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RESEARCH ARTICLE

Level of Stress and Common Coping Strategies Among Physician Assistant Students Lucille O’Brien, MPAS, PA-C; Kathleen Mathieson, PhD; Joan Leafman, PhD; Lori Rice-Spearman, PhD

Purpose: This study assessed levels of stress and coping strategies in physician assistant (PA) students. Methods: The study used a descriptive, cross-sectional design. Data were collected through an electronic survey that was sent to all current student members of the Texas Academy of Physician Assistants (N = 560). The Perceived Stress Scale was used to measure level of stress, and the Brief COPE Inventory was used to measure coping strategies. Results: A total of 146 (26.3%) students participated in the study. Most respondents were female, young, single, and Caucasian/non-Hispanic. The mean stress score was 33.3, higher than that reported in the overall general US population. Areas of most concern included feeling nervous and stressed, feeling upset about unexpected happenings, and an inability to control life’s irritations and manage personal problems. Self-distraction, venting, and self-blame were the most frequently used unhealthy coping strategies. Acceptance, active coping, and emotional support were the most frequently used positive coping strategies. Conclusion: The results of this study indicated that students in PA training experience higher levels of stress than the general population in the United States, making healthy coping strategies among PA students particularly important. The results of this study can inform future research, curriculum design, teaching methods, and educational intervention in PA training programs. J Physician Assist Edu 2012;23(4):25-29

Lucille O’Brien, MPAS, PA-C, is the clinical coordinator at the Physician Assistant Program, Texas Tech Health Sciences Center, Midland, Texas; Kathleen Mathieson, PhD, is an assistant professor at Arizona School of Health Science, A.T. Still University; Joan Leafman, PhD, is an associate professor at Arizona School of Health Sciences, A.T. Still University; Lori Rice-Spearman, PhD, is the Clinical Laboratory Science and Molecular Pathology program director and a professor at Texas Tech Health Sciences Center. Correspondence should be addressed to: Lucille O’Brien, MPAS, PA-C Physician Assistant Program Texas Tech Health Sciences Center 2607 Mark Lane Midland, Texas 79707 Telephone: (432) 528-1941 Email: [email protected]

INTRODUCTION Stress is a state of emotional or mental strain resulting in a number of normal bodily reactions to retain selfpreservation.1 Stress causes behavioral, psychological, and physiological changes in the body, which are met with a hyper-arousal response. The body responds to maintain physical equilibrium. Repeatedly adapting to physical challenges and psychosocial threats leads to substantial energy expenditure. Stress plays a major role in immune system diseases and processes related to immune conditions. Acute stress can enhance the immune system while chronic stress may suppress it.2 Students training to practice medicine experience psychological strains such as stress and anxiety as they progress from student to medical provider.1 Studies on stress during medical training focus on the documentation of stress and the continuation of stress from the training period into graduates’ medical practice.2, 3 Therefore, programs that help students address the psychosocial

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changes during their education are warranted.4 Stress levels among students in medical training may eventually reach burnout levels.5 The negative effects of stress may impair performance in the classroom and clinical practice6 and may include physical and psychological problems such as headache, insomnia, or decreased productivity.7 While physician assistant (PA) education may differ from physician education in some respects, the general academic experiences are similar. Medical students must complete approximately 75 semester hours of course work the first 2 years, followed by 2 years of clinical education. PA students complete 73 semester hours the first year in the didactic portion, followed by 48 clinical hours in the second year.8 Therefore, both groups experience the negative effects of stress, and there are other similarities such as classroom and clinical stressors. Typically, PA programs teach the practice of medicine in 24 to 36 months. Medical training for both medical students and PA students is intense due to the quantity of infor25

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Level of Stress and Common Coping Strategies Among Physician Assistant Students

mation students must absorb in a concentrated period. The pressure of acquiring the necessary skills and knowledge, combined with the strenuous schedule, may elevate stress levels. An increased understanding of student stress levels and coping strategies may assist PA educators to better design curricula and set attainable goals. This understanding may reduce stress and increase positive coping skills. These efforts, in turn, may lead to more positive outcomes for students, such as improved psychological and physical health and lower attrition rates. This study describes stress levels and coping strategies among PA students in Texas. The hypotheses were that PA students would report stress levels above the population average, as measured by the Perceived Stress Scale, and that greater than 50% of PA students would report using at least one unhealthy coping strategy. METHODS This was a descriptive, cross-sectional study conducted through an electronic survey. Participants were recruited from the student membership of the Texas Academy of Physician Assistants. Student membership at the time of the survey numbered 560 students. A link to the electronic survey instrument was sent by the Texas Academy of Physician Assistants via email with a follow-up reminder emailed 4 weeks after the initial email. All survey instruments were anonymous; no identifying information or IP addresses were collected. The study was approved by the A.T. Still University Institutional Review Board.

Survey Instrument The survey gathered demographic and education data including age, gender, whether the student was currently in the didactic portion or clinical por26

tion of the program, ethnicity, prior education, and marital status. The survey instrument was comprised of two validated instruments: the Perceived Stress Scale (PSS)9 and the Brief COPE Inventory (BCI),10 which is an abbreviated version of the COPE Inventory.11 The PSS is one of the most widely used psychological instruments for measuring perception of stress and the situations one considers stressful.9 An example of a question from the PSS is, “In the last month, how often have you felt that you were unable to control important things in your life?”9 The stress perceived by the student was addressed for the previous month and may not pertain specifically to school. The responses were on a 5-point Likert scale. The possible answers were: 1 = Never, 2 = Almost never, 3 = Sometimes, 4 = Fairly often, and 5 = Very often. Normal values for the PSS among those aged 18–44 are approximately 19.2–20.4.9 The BCI is a validated instrument used when there is a need to minimize time demands on participants while measuring responses known to be relevant to effective and ineffective coping.10 A sample question from the brief COPE is, “I have been taking action to try to make the situation better by…”.11

Scoring PSS scores were computed by reversing responses (eg, 0 = 4, 1 = 3, 2 = 2, 3 = 1, 4 = 0) to the four positively stated items (items 4, 5, 7, 8) and then summing across all scale items. The BCI measured self-distraction, active coping, denial, substance use, the use of emotional support and instrumental support, behavioral disengagement, venting, positive reframing, planning, humor, acceptance, religion, and selfblame. The skills considered to be negative were self-distraction, substance abuse, behavioral disengage-

ment, venting, and self-blame.10 While some people may not consider these to be negative strategies, venting can amplify the adverse effects of negative emotions.12 Self-distraction is defined as a negative coping strategy because it involves changing one’s focus from the problem to something else. In the short term, this can be positive, but in the long term may worsen the situation.13 Each coping strategy was measured by two questions that were then averaged for each participant.

Data Analysis SPSS Statistics (Version 19) was used for analysis. Descriptive statistics were calculated for all study variables.14 Average PSS scores were calculated for the sample as a whole and a one-sample t-test compared the sample average to the criterion level of 20.0, which is consistent with normal values among those aged 18–44.9 To address the second hypothesis, the number of students using unhealthy coping skills was calculated as a percentage. If an average for a negative coping strategy was 3 (“I have been doing this a medium amount”)10 or greater, the student was coded as using that coping strategy. Alpha was set at .05, two-tailed. RESULTS Of the 560 surveys distributed, six were returned as undeliverable. A total of 146 respondents completed the questionnaire, resulting in a response rate of 26.3%. Three of the questionnaires yielded only demographic data and were therefore excluded, for a sample of 143. Table 1 summarizes the descriptive characteristics of the sample. Most respondents were female, approximately 27 years old, single, and Caucasian/nonHispanic. Although the sample had a greater proportion of non-Caucasian students than the national PA student population (23.8% versus 19%), age 2012 Vol 23 No 4 | The Journal of Physician Assistant Education

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Level of Stress and Common Coping Strategies Among Physician Assistant Students

and gender in the sample closely mirrored the national PA student population.15 The percentages of students in the didactic and clinical portion of training were similar. Most respondents had earned a bachelor’s degree prior to attending PA school. The first hypothesis was that the average PSS score among PA students would be higher than that reported in the general population (20.0).9 Students’ PSS scores ranged from 27 to 41, and students’ average PSS score (33.3, ± 2.97) was significantly higher than the general population (P < .05). Table 2 details responses to the PSS. Areas of higher stress included feeling nervous or stressed, feeling upset about unexpected happenings, being unable to control irritations in life, and an inability to handle personal problems. The BCI10 was used to evaluate the second study hypothesis that greater than 50% of students used at least one unhealthy coping strategy. The results supported this hypothesis; 68.6% of the students surveyed reported using at least one unhealthy coping strategy. Figure 1 summarizes the most common unhealthy coping strategies. Selfdistraction, venting, and self-blame were used most frequently. Acceptance, active coping, and emotional support were the most common positive coping strategies used by the students (Figure 2). DISCUSSION This study sought to measure stress level and common coping strategies among PA students. Results indicated that PA students encounter high levels of stress during their education. The mean score on the PSS was notably higher than normative levels in the general population.9 Previous research indicated that medical training caused stress for the learner.2 PA education was created to be similar to medical education in many respects. The Journal of Physician Assistant Education | 2012 Vol 23 No 4

Table 1. Sample Characteristics Demographics Gender Male Female Mean Age (SD) Male Female Race Caucasian/non-Hispanic African American Hispanic Asian/Pacific Islander Marital Status Single Married Divorced Widowed Portion of Training Clinical Didactic Degree Prior to PA School Associate’s Bachelor’s Master’s Other

N = 143

Percentage

38/142 104/142

26.8 73.2

29.4 (6.12) 27.3 (5.70) 109/143 4/143 19/143 11/143

76.2 2.8 13.3 7.7

76/142 56/142 9/142 1/142

53.5 39.4 6.3 .7

69/141 72/141

48.9 51.1

2/143 122/143 14/143 5/143

1.4 85.3 9.8 3.5

Table 2. Perceived Stress Scale Items In the last month, how often have you:

Mean

SD

Felt nervous and “stressed”?

4.22

0.82

Felt confident about your ability to handle your personal problems? †

3.94

0.80

Been able to control irritations in your life? †

3.68

0.81

Felt that things were going your way?

3.63

0.71

Felt that you were on top of things?

3.37

0.81

Been upset because of something that happened unexpectedly?

3.03

0.83

Felt that you were unable to control the important things in your life?

3.00

1.07

Been angered due to things outside of your control? †

2.99

0.89

Found that you could not cope with all the things that you had to do? †

2.74

0.98

Felt difficulties were piling up so high you could not overcome them?

2.69

1.06

Possible responses: 1 = Never; 2 = Almost never; 3 = Sometimes; 4 = Fairly often; 5 = Very often Note: † Item reverse coded prior to scale computation.

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Level of Stress and Common Coping Strategies Among Physician Assistant Students

Figure 1. Percent of Students Who Used Negative Coping Strategies Based on the Brief Cope Inventory (N = 143)

Self-Distraction (items 1 & 19)

63.7

Venting (items 9 & 21)

38.5 25.3

Self-Blame (items 13 & 26) Behavioral Disengagement (items 6 & 16)

5.5

Substance Use (items 14 & 11)

5.1 4.4

Denial (items 3 & 8) 0

10

20

30

40

50

60

70

PERCENT

Figure 2. Percent of Students Who Used Positive Coping Strategies Based on the Brief Cope Inventory (N = 143)

Acceptance (items 20 and 24)

91.9

Active coping (items 2 and 7)

80.2

Positive reframing (items 12 and 17)

74.4

Use of emotional support (items 5 and 15)

74.4

Planning (items 14 and 25)

69.5

Use of instrumental support (items 10 and23)

66.4

Religion (items 22 and 27)

56.8 51.6

Humor (items 18 nd 28) 0

10

20

30

40

50

60

70

80

90

100

PERCENT

Therefore, it is reasonable to assume that the stress experienced by students in medical school is similar to that experienced by students in PA school. Although the stress is most often attributed to the curriculum itself, other areas in the PA student’s life that were not addressed in this study may also be important. For example, there may be special challenges when 28

families have high expectations for the student. Students who are married have the added stress of balancing studies with family life. Esch and colleagues3 portrayed stress as a challenge that demands behavioral, psychological, and physiological changes to successfully overcome. While stress has been identified as a major factor in diseases of

the immune system, acute stress prompts students to prepare for classroom assignments and activities. When determining the causes of stress and coping strategies of PA students, it is important to address the issue through curricula or teaching strategies. A limitation of this study is that the sample was restricted to only Texas 2012 Vol 23 No 4 | The Journal of Physician Assistant Education

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Level of Stress and Common Coping Strategies Among Physician Assistant Students

PA students. Another limitation is absence of available stress and coping studies on PA students. While this study’s findings are not representative of all PA students, the results may provide a basis for future research and useful information for PA education programs wishing to address stress levels among students. This study warrants future research on stress and coping among PA students. While some of the students documented the use of negative coping strategies, it is encouraging to see that many students also documented the use of positive coping strategies. Identifying students who need help in acquiring the ability to cope with the stressors of learning could represent an important advancement in educating physically and mentally healthy providers, thereby lowering the program’s attrition rate. REFERENCES 1.

2.

Dyrbye, L, Thomas M, Shanafelt T. Medical student distress: causes, consequences, and proposed solutions. http://www.mayoclinicproceedings. com/content/80/12/1613. Accessed March 3, 2011. Shaikh B, Kahloon A, Kazmi M, et al. Students, stress, and coping strategies: a case of Pakistani medical school. Biomed Center; 2006. http://www.biomedcentral.com/1472 -6920/7/26. Accessed March 1, 2011.

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3. Esch T, Stefano G, Fricchione G, Benson H. Stress-related diseases: a potential role for nitric oxide. Medical Science Monitor. 2002;8(6):103-118. http://www.MedSciMonit.com/pub/ vol_8/no_6/2755.pdf. Accessed March 1, 2011. 4. Wolf T, Von Almen T, Faucett M, Randall H, Franklin F. Psychosocial changes during the first year of medical school. Medical Education. 1991;25: 174-181. http://onlinelibrary.wiley. com/doi/10.1111/j.1365-2923.1991. tb00049.x/pdf. Accessed March 1, 2011. 5. Abdulghani H. Stress and depression among medical students: a cross-sectional study at a medical college in Saudi Arabia. Pakistan Journal of Medical Science. 24(1):12-17. http://www. pjms.com.pk/issues/janmar08/pdf/ stress.pdf. Accessed April 3, 2011. 6. Inam S, Saquib A, Alam E. Prevalence of anxiety and depression among medical students of private university. Journal of Pakistan Medical Association. http://www.jpma.org.pk/ full_article_text.php?article_id=2064. Accessed March 1, 2011. 7. Mayo Clinic. Stress symptoms: effects on your body, feelings and behavior. http://www.mayoclinic.com/health/ stress-symptoms/SR00008_D. Accessed January 20, 2012. 8. Texas Tech University Health Sciences Center. Curriculum. Texas Tech University Health Sciences Center Catalog. 2011.

9. Cohen S. Perceived Stress Scale. http://www.ncsu.edu/assessment/reso urces/perceived_stress_scale.pdf. Accessed March 3, 2011. 10. Carver C. You want to measure coping but your protocol’s too long: consider the Brief COPE. Int J Behav Med.1997;4(1):92-100. 11. Carver C, Scheier M, Weintraub J. Assessing coping strategies: a theoretically based approach. J Pers Soc Psychol. 1989;56(2):267-283. http://www. psy.miami.edu/faculty/ccarver/ documents/p89COPE.pdf. 1989. Accessed February 25, 2011. 12. Brown S, Westbrook R, Challagalla G. Good cope, bad cope: adaptive and maladaptive coping strategies following a critical negative work event. Journal of Applied Psychology. 2005;90(4):792-798. 13. Nydegger R, Nydegger L, Basile F. Posttraumatic stress disorder and coping among career professional firefighters. Journal of Health Sciences. 2011;2(1):11-20. 14. IBM Corp. Released 2010. IBM SPSS Statistics for Windows, Version 19.0. Armonk, NY: IBM Corp. 15. Physician Assistant Education Association. Twenty-Sixth Annual Report on Physician Assistant Educational Programs in the United States, 2009-2010. Alexandria, VA: PAEA; 2010.

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