This study explored pre-registration Bond University DPTHY students’ levels of perceived stress, burnout, and associated coping mechanisms. The first research question focused on differences in perceived stress and burnout over time. The quantitative data from the CSE and MBI-GS (S) scores showed no significant changes at time points and between time points. These results are in contrast to previous research. A previous study reported by Van Veld et al.3, conducted in the United States, found changes in CSE scores over time in first year DPHTY students. This difference between studies could be due to a variety of factors including timing of placement blocks, the curriculum coursework demands as well as the structure of the different programs.
Findings relating to the MBI-GS (S) are unique to this study, as it is the first study completed on physiotherapy students to utilise this version of the MBI. Previous studies4,5 have utilized the MBI, however an alternate version has meant the subscales differ from those within this study. Balogun et al. 4 completed a study in 1996 that determined that academic performance was not correlated with physiotherapy students’ perceived levels of burnout. In another study, the same authors 5 found the emotional exhaustion and depersonalisation scores for physiotherapy students, were higher than the norms reported for the general population and most human services professionals.
Qualitative data suggests that changes in written responses in regards to the type of stressors across the time points could have been associated with transition periods. These difficulties found within transition periods including; relocation adjustments, transition to academic life, transition to placement, and transition doubt, support the findings of previous18 studies conducted on students. This study determined that there was no strong correlation between stress and burnout. However, findings indicate a strong correlation between stress scores at the start of the course (T1) and pre-placement (T2). These results could have been due to similarities in stress perceptions and coping at these time points.
A strong theme throughout the open responses was that curriculum coursework within the program and examinations caused heightened levels of stress. Students reported periods of stress with coursework and course load commitments, which is in line with previous research3, 12, 14, 18, 23, 24 conducted on undergraduate and pre-registration postgraduate students in several countries including Australia, USA, Israel and Sweden. Students frequently reported that their social life was lacking, along with time to undertake their hobbies due to workload and demands of the program. Students are required to undertake written examinations, seminar presentations, and practical examinations (OSCEs). Participants within the study reported feeling underprepared and anxious in the week/s leading up to assessments. A previous cross- sectional study23 conducted in Australia and the United Kingdom found coursework stress to be the greatest source of stress for students. Similarly, Indian Bachelor of Physiotherapy students18 reported that unpredictability of examinations and fear of failure were sources of stress, which align with responses generated from this study.
Placement related stressors have been frequently identified across time points 1 and 3. Student responses were commonly related to professionalism, with stress arising when not given immediate feedback from clinical educators and having to complete self-directed learning and professional development tasks. Additionally, financial pressures arose as a theme throughout this study, and was amplified during the clinical placement block. Students often had to travel, therefore increasing accommodation costs, as well as finding difficulty to attain or maintain part time positions. Hampshire et al.36 found that negative placement experiences have a significant impact with the potential for becoming the ‘tipping point’ for students. This study by Hampshire et al. 36 proposed a variety of suggestions for avoiding attrition, which include flexible start and finish times, maximum travelling distances to placement, central feedback database, and student financial support funds. Similarly, a Dutch study10 on six undergraduate students conducted across three universities found placement stressors had an impact on the student’s well-being. Some stressors included demanding supervisors, worrying about not being good enough, and worrying about meeting expectations. Potentially, students are being taught the appropriate clinical and academic skills but are not being taught appropriate professional skills. Students may benefit from skills in taking on feedback and understanding the importance of reflective practice. If expectations of clinical placements are clearly defined prior, students may have reduced stress or better coping mechanisms.
The second research question focused on the influence of sex in relation to stress and burnout throughout the first year of the program. Whilst the current study did not identify sex to influence stress or burnout, there were unique differences across all three time points in the first year, and female students self-reported experiencing more stress. The sex difference has previously been reported, with females experiencing more stress than males20. This cross-sectional study completed on 231 undergraduate students in Pakistan reported that not only did women differ in their perception of stressors, but their reactions also differed, where they were more overtly reactive. It is explained this could be due to the gender role socialization of emotions, or that females are possibly more emotionally responsive. This cross-sectional study may have differing experiences of stress for females due to a variety of factors including the length of the study, the age of the participants, or the outcome measure utilised (Student Life Stress Inventory).
The third research question concentrated on coping mechanisms utilized by DPHTY students during the first year of their program. Qualitative themes from open-ended questions revealed a mix of maladaptive and positive coping strategies. Previously, a cross-sectional study reported28 that three general strategies exist in an attempt to cope with stressful situations: problem-focused coping, emotion-focused coping, and avoidance-focused coping. Within our study students reported that they wish they had been made aware of and equipped with effective coping strategies to overcome such stressors from course demands. The theme, course survival tips, demonstrated that students felt unprepared for the course demands, and desired more self-management strategies when stressful periods arise.
The most common problem-focused coping strategy reported in the current study was exercise, with reports of it being a beneficial stress reliever across all three time-points. Whilst the use of exercise as a coping strategy is potentially not surprising for a physiotherapy cohort, such strategies should be promoted due to its proven stress-relieving benefits23,35. For university students, opportunities to engage in sporting and social clubs often incur no additional costs, potentially promoting accessibility. This may be of benefit for HEIs; not only encouraging health and well-being, but also allowing for social interaction outside of class time. Students reported that maintaining social relationships within and outside of the program have been an effective emotion-focused coping strategy in managing stress. These findings concur with previous studies3,9 where maintaining relationships are important for coping. Being able to debrief and have open conversations appears to be imperative to the well-being of students.
Although the majority of students reportedly utilize positive coping strategies, there were also accounts of maladaptive coping strategies. The avoidance-focused coping strategies that have been identified as maladaptive include alcohol consumption, excessive eating, and gaming. Maladaptive coping strategies found by a cross-sectional American University study29 included alcohol abuse, drug abuse, and smoking. They further recommended that universities provide ongoing research outlining stress, how to detect when an individual may be experiencing high levels of stress, and positive strategies to deal with such stressors. Perhaps in future, HEIs could increase wellness education and services such as advisement and counselling. Students may benefit from group discussion around health and wellbeing, and the challenging aspects around maladaptive coping strategies. This environment may elicit more students to speak when feeling stressed or burnt out.
The findings from our study offer unique insights around the pressures and expectations of pre-registration physiotherapy students. Responses provide information to aid in the maintenance of student well-being, whilst ensuring production of quality health professionals, that may be of benefit to HEIs. It is important for physiotherapy programs to know the causes of stress and burnout in their students, and associated coping mechanisms utilised. Findings from previous studies36, 37 in which students also report burden with travel for placement, financial costs, inflexible timetabling, and clinical placement stressors, demonstrate commonality with this research. It would be valuable to determine the tipping point for students undertaking pre-registration physiotherapy programs and trial targeted intervention strategies to mitigate potential stress and burnout.