Physiotherapy 96 (2010) 206212

Sources of stress and psychological morbidity among undergraduate physiotherapy students

J.M. Walsh a, , C. Feeney a , J. Hussey a , C. Donnellan b,c
a

School of Physiotherapy, Trinity Centre for Health Sciences, St. Jamess Hospital, Dublin 8, Ireland b Department of Medical Gerontology, Trinity College Dublin, Ireland c School of Nursing and Midwifery, Trinity College Dublin, Ireland

Abstract Objectives Professional education can be a stressful experience for some individuals, and may impact negatively on emotional well-being and academic performance. Psychological morbidity and associated sources of stress have not been investigated extensively in physiotherapy students. This study explored sources of stress, psychological morbidity and possible associations between these variables in undergraduate physiotherapy students. Design A questionnaire-based survey. The Undergraduate Sources of Stress Questionnaire was used to identify sources of stress, and the General Health Questionnaire-12 (GHQ-12) was used to rate the prevalence of psychological morbidity, using a conservative GHQ threshold of 3 to 4 to determine probable cases. Uni- and multivariate tests of correlation were used to analyse the data. Setting An Irish educational institution. Participants One hundred and twenty-ve physiotherapy undergraduate students. Results More than one-quarter of all students (27%) scored above the GHQ threshold, indicating probable psychological morbidity. This is higher than the level of psychological morbidity reported by the general population. Regression analysis showed that academic ( = 0.31, P < 0.001) and personal ( = 0.50, P < 0.001) sources of stress subscales were signicant coefcients, explaining 48% of the variance in psychological morbidity after controlling for part-time employment and hours spent studying. Individual signicant items from these subscales were stressful events ( = 0.24, P = 0.004), mood ( = 0.43, P 0.001) and overall level of stress ( = 0.35, P 0.001). Conclusions The results highlighted the emotional vulnerability of a signicant proportion of physiotherapy students, with academic and personal issues being the greatest concern. While personal causes of stress such as stressful events and mood are more difcult to control, manipulation of curricular factors may have positive effects on academic sources of stress. 2010 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.
Keywords: Stress; Education; Undergraduate students; Physiotherapy; Psychological morbidity

Introduction Attending university is a positive experience for many students but can be a stressful experience for some. Lazarus and Folkman [1] dened stress as a particular relationship between the person and the environment that is appraised by the person as taxing or exceeding his or her resources and endangering his or her well-being. College students have to adapt to numerous new situations [2] and experience a high level of stress due to examinations, assignments,

Corresponding author. Tel.: +353 1 8962110; fax: +353 1 4531915. E-mail address: walshj7@tcd.ie (J.M. Walsh).

time pressure and uncertainty [3]. While not all stress can be viewed as negative [4], mental and physical health problems above a certain level can be associated with poorer academic outcomes [5,6]. Professional education of physiotherapists in Ireland is similar to that of medical and dental students, with a demanding physical and academic component from challenging lectures to intense clinical training [2,7]. The prevalence of high levels of psychological morbidity among medical students is well documented [6,825]. The prevalence of psychological morbidity among physiotherapy students is less well known; however, the available evidence in this area indicates high levels of academic stress [2,4,26]. A recent study

0031-9406/$ see front matter 2010 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.physio.2010.01.005

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carried out in undergraduate physiotherapy students in the UK and Western Australia [7] reported consistent ndings with earlier studies, as academic concerns were rated highest by students; amount to learn, time demands of the course and conict with other activities scored highest within this section. The majority of students (71%) perceived the course to be more difcult than expected. However, although sources of stress were identied, the level of psychological morbidity was not investigated, making comparison with other studies difcult. University places in physiotherapy programmes in Ireland are highly sought after, with the majority of applicants achieving high grades equivalent to the top 5% of candidates taking the nal secondary level examination [27]. This study took place in the Department of Physiotherapy, Trinity College Dublin. Physiotherapy in this institution is a 4-year programme leading to a Bachelor of Science degree. This department has recently moved to semesterisation; however, at the time of study recruitment, each year was divided into three terms. End-of-year examinations are scheduled in May and June of each year. Students spend 21 to 25 hours/week in lectures, tutorials and practical classes when based in the university, or 35 hours/week while on clinical placement, for approximately 32 weeks/year. Demands placed on students are high and graduate unemployment is a newly emerging problem in the Irish context. The programme is largely academic in the rst and second years, with an extensive clinical component totalling over 1000 hours, mainly over the third and fourth years. A higher level of stress related to clinical placement is consistent with ndings in other health science disciplines such as medical and nursing students [22,2831]. Helmers et al. [31] reported that the transition from basic science to clinical education was connected with an increase in stress and depressed mood in medical students. Conversely, a study carried out by Tucker et al. [7] reported that physiotherapy students showed significantly lower academic stress in their fourth year, which is primarily clinical. The present study arose out of observations of student stress reported by physiotherapy practice tutors during clinical placement. Therefore, the aim of this study was to estimate the prevalence of psychological morbidity and to identify associations between sources of stress and levels of wellbeing among undergraduate physiotherapy students.

Method Ethical approval was sought by the institutional ethics committee. Study information leaets were administered to students 1 week prior to data collection, outlining the purpose of the study, the data collection process and highlighting the voluntary nature of the study. Students were assured that their participation was anonymous and would have no impact on grades or progression in the course. Two research students, external to the study, were responsible for the administra-

tion and collection of questionnaires. A consent form was administered with the questionnaire and signed by all students who participated. An additional information leaet was also provided with details of the study, including information on available support services. Student background and demographic details, including age, gender, part-time employment and hours spent studying per night, were recorded in addition to the General Health Questionnaire (GHQ-12) [32] and the Undergraduate Sources of Stress (USOS) questionnaire [33]. The GHQ-12 [32] was used to measure psychological morbidity. This measure contains three factors anxiety and depression, social dysfunction and loss of condence with a recall period over the previous 4 weeks. The GHQ-12 has shown good validity and reliability when assessing psychological status in a young population [34], and has previously been validated specically in a student sample [35]. In the current study, Cronbachs alpha for the GHQ-12 was 0.78. The GHQ-12 [32] was scored in two ways: the standard method and the Likert method. The standard method involves scoring 0 if either of the rst two answer categories are chosen, or 1 if the third or fourth answer categories are chosen; the scaled scores are summed to produce a total maximum score of 12. This method was used for descriptive purposes only to indicate proportions of scores above and below the threshold. If the total score is above a set threshold, this is termed a case, supposedly to correspond to the level of stress of the average individual referred to a psychiatrist. To ensure comparison with available literature, a threshold score of 3 to 4 was chosen for the purposes of this study [6,22,24,36]. The Likert method of scoring involves assigning weights of 0, 1, 2 or 3 to each category. This method was used for further parametric statistics including mean and standard deviation (SD) scores, correlations and regression analysis by treating the total score as a continuous measure. The USOS questionnaire [33], developed by Blackmore and Tucker, was used to identify sources of stress in undergraduate physiotherapy and podiatry students. The authors recommend the use of this questionnaire to investigate these sources of stress in similar undergraduate samples. The questionnaire contains 18 items in three subscales: nancial (ve items), personal (seven items) and academic (six items). Students were asked to rate their level of stress on a scale from 0 to 4 (0, not at all; 1, a little; 2, somewhat; 3, quite a bit; 4, a great deal). Permission was granted by the author to use the USOS questionnaire. This measure has been shown to have moderate to good reliability, with internal consistency for academic demands, personal issues and nancial concerns of = 0.82, 0.79 and 0.67, respectively [33]. Similarly, this study showed moderate to good internal consistency (nancial, 0.67; academic, 0.77; personal, 0.81). In addition, the level of stress associated with having a part-time job was measured with an additional single item, scored 0 to 4 in correspondence with the USOS scale. All undergraduate physiotherapy students were eligible to participate in the study. The study questionnaire, including the GHQ-12, USOS and student demographic details, was

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administered during Hilary term, corresponding to January to March 2008, while students were on site at the university. The rst- and second-year students were on site throughout the whole of the study period and received the questionnaire in January. The questionnaire was administered to third-year students in January, as they were scheduled to go on clinical placement in February. Fourth-year students were on clinical placement until February, so questionnaires were administered to them on return from placement. The timing of this study did not correspond with an examination period.

Statistical analysis Descriptive statistics were used to present background and demographic data for each undergraduate year. Values given in the descriptive results are proportions, means and SDs. The KolmogorovSmirnov test was carried out to assess data distribution, and all variables analysed were normally distributed (P > 0.05). Differences between variables were examined using one-way analysis of variance. Associations between variables were examined using Pearsons correlation at a univariate level and linear regression at a multivariate level. Internal consistency was assessed for all measures using Cronbachs alpha and reported in the Method section. All statistical analyses were based on an alpha level of 0.05, unless otherwise stated, and were conducted using Statistical Package for the Social Sciences Version 15 (SPSS Inc., Chicago, IL, USA).

Table 2. One-way analysis of variance showed no statistically signicant differences between academic years for any of the three subscales. The only individual source of stress which was found to be signicant was time demands of the course after controlling for multiple comparisons using Bonferronis correction [F(3,120) = 3.59, P = 0.01]. Post-hoc analyses revealed that rst-year students were signicantly different from second- and fourth-year students (P = 0.03). The total mean (SD) scores of the sources of stress subscales for all academic years were 5.4 (4.0) for nancial sources, 7.5 (5.0) for personal sources and 12.4 (4.6) for academic sources. There were signicant differences between the three subscales [F(2,248) = 119.69, P < 0.001] in that all students reported academic sources of stress higher than nancial or personal sources of stress. Psychological morbidity The mean (SD) score for psychological morbidity for all students was 12.9 (5.19). There was no signicant difference in psychological morbidity for the four academic years (Table 3). Twenty-seven percent of all students scored above the threshold of 3 to 4, and no signicant difference was found between academic years for the proportion of cases above the threshold level. Associations between sources of stress and psychological morbidity Pearsons correlation showed that there were signicant positive relationships between the personal and academic sources of stress subscales and psychological morbidity for all academic years (r = 0.68, P < 0.0001 and r = 0.55, P < 0.0001, respectively). A signicant positive relationship between the nancial sources of stress subscale and psychological morbidity was only found for second-year students (r = 0.45, P = 0.007). Hierarchical linear regression showed that academic ( = 0.31, P < 0.001) and personal ( = 0.50, P < 0.001) sources of stress subscales were signicant coefcients, explaining 48% of the variance in psychological morbidity after controlling for part-time employment and hours spent studying (see Table 4). Further regression analyses were undertaken to examine the individual academic and personal sources of stress (see Table 5). Personal sources of stress were entered into the regression model at the second step after controlling for part-time employment and hours spent studying. Stressful events ( = 0.24, P < 0.004) and mood ( = 0.43, P < 0.001) were signicant coefcients at the second step, explaining 51% of the variance in psychological morbidity. Individual academic sources of stress were added to the regression model at the third step. The overall level of stress was the signicant coefcient, explaining a further 5% of the variance in psychological morbidity.

Results Background and demographics Student demographics, background information and response rate are shown in Table 1. A total of 125 students (including all four academic years) participated and completed the questionnaire. The overall response rate was high at 83%. The mean age of all students was 21.7 (SD 4.3) years with a range of 17 to 39 years. Eighty-four percent of students were female. The number of students in paid employment for all academic years was 42%, which varied per year of the undergraduate programme. Students with a part-time job were asked to rate their level of stress associated with this employment from 0 (no stress at all) to 4 (a great deal of stress). The mean reported stress associated with part-time work was 1.4 (SD 1.4), indicating a low level of stress. The mean overall number of hours worked was 10.8 (SD 5.7) hours/week. Sources of stress Mean scores for individual sources of stress items and the nancial, personal and academic subscales are shown in

J.M. Walsh et al. / Physiotherapy 96 (2010) 206212 Table 1 Student background and demographic details. Variable Academic year 1 Number of respondents Response rate (%) Gender (% female) Age (years), mean (SD) Part-time employment (%) Number of hours/week, mean (SD) Level of stress with part-time job, mean (SD) (scale 14, 1 = low, 4 = high) Direct contact hours in college (/week) Hours spent studying per night, mean (SD) SD, standard deviation. Table 2 Mean (standard deviation) scores for total subscales and individual sources of stress for all academic years. Sources of stress Academic year 1 Financial Personal nances Accommodation Transport Cost of books/equipment University fees Total nancial sources Personal Relationship with family members Relationship with partner Loneliness Physical health Psychological health Stressful events Mood Total personal sources Academic demands Intellectual demands of the course Physical demands of course Time demands of course Uncertainty about expectations of the course Amount of material to be learnt in the course Overall level of stress Total academic sources ns, not signicant. 1.4 (1.2) 0.7 (1.0) 1.2 (1.3) 0.9 (0.9) 1.0 (1.4) 5.1 (3.7) 1.0 (1.2) 0.8 (1.3) 1.0 (1.1) 0.8 (1.0) 0.7 (1.0) 1.5 (1.0) 1.4 (1.2) 6.9 (4.8) 2.4 (1.0) 0.8 (0.9) 1.5 (1.2) 2.2 (1.1) 3.0 (0.8) 2.0 (0.8) 11.7 (4.3) 2 1.4 (1.3) 0.8 (1.3) 1.4 (1.3) 1.4 (1.3) 0.7 (1.2) 5.6 (4.0) 0.8 (1.0) 1.0 (1.3) 0.8 (1.0) 1.2 (1.1) 0.6 (0.8) 1.8 (1.1) 1.4 (1.2) 7.3 (4.8) 2.5 (1.0) 1.0 (1.1) 2.2 (1.2) 2.6 (1.2) 2.8 (0.9) 2.1 (0.8) 12.8 (4.9) 3 2.2 (1.0) 1.2 (1.4) 1.1 (1.3) 1.1 (1.1) 0.8 (1.3) 6.4 (4.3) 1.4 (1.5) 0.6 (1.1) 0.8 (1.0) 1.2 (1.0) 0.9 (1.1) 2.0 (1.0) 1.4 (1.0) 8.3 (5.1) 2.3 (1.0) 1.3 (1.1) 1.8 (1.1) 2.4 (1.0) 2.8 (1.0) 2.2 (1.0) 12.9 (4.2) 4 1.6 (1.3) 0.3 (0.5) 0.7 (1.1) 0.7 (0.9) 0.7 (1.2) 3.9 (3.9) 0.6 (1.2) 1.1 (1.5) 0.6 (0.9) 0.8 (1.0) 0.9 (1.1) 2.2 (1.1) 1.3 (1.2) 7.5 (5.8) 2.2 (0.8) 1.3 (1.2) 2.3 (1.1) 2.3 (1.1) 2.2 (1.1) 2.0 (0.9) 12.3 (4.2) All years 1.6 (1.2) 0.8 (1.2) 1.2 (1.3) 1.0 (1.1) 0.8 (1.3) 5.4 (4.0) 1.0 (1.2) 0.8 (1.3) 0.8 (1.0) 1.0 (1.0) 0.7 (1.0) 1.8 (1.1) 1.4 (1.1) 7.5 (5.0) 2.4 (1.0) 1.1 (1.1) 2.3 (1.1) 2.4 (1.1) 2.7 (1.0) 2.1 (0.9) 12.4 (4.6) 37 93 78 21.5 (6.7) 39 10.6 (6.9) 1.5 (1.1) 24 1.6 (1.1) 2 34 92 84 21.4 (4.6) 50 11.3 (4.1) 1.5 (1.3) 23 2.1 (0.4) 3 32 76 80 21.9 (2.5) 60 11.9 (4.6) 1.3 (1.6) 21 2.2(1.5) 4 22 71 95 22 (1.8) 18 7.8 (0.96) 1.3 (1.3) 25 2.2 (1.0)

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All years 125 83 84 21.7 (4.3) 42 10.8 (5.7) 1.4 (1.4) 23 2.0 (1.0)

P-value 0.04 0.03 ns ns ns ns ns ns ns ns ns ns ns ns ns ns 0.02 ns 0.03 ns ns

Discussion Psychological morbidity and associated stressors have not been investigated extensively in physiotherapy students. The current study examined sources of stress and their association with psychological morbidity in an undergraduate

physiotherapy population using the USOS questionnaire and GHQ-12. A high response rate was achieved in this study. Results showed that over one-quarter of students scored above the GHQ threshold, indicating probable cases of psychological morbidity. All students reported that academic issues were the greatest sources of stress, and this was signif-

Table 3 Psychological morbidity mean scores (Likert scoring) and cases above threshold of 3 to 4 (standard method). Variable Academic year 1 Psychological morbidity, mean (SD) Probable cases, n (%) SD, standard deviation; ns, not signicant. 12.3 (4.8) 10 (27) 2 12.1 (5.4) 10 (29) 3 13.2 (5.2) 7 (22) 4 14.7 (5.4) 7 (32) Overall 12.9 (5.2) 34 (27) P-value ns ns

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Table 4 Summary of hierarchical regression analysis examining associations between sources of stress subscales and psychological morbidity. Variable Step 1 Have part-time job Hours spent studying 0.07 0.07 0.51*** 0.48*** R2 0.01 Adj R2 0.01

Step 2 Sources of stress subscales Academic 0.31*** Personal 0.50*** Financial 0.03 Adj, adjusted. P 0.05, **P 0.01, ***P 0.001.

icantly greater than personal and nancial sources of stress. Independent of having a part-time job and hours spent studying, academic and personal sources of stress determined higher psychological morbidity scores. The mean stress level in the physiotherapy undergraduate sample was 12.9 (SD 5.2); this is higher than scores reported in working men [9.0 (4.1)] and working school leavers [8.7 (5.1)] [36]. There are likely to be many reasons why the level of psychological stress in physiotherapy students may be higher than that in the normal population, including examination pressure, uncertainty and nancial pressure. However, the percentage of psychological morbidity reported in this study (27%) is lower than that reported by Guthrie et al. [24] of 37% and 33% among medical students in two different universities in the UK. Another subsequent study reported gures of 37%, 31% and 22% [6]. Aktekin et al. [10] reported that the percentage above the threshold was
Table 5 Summary of hierarchical regression analysis examining associations between individual sources of stress and psychological morbidity. Variable Step 1 Have part-time job Hours spent studying Step 2 Personal sources of stress Relationship with family Relationship with partner Loneliness Physical health Psychological health Stress events Mood Step 3 Academic sources of stress Intellectual demands of course Physical demands of course Time demands of course Uncertainty and expectations of course Amount of material to learn on course Overall level of stress Adj, adjusted. P 0.05, **P 0.01, ***P 0.001. 0.07 0.06 0.55 0.03 0.05 0.08 0.12 0.06 0.24** 0.43*** 0.63 0.03 0.004 0.12 0.03 0.09 0.35** 0.56 0.51 R2 0.09 Adj R2 0.01

48% in second-year medical students. A lower prevalence of psychological morbidity was reported among medical students in a Nepalese setting (21%) [37]. The level of psychological morbidity of the physiotherapy students in the present study, while warranting attention, was not as high as generally reported in medical students; this is consistent with available literature in the area [38]. A possible reason for this difference may be related to the practice tutor system on placement. In Irish physiotherapy programmes, practice tutors, based in the majority of clinical sites, are responsible for providing support and clinical teaching to students on placement. There is generally a 1:6 tutor:student ratio. This valued system of support for students and practice educators on placement may be partly responsible for a lower level of psychological morbidity compared with medical students, who have a different support system when on clinical placement. There may be many other reasons for this difference in psychological morbidity levels, ranging from smaller class sizes to different curricular factors. In this study, there was no signicant difference in the prevalence of psychological morbidity according to year of study, which may reect the fact that each year is similar in terms of intensity of coursework and number of contact teaching hours. There was a trend towards a slight decrease in the second academic year, which may reect an adaptation to the surroundings, and an increase in the third and fourth years which may reect the increased workload and increased pressure leading up to nal-year examinations. However, this trend was not statistically signicant. A similar trend was reported by Guthrie et al. [6], as the percentage of students displaying psychological morbidity increased in the nal academic year. There is some evidence to suggest that most stress occurs during the transition from preclinical to clinical training [30]; however, the ndings of this study did not support this, which may reect positively on the clinical education component of the course in the study institution. The main associations with higher psychological morbidity scores were personal and academic sources of stress. This nding is similar to that reported by OMeara et al. [2] and Guthrie et al. [24] in terms of academic stress. Other studies found similar associations in terms of personal stress [39,40]. There was no signicant association between nancial sources of stress and psychological morbidity in the current study. This nding may be explained by the fact that in an Irish context, other than registration fees, there are currently no tuition fees for undergraduate students undertaking their rst degree. The percentage of the student population in paid employment varied considerably from rst to fourth academic years, with nearly half of all students working part-time. It is possible that the nal-year students gave up their part-time work to focus on their studies, while second- and third-year students may have adjusted to university life and could partake in part-time employment. Perhaps contrary to expectations, there was no correlation between having a part-time job and associated increased levels of stress. However, it has been

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stated that if students work longer than average part-time hours, they may be less likely to engage in university life and culture [41]. Tucker et al. [7] reported that 76% of physiotherapy students from Western Australia worked in paid employment, compared with only 16% of students in the UK. It is not known whether there is a threshold beyond which negative effects of student employment are more likely than positive effects. The high response rate in this study compares favourably with that of Blackmore and Tucker [33]: 72% and 74%. Questionnaire completion was voluntary; however, despite the high response rate in the present study, it is possible that non-responders may have had increased psychological morbidity [32]. Therefore, the potential for non-response bias must be considered. In addition, this study was carried out in the middle of a term to avoid the stressful examination period, when levels of stress would be expected to increase. This study did not analyse whether gender had a bearing on psychological morbidity or sources of stress. However, available evidence in the area reveals no overall difference between men and women [6,8,22,36]. This study highlights the need to emphasise available support systems within universities, and shows the importance of encouraging students to maintain an appropriate worklife balance which is crucial for the rigors of professional life [7]. While personal factors may be more difcult to control, curricular factors such as the volume and intensity of work may need to be reviewed from an institutional perspective. Limitations This study had a few limitations. Although the GHQ-12 is one of the most widely used scales for measuring psychological morbidity, it is important to note that it is not a diagnostic tool, and is based on subjective self-report. In light of this, results should be interpreted with this limitation in mind. Guthrie et al. [6] reported that in fth-year medical students, a cut-off point of 3 to 4 gave a positive predictive value of 54%. This means that where the GHQ-12 is used as a screening tool, approximately half of those scoring above the threshold would, in fact, be non-cases. Therefore, some form of secondary screening in the form of psychiatric interviews [9] may be used to identify non-cases. In addition, it must be considered that some of the students who had low scores on the GHQ-12 may have been denying emotional difculties [6]. Another limitation of note is the cross-sectional design used in the current study. Although signicant results in relation to sources of stress and psychological morbidity in an undergraduate student population were found, a longitudinal design would have allowed predictions of well-being over time. This study did not examine student health behaviours, such as whether students used active coping strategies, how students seek help in terms of counselling and/or student use

of alcohol or illicit drugs. Notwithstanding these limitations, this study reports signicant results in terms of the emotional vulnerability of some physiotherapy students which may guide further research in the area.

Conclusion To the authors knowledge, this is the only study to date which has reported psychological morbidity in physiotherapy students, particularly within an Irish context. A novel approach of combining the USOS questionnaire and GHQ-12 was used to investigate associations between different sources of stress and psychological morbidity. This approach may be applied to other undergraduate student groups as this study found signicant results using this measure. Personal stresses are generally more difcult to inuence as a result of individual and environmental factors. However, academic sources of stress may be alleviated by planning modications in the curriculum and designing interventions that provide academic support. This study was a preliminary examination of psychological morbidity and sources of stress in physiotherapy undergraduate students. On the basis of the study ndings, a suggestion for further research is a prospective, longitudinal study following student cohorts over the duration of an academic course, which may yield ndings in terms of variability over time. Furthermore, coping strategies would be an additional variable of interest to examine in this student cohort. Ethical approval: Trinity College Dublin Ethics Committee. Conict of interest: None.

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