| Theme: Student wellbeing | |||
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| A study to explore perceptions of stress in UK medical students |
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Supervisors: Paul Bissell and Jill Thompson; Preparation of submission: Pirashanthie Vivekananda-Schmidt and Jim Crossley; Piloting: Rory Mackinnon; Presentation: Steven Churchill
Stress is something that medical students expect, accept, and often ignore to the point that it has become ‘the norm’. A belief amongst students that they should be able to deal with stress, that it is normal and necessary, makes it difficult to tackle and means students are reluctant to engage with solutions. However, the significant impacts on students’ quality of life and ability suggest that more needs to be done to tackle this issue.
This project was carried out in 2012 at the Sheffield School of Health and Related Research. Four medical schools took part in the project. In total, 332 medical students participated in this study (6%).
A review of the literature found that the level of stress in medical students has been persistently high for decades, and highlighted the multi-factorial nature of this stress. There have been a number of interventions aimed at stress reduction, but engagement with these by students has been limited. Particularly concerning given the severe consequences on mental health, ability and life satisfaction highlighted in the literature. We examined students perceptions of their own stress and that of their peers, how they coped with it and how it impacted upon them, in order to gain an in depth understanding of why this problem would appear so persistent and such a significant issue for the wider profession.
Methodology
This study used a mixed methods approach to establish perceptions of the stress, support and coping mechanisms. This included a survey at four medical schools, and three focus groups at one school.
Survey
A survey was carried out using online and paper questionnaires with students from all four medical schools involved. It was distributed by the individual medical schools, through e-noticeboards and newsletters. This gave a general view of students perceptions of stress, coping, impacts and how they are supported. Data was collected using the SurveyMonkey online data collection tool, and analysed using the websites built in capabilities. Descriptive analysis was also carried out. Ideas and themes that emerged were discussed in greater depth with the focus groups, and free text responses analysed as part of the wider qualitative data set.
Focus Groups
Three focus groups were carried out, allowing issues to be explored in greater detail. Participants responded to advertisements on Facebook and on the e-noticeboard. These groups gave an additional depth of understanding, and gave contextual information that aided interpretation of the data.The discussions was recorded and transcribed, and analysed using thematic analysis.
92.2% of participants (n= 332) reported feeling stressed at medical school, such that it affected their physical or mental health. Variation between medical school or year group was relatively small (13.2% and 9.4% respectively). This is not representative owing to the low participation rate (around 6%). It acted as a marker for further responses, and adds some weight to the belief amongst medical students that stress is highly prevalent within their peer group.
Attitudes to Stress
Students perceived stress to be a normal part of a medical degree, which was only to be expected. In some ways, this is understandable given the exceptionally high self-reported stress levels seen in the questionnaire. On student said:
“people judge their behaviour on the normative values of their peers. Before finals I went out with medic friends and we discussed not sleeping, eating and feeling depressed. I then went out with my boyfriends other uni friends on an arts course and they said "are you crazy? Why let your course do that to you?!" but we do. Stress is part of us”
But beyond the belief that stress is an accepted norm amongst medical students, some students believed that stress was a necessary part of the training to prepare for the inevitably greater stress of being a doctor:
“if you tackle the problem of stress in medical school, brilliant - but what are you going to do when you start working?”
Many students believed that stress was preparing them for their career, and that reducing stress was a bad thing. The saw the high levels of stress at medical school as teaching them how to live with it and get on with it, rather than as an issue that should be tackled or even a problem.
Coping with Stress
Students often adopted negative coping habits, acknowledging that these were not healthy behaviours - but viewing them as normal and not a cause of concern.
Eating habits were commonly flagged as being affected by high stress levels. Stress was used as a reward, or as a method of control. Students felt that this was particularly the case around exam periods, and noted that this meant for months at a time they would be eating in an unhealthily way, or have an unhealthy relationship with food. One student said:
“Me and this other guy…sat in the canteen and bought chocolate bars and muffins and cakes, and we bought them because we said, you know what? It’s the only thing that makes us happy”
Some students described more destructive experiences, where they had struggled to cope with stress, with one stating:
“I know when I’m really stressed because I’ll cry over nothing, I’ll be in floods of tears… just get some chocolate, get some wine, get some cigarettes, watch something tragic and just cry”
Alcohol was highlighted by a number of students, who felt that they used it to relax or unwind. There was a perception that while drinking wasn't good for you, using it as a coping strategy was not out of the norm.
Students felt that not being able to cope was a failure:
“You just have to 'keep calm and carry on' as the phrase goes. To do otherwise would be regarded as appearing weak”
They were fairly unforgiving of both themselves and their peers, describing stress as:
"a pruning mechanism"
Often students felt that it was their own reservations that held them back from asking for help:
“The only boundaries I faced when trying to access [support] was my own personal issues around accepting that I needed support”
It was clear that many students struggled to cope, and used damaging coping habits. Yet equally they struggled to face up to the difficulties, to ask for help or admit that they could not handle the situation alone.
Impacts of stress
Stress impacted three main areas: health, life satisfaction, and academic ability, demonstrating resultant strain - with 19% of students unable to do things owing to stress. One student stated:
“I feel I haven’t enjoyed my time at university. I haven’t been able to relax, enjoy myself fully. It feels like my life just stopped for 4 years”
These feelings were common among the responses.
Students reported significant impacts of stress, on ability and quality of life. However, they did not feel that these were anything abnormal or a cause for concern - and did not actively take any steps to address or change their stress levels or coping behaviours.
To some extent a degree of stress is inevitable, but the resultant strain placed upon the medical student population is reportedly substantial. Eliminating stress would be impractical, in particular as the literature highlights that many of the characteristics that are selected for at entry to medical school (high academic achievement, competitiveness) predispose the population to higher stress levels. However, stress is so prevalent that it is at risk of being trivialised by the population, meaning that there are limited steps to address it or engage with solutions. A large number of students described destructive coping habits, such as heavy drinking and unhealthy eating habits, as well as struggling to cope emotionally potentially leading to burn out. The absence of acknolwedgement that either stress or destructive coping mechanisms are a problem means that students fall into negative patterns of behaviour in order to cope with the strain they are under, which is worrying given the wider issues that the profession has with alcohol, drugs and mental health. Developing positive behaviours early may go some way to protecting the future workforce and profession, and more research is needed to establish how this can be achieved.
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