The Medical Student Stress Prole: a tool for stress

audit in medical training

Margaret ORourke,
1
Sean Hammond,
2
Siun OFlynn
1
& Geraldine Boylan
1
OBJECTIVES It is well recognised that medical
training can be extremely stressful and that
high stress is a risk factor for a wide range of
psychological and health-related consequences.
The primary aims of this study were to intro-
duce the Medical Student Stress Prole (MSSP)
and to demonstrate its psychometric quality as a
specic device for auditing medical student
stress. Secondary aims were to establish the
reliability, construct and criterion validity of
this instrument and to explore the relationships
between stress, coping, personality, motivation
and emotional intelligence in medical students.
METHODS A battery of self-report measures
including the MSSP was administered to a
sample of 239 undergraduate and graduate-
entry medical students. The battery included
indices of stress, coping with and proneness to
stress, as well as measures of emotional
intelligence, motivation style, personality traits,
educational environment perception and self-
reported symptomatology. Psychometric evalu-
ation of the MSSP was conducted along with a
correlation analysis of stress concomitants.
RESULTS The MSSP revealed good psycho-
metric properties and showed a substantial stress
load in the participant sample. The pattern of
correlations with concomitant measures con-
formed generally to expectations. Strong cohort
effects were observed, which suggest the impor-
tance of future investigation into the role of the
group in stress amelioration. Stress adversely
affects ratings of the educational environment as
measured by the Dundee Ready Education
Environment Measure.
CONCLUSIONS The MSSP was specically
developed for the medical training context and
may have utility for individual and group stress
audits of medical students and as a device to
inform remedial programmes in stress
management in medical education.
difculties in training
Medical Education 2010: 44: 10271037
doi:10.1111/j.1365-2923.2010.03734.x
1
School of Medicine, University College Cork, Cork, Ireland
2
School of Applied Psychology, University College Cork, Cork,
Ireland
Correspondence: Margaret ORourke, School of Medicine, Brookeld
Health Sciences Complex, University College Cork, Cork, Ireland.
Tel: 00 353 21 490 1595; Fax: 00 353 21 490 1594;
E-mail: m.orourke@ucc.ie
Blackwell Publishing Ltd 2010. MEDICAL EDUCATION 2010; 44: 10271037 1027
INTRODUCTION
It has long been recognised that medical training can
be extremely stressful and that high stress is a risk
factor for a wide range of psychological and health-
related consequences, such as headaches, gastroin-
testinal disorders, coronary heart disease, depression,
impaired judgement, absenteeism, and self-
medication with drugs and alcohol.
13
Furthermore,
it is recognised that doctors in training and in prac-
tice who fail to manage their stress levels are less likely
to be safe or competent health care providers.
4
High levels of stress do not always result in extreme
consequences, such as substance abuse or depression.
However, snowballing professional stressors, such as
high workload, examination stress and performance
pressure, as well as stressors in the individuals
personal life, can cause pervasive under-performance.
This may lead to psychological morbidity (anxiety or
depression), loss of objectivity, an increased inci-
dence of errors and even improper behaviour, such
as cheating in examinations, fraud or negligence.
4,5
Dyrbye et al.
5
note that widespread distress among
medical students has now been recognised for several
decades, but that studies are required to explore
causes, consequences and solutions for this problem
rather than simply chronicling the problem.
In the past, medical student stress has been assessed
using an array of broad or general measures of
distress, such as the General Health Questionnaire
(GHQ)
6
or the Maslach Burnout Inventory (MBI),
7
which often lack the specicity needed to support an
accurate and coherent prole of the students expe-
rience. In their systematic review of medical student
well-being and distress, Dyrbye et al.
5
conclude that
the lack of validated instruments to assess stress in
the vast majority of studies is a major limiting factor.
The objective evaluation of individual stress is com-
plicated by many factors, but particularly by the facts
that assessors must deal with the inherent subjectivity
of the construct and individuals in the same situation
may not encounter the same stressors and, if they do,
they will vary in their subjective responses to each
one.
8
There is much support for the viability of stress
reduction programmes for medical students.
9
Indi-
vidual stress appraisal methods vary depending upon
the research question being addressed. A generic
approach seeks to assess general psychological
adjustment and well-being as mediated by stress.
Researchers adopting this approach typically use
devices that focus upon the anxiety, depression
and sense of personal incompetence that may be
reasonably assumed to be the sequelae of stress.
However, although such measures may provide useful
information on the prevalence of stress reactions,
they are not sensitive to the particular context and
so do not address the specic causes of stress that
may be unique to the individuals situation.
Typically, stress measures provide a list of stressors
and request the respondent to indicate the degree of
stress each one produces. However, such an approach
does not recognise that the stressors on the list may
occur at different frequencies for different respon-
dents. Furthermore, two respondents troubled, for
example, by tensions with peers may experience the
stressor equally in frequency, but, whereas one of
them may not be much troubled by it, the other may
nd the situation intolerable. One way of addressing
this interaction between the incidence or frequency
of a stressor and its perceived severity is an approach
proposed by Spielberger and Vagg in their Job Stress
Survey.
8
Briey, this identies a list of potential
stressors and respondents are asked to indicate both
the frequency and the perceived severity of each.
A strain index for each stressor may be conceived as
a multiplicative interaction of its frequency and its
perceived intensity. The aggregation of these strain
indices provides an estimate of the stress load
experienced by the respondent. In this way an
idiosyncratic stress level is obtained by taking into
account the specic experiences and perceptions of
each respondent.
The strategy adopted in developing our assessment
protocol was informed by the need for a stress audit
of medical students; therefore, our protocol focuses
on the impact of the medical training context upon
the psychosocial well-being of students. Research into
training-induced stress has two important motiva-
tions. Firstly, it aims to understand the degree to
which such stress inuences physical and mental
health and decision making, and, secondly, it aims to
identify concomitant psychological characteristics
that may serve as inoculators against, or catalysts for,
the development of harmful reactions to stress. The
latter objective may serve as a basis for screening
vulnerable applicants in the selection process. To this
end, the Medical Student Stress Prole (MSSP) was
developed to measure medical student stress directly
and to evaluate the coping style and personal
resources that may help the individual to deal with
stress.
Of the personal resources that moderate stress,
research has found characteristics such as
1028 Blackwell Publishing Ltd 2010. MEDICAL EDUCATION 2010; 44: 10271037
M ORourke et al
perfectionism and neuroticism to be highly predictive
of stress in medical students.
10
Tyssen et al.
10
also
demonstrated the protective qualities of a hedonistic
combination of traits (high extroversion, low
neuroticism and low conscientiousness). In addition,
the relationship between emotional intelligence (EI)
and stress appears to suggest that EI may protect
against the effects of psychological stress.
1113
Landa
et al.,
13
for example, showed that, in a sample of
nurses, EI represented a protective factor against
stress, whereas others have demonstrated that EI
training may enhance well-being.
14
However, Gohm
et al.
15
found the relationship between EI and stress
to be a complex one which appears to be moderated
through personality and thus any ameliorating effect
of EI on stress is unlikely to be direct.
Much effort is now invested in the assaying of the
education environment as a surrogate marker of the
effect of curricular reform and for the purposes of
programme evaluation. The Dundee Ready Educa-
tional Environment Measure (DREEM),
16
one of the
most commonly used instruments, is used by our
institution; some sections in the DREEM measure
perceptions of atmosphere and social self-perception.
As these are surely confounded by individual stress
levels,
17
the present study explored the relationship
between stress and perceptions of the educational
environment as measured by the DREEM.
The study had the following objectives:
1 to introduce the Medical Student Stress Prole, a
new measure tailored specically to measure
medical student stress, and to establish its
psychometric value;
2 to evaluate the usefulness of the MSSP for
assessing medical student stress;
3 to explore the concomitants of stress symptoms
in order to identify characteristics that may have
possible protective or exacerbating effects in
relation to stress, and
4 to examine the relationship between stress and
perceptions of the learning environment as
measured by the DREEM.
METHODS
Participants
Three cohorts of medical students at the School of
Medicine, University College Cork, Cork, Ireland,
were sampled. Cohort 1 comprised those entering
their nal year in 2007 and Cohort 2 comprised those
entering their nal year in 2008. In addition, a third
cohort of graduate-entry medical students was sam-
pled for comparison as these students were similar in
age to nal-year students. These graduate-entry stu-
dents all held a previous degree in another discipline
and were in their rst year of a 4-year medical degree
programme. The complete sample consisted of 239
students.
Materials and instruments
Each participant completed a battery of self-report
tests comprising a total of 290 questions. This took
4050 minutes to complete. The battery consisted of
the following instruments:
the MSSP, the focal instrument of this study,
which consists of 100 items tapping stress, coping
and personal resources and measures ve facets
of situational stress (time-, course-, supervision-,
social- and patient-related), four facets of coping
with stress (emotion-focused, support-seeking,
passivity, rationalisation) and two measures of
personal resources (negative affect and self-
worth);
the International Personality Item Pool (IPIP),
18
a 50-item inventory measuring the Big Five
personality traits of extraversion, agreeableness,
conscientiousness, neuroticism and openness;
the Behavioural InhibitionActivation Inventory
(BIS BAS),
19
a 24-item inventory assessing
motivational style;
the Trait Emotional Intelligence Scale,
20
a
41-item measure of trait EI;
a symptom checklist assessing the degree of
debilitation caused by stress and designed for this
study to provide a measure for each of three
modalities of symptoms (physical, psychological
and behavioural), and
the DREEM,
16
a 30-item measure of students
perceptions of their educational context
comprising ve subscales measuring perceptions
of learning, perceptions of teachers, academic
self-perception, perceptions of atmosphere and
social self-perception.
Development of the MSSP
An initial pilot study was conducted involving two
cohorts of nal-year medical students in 2005 and
2006. The pilot cohorts questionnaire results,
themes from written reections on experiences in
medical school and their feedback from stress regu-
lation workshops were then used to identify stressors
Blackwell Publishing Ltd 2010. MEDICAL EDUCATION 2010; 44: 10271037 1029
Stress audit of medical students
for inclusion in the MSSP. The stressors were
identied according to:
1 thematic analysis using grounded theory of
2 years of reective portfolios documenting stu-
dent experiences on clinical rotations, which are
routinely completed by all students and routinely
corrected by the authors;
2 student workshops in identifying coping mecha-
nisms in stressful situations and decision-making
approaches, which are a component of profes-
sionalism training for all students and which are
conducted by the authors, and
3 informal interviews with four experienced
medical educators with clinical backgrounds.
Five a priori facets were identied, relating to,
respectively: Course Organisation; Supervision; Time
Pressures; Social Pressures, and Medical-Specic or
Patient issues.
The resulting Stress Index presents respondents with
52 stressors and asks them to estimate the frequency
at which each one occurs and then to indicate the
perceived severity of stress it produces. The indicators
use a 6-point rating scale of 05. Upon completion,
the square root of the product of the two ratings for
each stressor is obtained. This value is sometimes
known as the geometric mean or the dot product
and has the advantage of producing a value with the
same 05 range as the ratings. The sum of these values
provides the stress score estimate for each respondent.
The stress coping scale consists of 23 items. Respon-
dents are asked to rate how much they will typically
engage in each activity as a response to stress. This
measure has not been previously published, but has
been used successfully by students of the second
author for a number of years and has consistently
identied four facets that correspond closely to
those identied by Lazarus and Folkman.
21
These
facets are labelled Emotive Response, Rationalisation
Response, Support-seeking Response and Passive
Response. The Personal Resources Index was deve-
loped from an informal scale developed by Beech
22
to indicate emotions and behaviour that pertain to
proneness to stress. Twenty-ve items were selected
that reected the two correlated facets of negative
affect (13 items) and positive self-worth (12 items).
Procedure
Before proceeding, ethical approval was obtained
from the Clinical Research Ethics Committee of Cork
Teaching Hospitals.
Each participant in the present study was asked to
complete the MSSP and the battery of self-report tests
described above. The test battery was presented
during a timetabled lecture dedicated to the topic of
stress. Although participation was optional and
students were free to withdraw, we achieved 100%
compliance. This level of compliance was possibly
inuenced by student curiosity as all participants
were given an individual analysis. Students were
informed about the options available for help and
support with stress if required.
Data management and analyses
The completed questionnaire responses were entered
into an anonymised database for subsequent analysis.
Data analysis was performed using SPSS Version 15
(SPSS, Inc., Chicago, IL, USA) and a conrmatory
factor analysis using the multiple group factor anal-
ysis (MGFA) procedure was performed. In view of the
dearth in commercial software for performing MGFA,
a custom-built program was written for the analysis by
the second author using a program written for a
WINDOWS platform.
RESULTS
Of the 239 medical students participating in this
study, 151 were female and 87 were male (one person
did not register gender). The median age of partic-
ipants was 22 years (range 1739 years). The rst
cohort comprised nal-year medical students sur-
veyed in 2007 (n = 102); the second comprised nal-
year medical students surveyed in 2008 (n = 99) and
the third comprised rst-year graduate-entry medical
students surveyed in 2008 (n = 38).
Psychometric properties of the MSSP
The psychometric properties of the MSSP indices are
summarised in Table 1. A classical itemetric analysis
was performed on each index, resulting in a lower
bound estimate of reliability based upon the internal
consistency of the items in each scale. Cronbachs
23
alpha is reported in column 5 of Table 1. In addition,
each index was subjected to a conrmatory MGFA
24
in order to evaluate its hypothetical factor structure.
An index of t for each factor was identied
25
and is
presented in column 6. One advantage of the MGFA
is that it is non-iterative and thus it is a simple matter
to t a large number of alternative models in order to
test the hypothesised structure against alternatives.
For each MGFA carried out, 5000 alternative random
models were generated and tested. For brevity, the
1030 Blackwell Publishing Ltd 2010. MEDICAL EDUCATION 2010; 44: 10271037
M ORourke et al
MGFA is presented in a summarised form in Table 2;
a full listing of the factor pattern matrices may be
obtained from the second author. In each case the
hypothesised model showed the best t to a statisti-
cally signicant degree.
The psychometric properties of the Stress Index are
quite acceptable. No alpha coefcient falls below 0.70
and this is a widely accepted criterion for reasonable
internal consistency.
26
The factor t indices are also
good, which indicates that the items fall reliably
into the scales to which they are assigned. However,
although it showed a good factor t, the Coping
Index did not manifest the internal consistency
expected. Although the passivity scale is weak but
acceptable, the rational scale manifested poor reli-
ability. In subsequent analysis this scale is removed.
The Personal Resources Index provides two scales
with an acceptable degree of internal consistency
and excellent t to the scales structure proposed.
Overall, 25% of the students manifested appreciable
stress, with total stress scores > 130, and 3.3% dem-
onstrated extreme levels of stress with scores > 156.
These cut-off scores are approximations and await
conrmation based upon continuing clinical apprai-
sal. They are predicated upon the fact that a score of
130 indicates an average stress rating of 2.5 on a scale
of 05 and a score of 156 indicates an average > 3.0.
An advantage of taking a situation-specic approach
to stress appraisal is that each stressor is identied to
be directly salient to the individuals environment.
This means that each stressor can be examined
individually and those carrying out the stress audit
can examine the specic sources of greatest stress for
each individual or group. Table 3 summarises the
responses to the MSSP for the total merged sample.
Column 3 shows the mean rating of the frequency
with which the stressor occurs; column 4 reports the
mean rating of the subjective severity of the stressor,
and column 5 shows the combined stress load for
that stressor, taking into account its frequency and
severity. The stressors are ordered according to their
stress load.
From Table 3 it is apparent that examinations and
lack of time for exercise and social interactions
represent more severe stressors for students than
perceived discrimination on the course or the death
of patients. The latter is likely to reect little real-life
experience of patient mortality at this stage in
students careers. Interestingly, fear of failure is also a
signicant stressor.
It is also worth comparing the frequency with the
intensity rating of each stressor. Thus, complaining
among peers (item 34) appears to be quite prevalent,
but respondents do not generally consider this to be
particularly stressful and therefore it carries a rela-
tively low stress load (1.84). By contrast, inadequate
guidance from supervisors (item 38) is highly stressful
but infrequent and this also carries a similarly low
stress load (1.80). This table provides course manag-
ers with indications of potential stress points in
Table 1 Psychometric properties of the Medical Student Stress
Prole scales
Scale Mean SD n a Fit
Stress prole
Time pressure 24.66 9.37 10 0.81 0.88
Intrinsic factors 13.78 8.38 8 0.82 0.77
The course 17.16 8.61 9 0.81 0.80
Isolation 9.39 5.64 4 0.84 0.94
Supervision 9.38 4.99 5 0.72 0.84
Total 106.77 34.69 52 0.89 0.80
Coping prole
Emoting 10.86 5.25 5 0.75 0.94
Passivity 11.71 5.45 7 0.65 0.81
Support seeking 11.74 3.97 4 0.73 0.88
Rationalising 21.23 5.12 7 0.55 0.87
Resource prole
Negative affect 32.80 8.02 13 0.72 0.95
Positive self-worth 34.52 7.82 12 0.71 0.90
SD = standard deviation
Table 2 Summary of multiple group conrmatory factor
analyses of Medical Student Stress Prole measures
Stress
prole
Coping
prole
Resource
prole
Number of factors 5 4 2
Index of overall t 0.80 0.88 0.95
Mean t for
5000 random patterns
0.62 0.81 0.85
Standard deviation 0.04 0.03 0.04
Approximate statistical t (z) 4.50 2.33 2.50
Values shown in italics are signicant at p < 0.05
Values shown in bold italics are signicant at p < 0.01
Blackwell Publishing Ltd 2010. MEDICAL EDUCATION 2010; 44: 10271037 1031
Stress audit of medical students
course provision and might serve to aid in the
remediation of student stress by facilitating more
detailed consideration of the emphases in course
structure and organisation.
Concomitants of the MSSP
Two-way analyses of variance (ANOVA) were carried out
for each MSSP scale. The results are summarised in
Table 4. The F -value and effect size (partial e
2
) are
presented for each effect. The rst two columns
Table 3 Mean ratings and strain values for each stressor
utilised in the Medical Student Stress Prole
Index
no. Stressor Frequency Severity Stress
32 Discrimination 1.55 0.79 0.78
46 Death of patients 1.83 1.04 0.98
23 Partner resents time
spent
2.19 1.16 1.27
27 Unsupportive people
outside the course
1.68 1.48 1.30
21 Hard to talk to
supervisor
1.48 2.15 1.36
20 Peers do not pull
weight
1.33 2.41 1.37
29 Unsocial hours 1.35 2.75 1.39
48 Chronic patients 2.44 1.44 1.48
51 Discussing personally
sensitive matters
2.85 1.33 1.51
18 Inadequate student
facilities
1.50 2.75 1.59
26 No say in course
organisation
1.85 2.39 1.61
50 Physical
examinations
2.62 1.52 1.63
43 Placed in physical
danger
2.01 1.52 1.64
25 Too much
responsibility
1.43 2.70 1.67
47 Terminally ill patients 1.94 2.00 1.71
31 Lecturers do not
listen
2.05 1.76 1.77
11 Financial pressure 1.79 2.33 1.79
28 Poor lecturers 1.62 2.70 1.80
38 Inadequate guidance 1.71 2.90 1.80
34 Complaining among
peers
3.18 1.51 1.84
2 Unsupportive
supervisors
2.37 1.90 1.88
49 Fear of infection 2.81 1.79 1.90
39 Unpleasant patients 1.69 2.70 1.91
17 Boredom 1.86 2.63 1.97
19 Course interferes
with home
life
1.95 2.70 2.00
1 Not getting on with
peers
2.31 2.05 2.00
Table 3 (Continued)
Index
no. Stressor Frequency Severity Stress
3 Unsupportive department 2.09 2.24 2.01
35 Workload 2.20 2.29 2.03
22 Inadequate patient
facilities
2.35 2.22 2.05
33 Less able students getting
credit
2.03 2.44 2.14
42 Going nowhere 2.34 2.17 2.16
52 Discussing sexual matters 2.60 2.22 2.17
8 No time for
extracurricular activities
2.38 2.35 2.20
5 Loneliness 2.27 2.47 2.21
10 Peer competition 2.92 2.13 2.22
44 Course unchangeable 2.68 2.26 2.23
4 Unsupportive lecturers 2.11 2.88 2.31
16 Not enough time 3.46 2.24 2.34
7 Strain on relationship 2.20 3.30 2.35
15 Dependent on nancial
support
2.89 2.76 2.39
24 Not getting enough credit 2.77 2.43 2.47
30 Unsupportive peers 2.75 2.50 2.52
12 Rote learning 3.27 2.51 2.55
37 Isolated on course 2.64 2.82 2.64
45 Consequences of
decisions
are serious
3.26 2.49 2.70
14 No time for rest 3.07 2.81 2.80
40 Insufcient support staff 2.99 2.79 2.85
36 Work family conict 2.96 3.31 2.98
6 Fear of failure 3.47 3.33 3.23
41 Course versus social life 3.52 3.27 3.34
13 No time for exercise 3.75 3.33 3.43
9 Examinations 3.79 3.58 3.59
1032 Blackwell Publishing Ltd 2010. MEDICAL EDUCATION 2010; 44: 10271037
M ORourke et al
depict the cohort effect; the second two columns
represent the sex effect, and the last two columns
show the interaction (cohort by sex) effect.
The most notable, and unexpected, nding is that
there is a highly signicant cohort difference on all
the stress scales. In each case, the 2007 cohort
manifested low stress scores, whereas the 2008
cohort and the graduate-entry cohort revealed no
difference in stress levels as measured by the MSSP.
There were also statistically signicant differences
on the coping scales, demonstrating that the 2007
cohort was less passive and less likely to rationalise
stress than the other two cohorts. However, although
the F -ratios suggest statistical signicance, the effect
sizes for these differences are very low. Finally, the
2007 cohort showed less negative affect and greater
positive self-worth than the other cohorts.
Sex differences inMSSPscores are only weakly evident.
Womenmanifested greater isolationstress and showed
greater support-seeking and emotion-focused coping
styles reected by statistically signicant F -values.
These sex differences are inkeeping withexpectations,
but it should be noted that the effect sizes are very
small, which makes generalisation quite difcult.
Finally, the correlations between the MSSP scales
and the other measures employed in this study,
including age, are presented in Table 5. It is
apparent that the stress scales (15) are highly
correlated with one another with the exception of
that for time-related stress, which proves to be
essentially unrelated to all the other stress scales
except for the scale measuring supervision-induced
stress. It is also clear that negative affect (11) is
closely correlated with stress, as expected, and the
negative correlations with positive self-worth (12)
indicate that stress may be moderated by positive
affect and self-worth. The weak correlation between
these two scales indicates that they have a true
incremental effect upon stress.
The additional trait measures reveal a pattern of
correlations that is entirely expected from the
research literature. Emotional intelligence is moder-
ately associated with total stress, but particularly with
time-related stress, and is also related to greater use of
emotional and less use of passive coping strategies.
Emotionally intelligent individuals are also less
likely to manifest negative affect and more likely to
have high positive self-worth scores. Counter to
expectations, motivational style, as measured by the
BIS-BAS scales, and the Big Five personality traits,
as measured by the IPIP, do not generally relate to
stress except for time-related stress, for which the
extraverted, conscientious and neurotic scales
manifest positive correlations.
Table 4 ANOVA summary of each Medical Student Stress Prole scale by cohort and sex
Scale
Cohort effect Sex effect Cohort by sex
F - value e
2
F - value e
2
F - value e
2
Total stress 86.13

0.43 0.18 0.00 0.86 0.00

Time stress 6.09

0.05 0.71 0.00 1.03 0.01

Intrinsic stress 75.96

0.41 0.35 0.00 1.42 0.01

Course stress 125.78

0.53 0.04 0.00 0.46 0.00

Isolation stress 182.20

0.61 3.83* 0.02 2.55 0.02

Supervisor stress 38.26

0.25 0.00 0.00 0.65 0.00

Passive 5.98* 0.05 0.32 0.00 0.09 0.00
Support seeking 1.09 0.01 16.29

0.07 2.00 0.02

Rational 9.34

0.07 1.67 0.01 0.15 0.00

Emotional 0.61 0.00 12.44 0.05 0.45 0.00
Negative affect 8.23

0.06 1.87 0.01 0.17 0.00

Positive self-worth 76.40 0.40 2.28 0.01 8.12

0.06
* p < 0.05

p < 0.01
Blackwell Publishing Ltd 2010. MEDICAL EDUCATION 2010; 44: 10271037 1033
Stress audit of medical students
Symptom reporting is highly related to time-related
stress, but not to the other sources. However, the
emotional and passive coping styles, as well as the
negative effect scales, are also correlated with
greater numbers of symptoms, which is largely
expected. These relationships hold across all symp-
tom modalities, be they physical, emotional or
behavioural.
Table 5 Correlations between the 12 Medical Student Stress Prole scales, trait measures, educational perceptions and self-reported
symptoms
1 2 3 4 5 6 7 8 9 10 11 12
1 Time 1
2 Intrinsic ) 0.032 1
3 Course 0.074 0.620 1
4 Isolation ) 0.010 0.585 0.718 1
5 Supervision 0.265 0.436 0.621 0.586 1
6 Total stress 0.413 0.738 0.847 0.776 0.757 1
7 Emotional 0.487 0.146 0.159 0.253 0.354 0.393 1
8 Passive 0.231 0.342 0.267 0.327 0.299 0.405 0.512 1
9 Support 0.086 0.138 0.172 0.152 0.042 0.178 0.220 0.149 1
10 Rational 0.161 0.054 0.118 0.019 ) 0.051 0.103 ) 0.054 0.098 0.273 1
11 NegAffect 0.443 0.306 0.403 0.430 0.484 0.569 0.530 0.414 0.248 0.114 1
12 PosWorth 0.133 ) 0.327 ) 0.380 ) 0.428 ) 0.264 ) 0.336 ) 0.087 ) 0.221 0.005 0.185 ) 0.125 1
Trait measures
Emotional IQ ) 0.252 0.080 0.056 0.047 0.097 ) 0.171 ) 0.269 ) 0.255 ) 0.019 0.049 ) 0.174 0.204
BAS Drive 0.261 ) 0.068 ) 0.158 ) 0.153 ) 0.040 ) 0.024 0.153 0.023 0.015 ) 0.011 0.013 0.072
BAS Fun 0.089 0.048 ) 0.064 ) 0.009 0.058 0.044 0.147 0.047 ) 0.111 ) 0.053 0.028 0.023
BAS Reward 0.067 0.128 0.109 0.190 0.143 0.181 0.198 0.151 0.058 0.059 0.166 ) 0.097
BIS ) 0.015 ) 0.064 ) 0.114 ) 0.098 ) 0.050 ) 0.085 0.013 ) 0.006 0.002 0.031 ) 0.144 0.185
Extravert 0.356 0.061 0.003 0.007 ) 0.010 0.201 0.169 0.068 ) 0.018 ) 0.193 0.156 0.059
Conscientious 0.314 0.124 0.114 ) 0.068 ) 0.013 0.219 0.055 0.027 ) 0.077 ) 0.238 0.075 0.012
Agreeable 0.176 ) 0.047 ) 0.162 0.111 ) 0.139 0.006 0.104 0.073 ) 0.028 ) 0.139 0.037 ) 0.080
Neurotic 0.301 0.100 0.042 0.011 ) 0.008 0.192 0.074 ) 0.002 ) 0.092 ) 0.187 0.039 0.050
Open 0.215 0.050 0.070 ) 0.118 0.005 0.123 0.048 ) 0.032 ) 0.177 ) 0.252 0.027 ) 0.029
DREEM
Learning ) 0.011 ) 0.258 ) 0.343 ) 0.250 ) 0.305 ) 0.328 ) 0.101 ) 0.129 ) 0.026 0.246 ) 0.160 0.313
Course ) 0.013 ) 0.282 ) 0.364 ) 0.312 ) 0.310 ) 0.357 ) 0.087 ) 0.140 0.012 0.281 ) 0.197 0.331
Academic self ) 0.198 ) 0.014 ) 0.110 ) 0.047 ) 0.203 ) 0.165 ) 0.185 ) 0.170 0.035 0.301 ) 0.162 0.204
Atmosphere ) 0.033 ) 0.262 ) 0.336 ) 0.309 ) 0.280 ) 0.350 ) 0.108 ) 0.178 0.017 0.271 ) 0.198 0.302
Social self ) 0.142 ) 0.156 ) 0.230 ) 0.214 ) 0.217 ) 0.282 ) 0.180 ) 0.167 0.021 0.271 ) 0.225 0.195
Total DREEM ) 0.054 ) 0.231 ) 0.325 ) 0.268 ) 0.290 ) 0.333 ) 0.104 ) 0.133 0.014 0.306 ) 0.181 0.315
Symptoms
Physical 0.270 ) 0.050 ) 0.036 0.014 0.109 0.083 0.353 0.216 0.069 0.074 0.283 ) 0.018
Psychological 0.329 ) 0.068 ) 0.075 0.063 0.144 0.115 0.348 0.232 0.101 ) 0.002 0.367 0.077
Behavioural 0.279 ) 0.048 ) 0.088 0.014 0.154 0.077 0.318 0.272 0.032 ) 0.023 0.341 0.069
Age 0.039 ) 0.020 ) 0.024 0.166 ) 0.113 ) 0.019 0.131 ) 0.00 0.081 0.072 0.100 ) 0.111
Values shown in italics are signicant at p < 0.05
Values shown in bold italics are signicant at p < 0.01
NegAffect = negative affect; PosWorth = positive self-worth; BAS = Behavioural Activation Inventory; BIS = Behavioural InhibitionActivation
Inventory; DREEM = Dundee Ready Educational Environment Measure
1034 Blackwell Publishing Ltd 2010. MEDICAL EDUCATION 2010; 44: 10271037
M ORourke et al
Perceptions of training environment, as measured by
the DREEM, show a pattern of negative correlations
with stress. This is expected because students who
experience their course as highly stressful are likely to
perceive the course in a negative light. The role of
person state in rating the course is also evident by the
fact that negative affect and positive self-worth are
also highly correlated with the DREEM, which raises
doubts about its objective basis.
The correlations with age reveal only one statistically
signicant relationship, indicating that older partic-
ipants experience greater isolation stress. However,
the lack of age variability in the sample makes any
clear interpretation of these ndings difcult. In
summary, the concurrent validation of the MSSP
appears to be quite strong and reveals a pattern of
relationships that conform well with expectations.
DISCUSSION
The Medical Student Stress Prole is a psychometri-
cally viable tool for assessing the stress levels of
medical students. The correlates of the MSSP scales
presented here provide a reasonable basis for their
concurrent validation. The pattern of relationships
is largely as expected, although the apparent
separation of time-related stress from the other facets
identied is curious and merits further investigation.
The construct validity of the scales was strongly
supported by the conrmatory factor analysis
summarised in Table 2 and provides additional
condence in the measurement properties of the
MSSP.
The MSSP is predicated upon the fact that the
appraisal of situational stress requires tailor-made
measurement tools that target stressors that are
specic to that situation. As such, the MSSP is
recommended for stress audit research in the medical
education context. The MSSP utilises a list of stressors
that are particular to the study of medicine. More
general stress measures are available,
8,27
but these are
less useful in carrying out a stress audit in a medical
training context.
A notable nding concerns the signicant cohort
variation in the stress experienced. Many third-level
educators will attest to the anecdotal observation that
student cohorts vary in terms of motivation and
character; however, it is unlikely that our ndings
indicate that one cohort was inherently less stress-
prone than the others. It is far more likely that some
aspect of the situation, environment or peer group
interactions for Cohort 1 protected against stress.
Our nding of a clear distinction between cohort
groups suggests a fruitful avenue for research into
group effects on the amelioration or exacerbation of
student stress.
Medical schools have an increasingly important role
to play in auditing the stress experienced by their
students and they may be the rst line of detection
and defence.
28
The requirement for a needs
assessment device to inform possible interventions
relating to student stress was a primary motivation
for the development of the MSSP. There are a
number of advantages to medical school-based
interventions: attendance is compulsory and the
level of stigma attached to medical school stress
regulation training is much lower than that associ-
ated with attending individual therapy. Medical
schools can provide long-term continuous support
for students, and thus monitor their progress and
preparedness for practice more effectively.
29
To this
end, stress regulation and mental health promotion
targeted at medical school students have become a
focus of concern nationally and globally.
5
The
application of the MSSP for individual and group
stress audit has been alluded to. The prole
provided by the MSSP will inform intervention
strategies: in the present case, for example, students
from this sample may need help to prioritise and
manage their time. Findings here also suggest that
stress levels, especially time-related stress, have a
strong relationship with self-reported physical,
emotional and behavioural symptomatology.
In the past, medical stress has been assessed using an
array of broad, generalist or non-specic assessments,
which often lack the specicity needed to support an
accurate and coherent prole of individual experi-
ence. The MSSP is designed to focus specically
upon the unique experience of medical student
stress and provides a prole for each student that
should:
1 increase self-awareness through a prole of
strengths and vulnerabilities;
2 inform individualised strategies for managing the
stress of medical training before it impinges
deleteriously upon the learning and practice of
young medical practitioners, and
3 ultimately assist in the process of suitability
assessment for medical training or specialisation.
It is appropriate that educators evaluate courses and
the DREEM is an instrument used extensively for this
purpose. Our data suggest that individual and cohort
Blackwell Publishing Ltd 2010. MEDICAL EDUCATION 2010; 44: 10271037 1035
Stress audit of medical students
characteristics related to stress levels, stress proneness
and coping should also be assayed in order to
interpret such data.
The present study has limitations in that its sample
comes from only one medical school and the
heterogeneity across cohorts means that the nor-
mative data collected so far are still only approxi-
mate. This limitation will be removed by further
ongoing research. This paper has been limited to
presenting the psychometric status of the MSSP and
has been less forthcoming on more substantive
issues of stress among medical students. Neverthe-
less, the development of the MSSP is one compo-
nent of wider-ranging research into the provision of
stress reduction interventions and audit within
medical training.
Ongoing and future research with the MSSP will
focus upon the causes, extent and consequences of
stress across all years of the medical curriculum. In
addition, it will be used to develop explanatory
models of medical student stress. Cohort and indi-
vidual differences will be further examined in order
to help with the development of effective
interventions.
CONCLUSIONS
The present research is psychometric in scope and
serves as a springboard for a more substantive and
ongoing programme of research into medical
student stress awareness and self-care. The existence
of a psychometrically sound and highly specic
instrument for the auditing and appraisal of
medical student stress is a necessary precursor to
this research initiative. The MSSP is introduced as
such a device and it is suggested that it may
have great utility for research into medical student
stress.
Contributors: MOR conceived the project, contributed to
the interpretation of data and authored the rst draft of the
paper. SH was responsible for the design of the project and
oversaw the data collection, analysis and interpretation.
SOF and GB reviewed the relevant literature and fed into
the construction of the paper. All authors contributed to
the revision of the paper and approved the nal manuscript
for publication.
Acknowledgements: the authors thank Simon Smith, School
of Medicine, University College Cork for discussion and
insights into the form of the questions asked.
Funding: none.
Conicts of interest: none.
Ethical approval: this study was approved by the
Clinical Research Ethics Committee of Cork Teaching
Hospitals.
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Received 2 November 2009; editorial comments to authors 9
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Stress audit of medical students
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