	Odds Ratio	χ2	p value
Constant	--	--	-2.13	--	3.433	0.064
Sexual orientation	Not heterosexual	Heterosexual	1.09	2.98 [1.09. 8.17]	4.512	0.034*
Religion	Religious	Not religious	0.65	1.92 [0.69. 5.33]	1.563	0.211
Academic performance has changed after the pandemic COVID-19	No	Yes, for better	2.75	15.68 [1.68. 146.55]	5.823	0.016*
	Yes, for worse	Yes, for better	1.23	3.41 [0.89. 13.09]	3.193	0.074
Self-harm	No	Yes	1.67	5.31 [1.87. 15.09]	9.818	0.002*
Depression	--	--	0.01	1.01 [0.57. 1.79]	0.001	0.978
Coping style: confrontation	--	--	-0.05	0.95 [0.78. 1.15]	0.269	0.604
Coping style: acceptance of responsibility	--	--	-0.13	0.88 [0.57. 1.36]	0.344	0.557
Coping style: avoidance	--	--	-0.16	0.85 [0.62. 1.17]	0.975	0.323
Coping style: positive	--	--	0.05	1.054 [0.96. 1.15]	1.270	0.260

DISCUSSION

LGBTQIAPN+ nursing students did not perceive the pandemic as having impacted their academic performance and did not report NSSI. The association between this profile and suicidal ideation was identified in the present study. The findings contribute to a deeper understanding of the effects of the pandemic on academic performance and the relationship between suicidal ideation and the absence of NSSI among nursing students.

Nursing students from sexual minorities were twice as likely to present suicidal ideation compared to their heterosexual peers. These findings are consistent with studies conducted among students in Brazil and with the adult population in the United States and Belgium, which found that sexual and gender minority adults who experienced violence were three times more likely to report lifetime suicide attempts(⁸,¹³–¹⁵). Transgender students presented higher rates of suicidal ideation(⁸). Experiences of violence, lack of social acceptance, and awareness of the stigma they face in society were identified as factors associated with suicidal ideation in the past year and with lifetime suicide attempts(⁸,¹⁴).

In this regard, the results indicate that suicide prevention interventions must also address structural-level factors, since structural discrimination impacts the mental health of nursing students from sexual minorities. Structural discrimination is a fundamental cause of health inequities and occurs when interconnected systems of power, privilege, and oppression are embedded in public policies, institutional norms, cultural practices, and belief systems(¹⁶).

Despite efforts to guarantee the rights of sexual minorities, Brazil remains one of the most stigmatizing countries regarding sexual minority identities and offers fewer healthcare resources for this population. Although suicidal ideation was more prevalent in this group, this does not imply that all nursing students belonging to sexual minorities will have a higher prevalence of suicidal ideation.

The present study’s hypothesis was not confirmed, as no association was found between the effects of the pandemic on worsening academic performance, routine overload and professional future prospects, and the presence of suicidal ideation. The findings indicated that not perceiving an impact on academic performance after the pandemic increased the risk of suicidal ideation among nursing students by 16 times. In this study, it can be inferred that academic performance prior to the pandemic may have been perceived as unsatisfactory, directly and indirectly influencing the presence of suicidal ideation. Academic performance is one of the determinants of psychological distress among university students(¹⁶–¹⁸). It is evident that beyond academic performance, the broader context—including cumulative curricular activities, interpersonal relationships with peers and faculty, and the personal characteristics of each nursing student—must be considered.

Additionally, studies have found that, according to nursing students’ and healthcare professionals’ perception, the factors influencing the teaching-learning process include peer relationships, family structure, socioeconomic conditions, the quality of basic education(¹⁷–¹⁹), and the social roles of being both a student and a woman, along with the transition into adulthood.

Specific educational programs have been implemented by universities as structured suicide prevention strategies, with a focus on promoting students’ mental health. One example is the “Talk to Me” suicide prevention program for university students in Australia, which resulted in increased help-seeking for mental health care, greater resilience, and reduced academic stress(²⁰). In Brazil, affirmative action and student retention initiatives, along with educational, therapeutic, and student support activities—including physical, sports, cultural, and leisure activities—are feasible strategies for addressing psychological distress among university students(¹⁷,¹⁸).

NSSI was not associated with suicidal ideation; rather, nursing students without NSSI were five times more likely to present suicidal ideation compared to those with a history of NSSI. These results are consistent with a cohort study in England with young people, where NSSI characteristics were not strong predictors of future suicide attempts(²¹). In England, individuals aged 16 to 24 reported engaging in NSSI to relieve unpleasant feelings of anger, tension, anxiety, or depression(²²)

Furthermore, depression functions as a mediator in the relationship between unmet interpersonal needs—which generate the emotional response of feeling like a burden—and NSSI(⁷).

In line with the findings of this study, a systematic review with meta-analysis found a weak association between escape/avoidance behaviors and NSSI, and a moderate to strong association with suicidal behavior(²³). Contemporary evidence suggests that NSSI produces an emotional reaction perceived as relief through the sensation of pain(²³).

Psychological models of suicidal behavior describe the experience of intense and overwhelming feelings—such as defeat and entrapment caused by external and/or internal stressors—as functioning as strategies to escape overwhelming emotions and/or negative thoughts, in which individuals perceive no hope for the future and no realistic possibility of help(²³).

A quantitative study found an association between lower coping flexibility and suicide risk among Chinese students with depressive symptoms(²⁴). A Brazilian study with health sciences students identified that the severity of depressive symptoms was related to lower mean scores in the psychological domain of quality of life(²⁵). In the present study, approximately 32.86% of nursing students presented mild to moderate levels of depression. The low prevalence of severe depressive symptoms among nursing students may explain the results found, in which, in the final adjusted model, there was no association between depression, coping strategies such as distancing, acceptance of responsibility, escape/avoidance, and positive reappraisal with the risk of suicidal ideation.

These results contrast with the broader scientific evidence on the topic. A quantitative study conducted in Belgium, for instance, found an association between escape/avoidance and passive coping and a higher likelihood of suicidal ideation among young adults from sexual minorities(¹⁴). Iranian students with dysfunctional attitudes and emotion-focused coping presented a significantly higher risk of suicidal ideation(²⁶). Insecure attachment styles (ambivalent and avoidant) serve as mediators between dysfunctional attitudes and emotion-focused coping(²⁶).

Nurses who employ both problem-focused and emotion-focused coping strategies are able to regulate stress in the workplace(²⁷). Resilience plays an important mediating role between stressful situations and the implementation of proactive strategies and emotional regulation(²⁷).

According to the Integrated Motivational-Volitional Model of Suicidal Behavior, cognitive processes related to passive coping are similar to rumination, which is a major contributor to suicidal ideation(²⁸). Individuals who are regularly victimized due to their LGBTQIAPN+ identity may avoid certain situations or individuals; as a result, their mental health may be temporarily preserved in the short term, but it remains unclear how this affects mental health in the long term(⁸,¹⁵). Avoiding situations, places, and/or people can limit socialization and self-awareness, as well as awareness of one’s identity, which may lead to maladaptive coping in response to stress. A literature review found that students who lack friends to share social experiences with present greater isolation and psychological distress(¹⁷).

From the perspective of developing a positive sense of self, self-labeling can influence how individuals deal with emotional distress, with potential positive and negative effects on their lives(²⁹). A contemporary study with psychology undergraduates in the United States found that self-labeling (e.g., “I am depressed”) was associated with lower perceived control over depression, catastrophic thinking, reduced capacity for perspective-taking, reorientation, reappraisal, planning, and help-seeking attitudes toward medication, though not toward therapy(²⁹).

It was also identified that the indirect mediation of coping strategies such as escape/avoidance, distancing, acceptance of responsibility, and positive reappraisal in relation to suicidal ideation points to some hypotheses: acceptance of responsibility and positive reappraisal may lead to self-labeling (e.g., “I am responsible for everything bad that happens to me”) and may not be sufficient to produce cognitive responses necessary for emotional regulation. Within the stress-diathesis model of suicide, factors related to diathesis may hinder the development of emotionally regulated responses and foster the desire for suicide(³⁰).

Study limitations

A limitation of this study is the absence of a specified stressor in the application of the coping questionnaire. Therefore, the results should be interpreted with caution, as individuals may employ different coping strategies depending on the specific stressful situation. Furthermore, since this was a convenience sample, the generalization of the findings to other contexts should also be viewed with caution.

Contributions to health, nursing or public policy

The results of this study highlight lessons learned from the COVID-19 pandemic that may help students at greater risk of suicidal ideation. First, providing pedagogical support to all nursing students represents a pedagogical strategy for developing time management skills and coping with academic demands. Second, it is important to develop psychosocial interventions so that sexual minority students can use problem- and emotion-focused coping strategies in stressful situations, especially situations of discrimination and social exclusion. Policies guaranteeing human rights and literacy for university faculty should be implemented to combat the structural prejudice that still exists against sexual minority nursing students. Third, it is important to share the results with the management bodies of the healthcare network, particularly the psychosocial care network and public health services in the municipality in question so that healthcare professionals are aware of and prepared to address the study population’s mental health needs. This can also be extrapolated to the university population in general, considering the similar academic, emotional, and social challenges faced by these groups. Fourth, nursing students’ psychosocial needs must be addressed, not exclusively related to academic demands. Empathic listening and support must be implemented for students who primarily implement emotion-focused strategies, in which stressful situations can be perceived as a burden and without a solution.

CONCLUSIONS

Sexual minority nursing students who did not perceive a worsening in academic performance two years after the social restrictions of the pandemic and who did not report NSSI were identified as being at greater risk for suicidal ideation. In bivariate analysis, severe depressive symptoms and the use of coping strategies such as distancing, acceptance of responsibility, escape/avoidance, and positive reappraisal appeared to have indirect mediating effects on the presence of suicidal ideation.

These findings may contribute to a better understanding of the risk factors affecting this population in the post-pandemic period and, consequently, help guide nurses and educators in implementing early detection actions for suicide risk as well as strategies for promoting well-being within undergraduate nursing programs at universities.

FUNDING

• Undergraduate Research Scholarship – Brazilian National Council for Scientific and Technological Development.

AVAILABILITY OF DATA AND MATERIAL

The research data are available within the article.

REFERENCES

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Edited by

• EDITOR IN CHIEF
  Dulce Barbosa

• ASSOCIATE EDITOR
  Alexandre Balsanelli

Publication Dates

• Publication in this collection
  27 Feb 2026
• Date of issue
  2026

History

• Received
  07 Apr 2025
• Accepted
  18 Aug 2025