The Relationship between Shame and Mental Health Problems in Nursing Students Experiencing Bullying at a University in Central Java

Ma’rifatul Ngajib1*, Nur Setiawati Dewi, Zubaidah Zubaidah

Department of Nursing, Faculty of Medicine, Diponegoro University, Semarang 50275, Indonesia

*Corresponding Author’s Email: ajibkbm485@gmail.com

ABSTRACT

Background: Bullying is a major factor contributing to mental health problems in Indonesia, including depression, anxiety, and stress. Preliminary research found a high rate of bullying among nursing students at a university in Central Java, with verbal bullying being the most common (33.33%). This study explored the relationship between shame and mental health problems in nursing students who have experienced bullying at a university in Central Java. Methods: The research employed a cross-sectional design, targeting a population of 607 students, with a total sample of 265 participants selected through random sampling. The data collection utilised two main instruments: the External and Internal Shame Scale (EISS), which included four valid items measuring internal shame (α=0.850), and the Depression Anxiety Stress Scale (DASS-21), comprising 21 valid items to assess mental health problems (α=0.85, 0.84, 0.84). Pearson’s Product Moment correlation test was applied for data analysis. Results: Results showed a significant correlation between shame and mental health problems (P=0.000, r=0.733), with stress being the most common mental health issue. Conclusion: The study revealed that nursing students who experienced bullying reported high levels of shame, with stress identified as the most prevalent mental health issue. A significant relationship was found between shame and mental health problems, underscoring the urgent need for targeted interventions.

Keywords: Bullying; Mental Health Problems; Nursing Student; Shame

INTRODUCTION

Mental health is a growing global concern, including in Indonesia. According to the data presented by the World Health Organisation (2022), 301 million people worldwide suffer from anxiety disorders, 280 million experience depression, and millions more struggle with mental health conditions such as bipolar disorder, schizophrenia, and eating disorders. In Indonesia, mental health issues significantly impact society, with 12,616.54 individuals per 630,827 people affected in 2023 (Health Development Policy Agency, 2023). University students, particularly nursing students, are at high risk of mental health issues due to academic pressure, clinical training demands, and social stressors. A study by WHO’s World Mental Health International College Student found that 35% of university students experience DSM-IV mental disorders, with 31% suffering from major depression, anxiety disorders, and other conditions (Auerbach et al., 2018). In Indonesia, 90.4% of nursing students report experiencing anxiety (Malfasari et al., 2018); 35.6% have mild stress, 57.4% have moderate stress, and 6.9% have severe stress (Ambarwati Pinilih & Astuti, 2017).

Bullying has been identified as a major risk factor for mental health problems, especially in academic settings. Studies across various countries show that nursing students frequently experience bullying in different forms, including verbal, social, physical, and cyberbullying. Research conducted at 47 universities in four countries (Argentina, Estonia, Finland, and the United States) found that bullying is often perpetrated by peers or faculty members, leading to severe consequences such as anxiety, depression, and sleep disturbances (Pörhölä et al., 2020). Another study in Ghana reported that 83% of students were involved in cyberbullying (Sam et al., 2019), while research in China found that 41.7% of university students experienced verbal bullying, 33.0% relational bullying, and 24.1% physical bullying (Zhang et al., 2019). In Indonesia, a study at Universitas Gadjah Mada revealed that 78.74% of nursing students had been bullied, with verbal bullying (31.4%), social bullying (12.16%), and physical bullying (2.32%) being the most common forms (Ghafara et al., 2022).

Bullying has long-term consequences for mental health, including an increased risk of Post- Traumatic Stress Disorder (PTSD). Studies indicate that 57% of bullying victims meet the threshold for PTSD symptoms (Matthiesen & Einarsen, 2004). One of the most significant emotional responses to bullying is shame, which can worsen mental health problems by lowering self-esteem, triggering social withdrawal, and increasing self-blame. Research shows that shame intensifies anxiety and depression and negatively impacts the professional development of nursing students, particularly in clinical skills and social interactions (Kotera, Conway & Van Gordon, 2019).

A preliminary study in September 2024 on 33 medical faculty students in Central Java found that 15 students experienced bullying, including physical, verbal, relational, and cyberbullying. All bullied students reported feelings of shame, particularly from verbal humiliation about their appearance or academic abilities. Nursing students had the highest prevalence of bullying (33.33%) compared to other disciplines. This study aims to examine the relationship between shame and mental health problems among bullied nursing students in Central Java. The hypothesis is that shame significantly correlates with mental health issues, with the findings expected to inform intervention strategies for managing bullying's psychological impact.

METHODOLOGY

Research Design

This study employs a descriptive correlational design with a cross-sectional approach to examine the relationship between variables, namely the independent and dependent variables, which are collected simultaneously. The independent variable in this study is shame, while the dependent variable is mental health problems among nursing students who have experienced bullying in Central Java.

Study Population and Sampling

This study involved undergraduate nursing students from a university in Central Java, using total sampling to include all students meeting the inclusion criteria and willing to participate. The criteria were (1) students who had experienced bullying (physical, verbal, relational, or cyberbullying) during their academic studies and (2) students actively enrolled in the nursing programme. Data were collected via Google Forms, distributed by the researcher in each class. Participants first reviewed a consent statement detailing the study’s purpose, voluntary participation, and confidentiality. Students who had experienced bullying and agreed to participate signed an electronic consent form. Of 607 contacted students, 265 met the criteria and participated. Data collection was conducted in a private setting after students were briefed on the study’s purpose and procedures, and an informed consent was obtained.

Data Collection

Data were collected in March 2024 via an online questionnaire using Google Forms. Two primary instruments were utilised. The first was the External and Internal Shame Scale (EISS) developed by Ferreira et al. (2022), with permission obtained. It contains 8 items divided into external and internal shame subscales (4 items each), assessing four domains: inferiority/incompetence, exclusion, emptiness, and criticism. Responses were rated on a 5- point Likert scale (0 = "never" to 4 = "always"), with higher scores indicating greater shame. This study focused specifically on internal shame. As the EISS had not been previously adapted for Indonesia, it underwent validity and reliability testing with 50 nursing students who had experienced bullying at a university similar to the study setting. Validity testing using Pearson’s correlation showed high construct validity (r=0.818–0.841). Reliability testing yielded a strong Cronbach’s alpha (α=0.850), confirming the instrument’s suitability.

The second instrument was the Indonesian version of the Depression Anxiety Stress Scale (DASS-21), translated by Arjanto (2022) from the original by Lovibond and Lovibond (1995), with usage permission granted. The DASS-21 consists of 21 items covering depression, anxiety, and stress, with responses rated from 0 ("did not apply to me at all") to 3 ("applied to me very much or most of the time") and classified into severity levels. Psychometric evaluation showed excellent validity (CFI and TLI > 0.90; RMSEA and SRMR < 0.08; factor loadings 0.49–0.75) and strong reliability (α=0.85 for depression, 0.84 for anxiety and stress).

Data Analysis

Data analysis included univariate and bivariate analyses. Univariate analysis used relative frequency distribution to present the distribution and percentages of variables such as gender, age, academic year, shame, and mental health problems. Bivariate analysis tested normality with the Kolmogorov-Smirnov test, showing that the data were normally distributed (p=0.200), allowing the use of Pearson's Product-Moment Correlation. All analyses were performed using JASP software (version 0.19.1.0).

Ethical Consideration

The research obtained ethical clearance from the Research Ethics Committee, Faculty of Medicine, Diponegoro University, Indonesia with Reference Number JKEtika 075/EC/KEPK/FK-UNDIP/II/2024 on 26th February 2024.

RESULTS

Univariate Analysis Respondent Characteristics

Table 1: Frequency Distribution of Respondent Characteristics in Nursing Students Experiencing Bullying at a University in Central Java, March 2024 (n=265)

Table 1 shows that the majority of respondents were female (92.1%), the majority were 20 years old (31.7%), and most were from the 2021 cohort (38.9%). The sense of isolation/exclusion was the highest shame domain, with a score of 2.65 ± 0.97, while stress was the highest mental health problem domain, with a score of 18.29 ± 8.58.

Shame and Mental Health Problems

Table 2: Shame and Mental Health Problems in Nursing Students Experiencing Bullying at a University in Central Java, March 2024 (n=265)

Table 2 shows that bullied nursing students had an average shame score of 9.25 ± 2.23, with the highest domain being isolation/exclusion (2.65 ± 0.97). The average mental health score was 24.24 ± 11.97, with stress as the most common issue (18.29 ± 8.58) and depression the least (12.66 ± 8.93). In depression, item 5 scored highest (1.21 ± 0.861), reflecting motivational difficulties. In anxiety, items 9 and 19 (1.60 ± 0.949; 1.60 ± 0.878) highlighted the impact of peer pressure and verbal bullying. In stress, item 18 (2.18 ± 0.835) indicated heightened emotional sensitivity and low self-confidence.

Bivariate Analysis

Table 3: Relationship between Shame and Mental Health Problems in Nursing Students Experiencing Bullying at a University in Central Java, March 2024 (n=265)

*Pearson's product moment correlation test, p-value 0.001

Table 3 shows significant correlations between negative emotions and mental health problems, including depression, anxiety, and stress. Shame was the strongest predictor, with high correlations to overall mental health (r = 0.733), depression (r = 0.726), anxiety (r = 0.609), and stress (r = 0.673), all at p = 0.001. Isolation/exclusion also showed strong associations with overall mental health (r = 0.616) and depression (r = 0.642). Inferiority/inadequacy and uselessness/emptiness had moderate-to-strong correlations with all mental health domains. Criticism/judgement showed moderate but significant correlations, indicating a notable yet lesser impact on mental health outcomes.

DISCUSSION

Shame (Internal Shame)

According to the findings of the research, nursing students who experience bullying tend to have higher levels of shame compared to students who do not experience bullying in previous studies (Kotera et al., 2023). Shame is a complex emotion that is often felt by nursing students who experience bullying. This is in line with the study of Jungert, Sarıca and Bäckström (2025), which stated that shame in nursing students who experience bullying increases because they often receive negative messages such as insults, ridicule or rejection. Another study stated that the shame of someone who experiences bullying increases when they feel pressured by negative judgements from others and feel isolated and prevents individuals from seeking help (Badillo-Sánchez et al., 2025; Rutherford et al., 2025).

The research findings also indicate that the highest average level of shame among nursing students who experienced bullying was found in the domain of isolation or exclusion. This isolation can add layers of shame to the experience, so that when individuals feel alone, they tend to internalise the shame even deeper (Li et al., 2025). In addition, the shame of individuals who experience bullying associated with the experience of isolation can also be exacerbated by the individual's inability to express what they are feeling. In many cases, nursing students who experience bullying are afraid to share their experiences with others (Zhang et al., 2025). This approach leads to social withdrawal, where individuals begin to focus on negative feelings that create more isolation so that shame can develop (Gallagher, 2025).

Mental Health Problems

The study finds stress to be the most prevalent mental health issue among nursing students who experienced bullying, with depression being the least common. This aligns with previous research by Dolezal (2022), which also identified stress as a primary concern. Factors such as intensive clinical practice, time management challenges, and external influences like peer pressure contribute to increased stress (Barta & Kiropoulos, 2022; Ramiro, Domínguez & González-Sanguino, 2024). Verbal or relational bullying can lead to shame, social anxiety, and loneliness (Li et al., 2020). Prolonged shame may elevate stress levels and contribute to more severe mental health issues, including depression (Farr, Ononaiye & Irons, 2021).

Depression

The highest average score in the depression domain corresponds to the statement, “I found it difficult to work up the initiative to do things.” Research shows that the shame felt by most nursing students who experience bullying such as insults, teasing, and social exclusion causes depression (Cao et al., 2025; Feng et al., 2024). MacGinley, Breckenridge and Mowll (2019) describe how feelings of shame in individuals who experience bullying can damage self-esteem and self-image, making victims more susceptible to feelings of hopelessness and helplessness, which are typical symptoms of depression (Huang, Ho & Cheung, 2024). This ongoing shame narrative not only internalises negative beliefs about one's self-worth but also catalyses an avoidance cycle in which students may withdraw from social interactions to avoid further humiliation (Hikmat et al., 2024). Such withdrawal can lead to increased feelings of academic inadequacy, distress, and, ultimately, poor mental health outcomes (Cao et al., 2025; Huang, Ho & Cheung, 2024).

Anxiety

The highest average score in the anxiety domain corresponds to the statement, “I was worried about situations in which I might panic and make a fool of myself, and I was aware of the action of my heart in the absence of physical exertion (e.g., sense of heart rate increase, heart missing a beat).” Shame in nursing students who experience bullying can trigger a variety of psychological and physiological responses, including excessive anxiety and physical symptoms such as heart palpitations (Cao et al., 2025). This shame further exacerbates anxiety, causing students to feel anxious about social or academic situations that require interaction or evaluation by others. Ricker (2024) emphasised that fear of negative evaluation can lead to avoidance behaviour, in which students choose to withdraw from situations involving social interaction.

Stress

Research findings indicate that the highest average score in the stress domain corresponds to the statement, “I felt that I was rather touchy.” Stressful experiences among nursing students are primarily exacerbated by feelings of emotional sensitivity, which are often exacerbated by bullying experiences. Recent findings highlight that this sensitivity may manifest as an increased response to perceived criticism and social interactions, ultimately affecting nursing students’ emotional and psychological well-being (Cao et al., 2025; Feng et al., 2024). Research conducted by Jones, Garzon and Ford (2023) demonstrated profound feelings of shame and inadequacy in individuals who experienced bullying, resulting in students feeling unappreciated and incompetent. These students often reported feelings of isolation and repeated humiliation, which significantly increased emotional sensitivity and overall stress level (Feng et al., 2024; Huang, Ho & Cheung, 2024). The emotional impact of such experiences may lead to a chronic stress response, in which students react with disproportionate emotional responses to situations that may have been perceived as manageable (Hikmat et al., 2024).

Relationship Between Shame and Mental Health Problems in Nursing Students Experiencing Bullying at a University in Central Java

The study finds out a strong correlation between shame and mental health issues among nursing students in Central Java who have experienced bullying, with a correlation coefficient of 0.733. Shame was found to be the most influential factor, strongly linked to depression, anxiety, and stress, surpassing other negative emotions like isolation and feelings of incompetence. Although worthlessness and judgement had a lesser impact, they still contributed to mental health problems. These findings support previous research indicating that internalised shame is a key factor in mental health issues (Foster et al., 2019). Studies show that bullying-related shame increases the risk of mood, cognitive, and behavioural issues, leading to long-term problems like depression and low self-esteem (Kotera, Van Laethem & Ohshima, 2020; Mendy et al., 2025).

Social mentality theory (Gilbert, 2020) provides a useful framework for understanding the relationship between shame and mental health problems in bullied nursing students. Shame in bullied nursing students in this context can be viewed as a response to negative self-evaluations, which in turn contribute to broader mental health problems. Research by Stone-Sabali et al. (2025) suggests that individuals with high shame tendencies who experience bullying experience greater impacts from social discrimination, which in turn contributes to poor mental health. Another study suggested that the shame experienced by someone who experiences bullying directly interferes with the individual’s ability to seek help or support, leading to social isolation, thus worsening mental health (Woller et al., 2025).

The lack of effective interventions for shame in bullied students often exacerbates mental health issues. Gilbert (2020) highlights the role of social support and mental health resources in mitigating shame's negative effects on nursing students (Stone-Sabali et al., 2025). Without support, students may feel trapped in their emotions, worsening mental health trends. Developing bullying prevention programmes within nursing education can help reduce shame, improve student connection, and prevent deeper mental health issues. Therapeutic interventions, such as cognitive-behavioural and mindfulness-based approaches, have been shown to reduce shame and improve students' ability to connect with others, fostering a positive mental attitude (Woller et al., 2025).

Limitation

This study has several limitations. The sample was limited to nursing students from one university in Central Java, reducing generalizability to other regions or institutions. The study focused only on internal shame, excluding external shame, which may also impact mental health. Additionally, it did not consider moderating factors such as resilience, coping strategies, or social support, which may influence the relationship between shame and mental health in bullied students. Caution is advised in applying these findings broadly. Future research should include diverse samples, assess external shame, and use longitudinal designs to explore causal relationships and contributing factors more comprehensively.

CONCLUSION

This study found that nursing students who experienced bullying reported high levels of shame, with stress being the most common mental health issue. Shame was significantly associated with mental health problems, highlighting the need for targeted interventions. Universities should provide psychological support, including counselling, peer support, and resilience training. A comprehensive anti-bullying framework is also recommended, involving training, awareness campaigns, and clear policies. Regular assessments can guide intervention efforts. Future research should use longitudinal designs, include diverse student populations, and explore mediating or moderating factors like social support and resilience to enhance understanding and intervention effectiveness.

Conflict of Interest

The authors declare that they have no competing interests.

ACKNOWLEDGEMENT

The authors would like to express gratitude to the participant mothers who took part in the study and disclosed the information about their children to advance autism research.

REFERENCES

Ambarwati, P. D., Pinilih, S. S., & Astuti, R. T. (2019). Gambaran tingkat stres mahasiswa [Overview of student stress levels]. Jurnal Keperawatan Jiwa, 5(1), 40-47. Retrieved from: https://jurnal.unimus.ac.id/index.php/JKJ/article/view/4466/4081. Accessed on 18th January 2023.

Arjanto, P. (2022). Uji Reliabilitas dan Validitas Depression Anxiety Stress Scales 21 (DASS-21) pada Mahasiswa [Reliability and validity test of depression anxiety stress scales 21 (DASS-21) in college students]. Journal of Perceptual Psychology, 7(1). https://doi.org/10.24176/perseptual.v7i1.6196

Auerbach, R. P., Mortier, P., Bruffaerts, R., Alonso, J., Benjet, C., Cuijpers, P., Demyttenaere, K., Ebert, D. D., Green, J. G., Hasking, P., Murray, E., Nock, M. K., Pinder-Amaker, S., Sampson, N. A., Stein, D. J., Vilagut, G., Zaslavsky, A. M., Kessler, R. C., & WHO WMH- ICS Collaborators. (2018). WHO world mental health surveys international college student project: Prevalence and distribution of mental disorders. Journal of Abnormal Psychology, 127(7), 623–638. https://doi.org/10.1037/abn0000362

Badillo-Sánchez, N., Gómez-Salgado, J., Allande-Cussó, R., Yildirim, M., López-López, D., Goniewicz, K., Prieto-Callejero, B., & Fagundo-Rivera, J. (2025). Impact of the COVID-19 pandemic on the mental health of nursing students: A systematic review and meta-analysis. Medicine, 104(2). https://doi.org/10.1097/MD.0000000000040797

Barta, T., & Kiropoulos, L. (2022). The mediating role of stigma, internalized shame, and autonomous motivation in the relationship between depression, anxiety, and psychological help-seeking attitudes in multiple sclerosis. International Journal of Behavioral Medicine, 30(1), 133–145. https://doi.org/10.1007/s12529-022-10078-6

Cao, H., Wang, S., Zhou, N., & Liang, Y. (2025). From childhood real-life peer victimization to subsequent cyberbullying victimization during adolescence: A process model involving social anxiety symptoms, problematic smartphone use, and internet gaming disorder. Psychology of Violence, 15(1), 106–120. https://doi.org/10.1037/vio0000548

Dolezal, L. (2022). Shame anxiety, stigma and clinical encounters. Journal of Evaluation in Clinical Practice, 28(5), 854–860. https://doi.org/10.1111/jep.13744

Farr, J., Ononaiye, M., & Irons, C. (2021). Early shaming experiences and psychological distress: The role of experiential avoidance and self‐compassion. Psychology and Psychotherapy Theory Research and Practice, 94(4), 952–972.https://doi.org/10.1111/papt.12353

Feng, Y., Zhang, S., Liao, X., Jia, Y., Yang, Y., & Zhang, W. (2024). Association between bullying victimization and mental health problems among Chinese left-behind children: A cross-sectional study from the adolescence mental health promotion cohort. Frontiers in Psychiatry, 15. https://doi.org/10.3389/fpsyt.2024.1440821

Ferreira, C., Moura-Ramos, M., Matos, M., & Galhardo, A. (2022). A new measure to assess external and internal shame: development, factor structure and psychometric properties of the External and Internal Shame Scale. Current Psychology, 41(4), 1892–1901. https://doi.org/10.1007/s12144-020-00709-0

Foster, K., Withers, E., Blanco, T., Lupson, C., Steele, M., Giandinoto, J.-A., & Furness, T. (2019). Undergraduate nursing students’ stigma and recovery attitudes during mental health clinical placement: A pre/post‐test survey study. International Journal of Mental Health Nursing, 28(5), 1068–1080. https://doi.org/10.1111/inm.12634

Gallagher, A. (2025). 30 years of nursing ethics: Reflections on progress in the field. Nursing Ethics, 32(1), 7–14. https://doi.org/10.1177/09697330241312536

Ghafara, R. A., Fandi Achmad, B., Harjanto, T., & Setiyarini, S. (2022). Bullying on nursing students. Jurnal Berita Ilmu Keperawatan, 15(2), 229–237.https://doi.org/10.23917/bik.v15i2.17859

Gilbert, P. (2020). Compassion: from its evolution to a psychotherapy. Frontiers in Psychology, 11. https://doi.org/10.3389/fpsyg.2020.586161

Health Development Policy Agency. (2023, December 2). Indonesian health survey 2023. Retrieved from: https://drive.google.com/file/d/1NMZwTtFMamkmMe- H8OpZwan105kiSQtq/view. Accessed on 15th April 2023.

Hikmat, R., Yosep, I., Hernawaty, T., & Mardhiyah, A. (2024). A scoping review of anti- bullying interventions: reducing traumatic effect of bullying among adolescents. Journal of Multidisciplinary Healthcare, 2024(17), 289-304. https://doi.org/10.2147/JMDH.S443841

Huang, Q.-L., Ho, W.-S., & Cheung, H.-N. (2024). Exploring the mediating role of self- regulation in bullying victimization and depressive symptoms among adolescents: A cross-regional and gender analysis. Healthcare, 12(15), 1486. https://doi.org/10.3390/healthcare12151486

Jones, T., Garzon, F. L., & Ford, K. (2023). Christian accommodative mindfulness in the clinical treatment of shame, depression, and anxiety: Results of an N-of-1 time-series study. Spirituality in Clinical Practice, 10(2), 118–130. https://doi.org/10.1037/scp0000221

Jungert, T., Sarıca, S., & Bäckström, M. (2025). The impact of witnessing school bullying in the classroom: exploring perceptions and responses among turkish students. International Journal of Bullying Prevention, 1-12. https://doi.org/10.1007/s42380-025-00292-7

Kotera, Y., Conway, E., & Van Gordon, W. (2019). Mental health of UK university business students: Relationship with shame, motivation and self-compassion. Journal of Education for Business, 94(1), 11–20. https://doi.org/10.1080/08832323.2018.1496898

Kotera, Y., Jackson, J. E., Kirkman, A., Edwards, A.-M., Colman, R., Underhill, A., Jackson, J. G., Baker, D., & Ozaki, A. (2023). Comparing the mental health of healthcare students: mental health shame and self-compassion in counselling, occupational therapy, nursing and social work students. International Journal of Mental Health and Addiction, 22. https://doi.org/10.1007/s11469-023-01018-w

Kotera, Y., Van Laethem, M., & Ohshima, R. (2020). Cross-cultural comparison of mental health between Japanese and Dutch workers: relationships with mental health shame, self- compassion, work engagement and motivation. Cross Cultural & Strategic Management, 27(3), 511–530. https://doi.org/10.1108/CCSM-02-2020-0055

Li, H., Mu, M., He, Y., Wang, J., Cai, Z., Tang, H., Zhang, B., Luo, H., & Zeng, W. (2025).Prevalence of workplace bullying among medical students: A meta-analysis and systematic review protocol. PLOS One, 20(2). https://doi.org/10.1371/journal.pone.0310076

Li, H., Zheng, L., Le, H., Zhuo, L., Wu, Q., Ma, G., & Tao, H. (2020). The mediating role of internalized stigma and shame on the relationship between COVID-19 related discrimination and mental health outcomes among back-to-school students in Wuhan. International Journal of Environmental Research and Public Health, 17(24). https://doi.org/10.3390/ijerph17249237

Lovibond, P. F., & Lovibond, S. H. (1995). The structure of negative emotional states: comparison of the depression anxiety stress scales (DASS) with the beck depression and anxiety inventories. Behaviour Research and Therapy, 33(3), 335–343. https://doi.org/10.1016/0005-7967(94)00075-U

MacGinley, M., Breckenridge, J., & Mowll, J. (2019). A scoping review of adult survivors’ experiences of shame following sexual abuse in childhood. Health & Social Care in the Community, 27(5), 1135-1146. https://doi.org/10.1111/hsc.12771

Malfasari, E., Devita, Y., Erlin, F., & Ramadania, I. (2018). Lingkungan Rumah Sakit dan Tingkat Kecemasan Mahaiswa Saat Melakukan Praktek Klinik [Hospital environment and students anxiety levels when doing clinical practice]. Journal of the Indonesian National Nurses Association, 2(2), 117–125. https://doi.org/10.32419/jppni.v2i2.89

Matthiesen, S. B., & Einarsen, S. (2004). Psychiatric distress and symptoms of PTSD among victims of bullying at work. British Journal of Guidance & Counselling, 32(3), 335–356. https://doi.org/10.1080/03069880410001723558

Mendy, C. B., Umukoro Onofa, L. E., Olujobi, A. O., Jallow, M. S., Agboola, Afis A., Nano, K., Eniade, O., Jarju, A., Olubodun, Y., & Ogun, G. (2025). Bullying and its effects on mental health among students of a Senior Secondary School in Banjul, The Gambia. Psychiatry and Psychological Disorders, 4(1). https://doi.org/10.58489/2836-3558/029

Pörhölä, M., Cvancara, K., Kaal, E., Kunttu, K., Tampere, K., & Torres, M. B. (2020). Bullying in university between peers and by personnel: Cultural variation in prevalence, forms, and gender differences in four countries. Social Psychology of Education, 23(1), 143–169. https://doi.org/10.1007/s11218-019-09523-4

Ramiro, B. M. F., Domínguez, S. G., & González-Sanguino, C. (2024). Stigma towards child and adolescent mental health problems among fathers and mothers. A cross-sectional study. Clinical and Health, 35(1), 27-33. https://doi.org/10.5093/clysa2024a8

Ricker, B. T. (2024). Interactive effects of parental support and psychological control on children’s emotion regulation. Journal of Family Psychology, 38(6), 956–965. https://doi.org/10.1037/fam0001235

Rutherford, D., Gillespie, G. L., Bresler, S., Johnson, K., & Smith, C. R. (2025). Bullying behaviors in clinical settings. Nursing Education Perspectives, 46(4), 246-248. https://doi.org/10.1097/01.NEP.0000000000001380

Sam, D. L., Bruce, D., Agyemang, C. B., Amponsah, B., & Arkorful, H. (2019). Cyberbullying victimization among high school and university students in Ghana. Deviant Behavior, 40(11), 1305–1321. https://doi.org/10.1080/01639625.2018.1493369

Stone-Sabali, S., Uanhoro, J. O., McClain, S., & Devese, K. (2025). Disentangling the discrimination and mental health relationship among diverse college students: Moderation analyses of shame-proneness across race, gender, and race-by-gender interactions. Cultural Diversity & Ethnic Minority Psychology, 31(1), 151–163. https://doi.org/10.1037/cdp0000620

Woller, S. J., Boffa, J. W., Viana, A. G., Albanese, B. J., & Vujanovic, A. A. (2025). PTSD symptoms, suicidal ideation, and suicidal risk among university students: The role of shame. Psychological Trauma: Theory, Research, Practice, and Policy, 17(1), 145–153. https://doi.org/10.1037/tra0001829

World Health Organisation. (2022, June 8). Mental disorders. Retrieved from https://www.who.int/en/news-room/fact-sheets/detail/mental-disorders. Accessed on 19th January 2023.

Zhang, D., Fu, M., Zhang, J., Li, Y., Chen, L., Chen, Y.-J., Zhong, Z., & Zhang, Y.-P. (2025). Evaluating whether nonimmersion virtual reality simulation training improves nursing competency in isolation wards: randomized controlled trial. Journal of Medical Internet Research, 27. https://doi.org/10.2196/63131

Zhang, G.-B., Wang, G.-F., Han, A.-Z., Xu, N., Xie, G.-D., Chen, L.-R., & Su, P.-Y. (2019). Association between different stages of precollege school bullying and murder-related psychological behaviors among college students in Anhui Province, China. Psychiatry Research, 282. https://doi.org/10.1016/j.psychres.2019.112593