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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
February 2010; accepted for publication 8 April 2010
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Stress audit of medical students
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