Demographic characteristics of participants
Of the 61 DPHTY first year students invited to participate in the study, 38 (62%) participated across any of three timepoints. Of these respondents, 27 (71%) responded at T1, 30 (79%) responded at T2, and 20 (53%) responded at T3. The median age of students n=38) was 24.0 years of age, ranging from 20.0 to 38.0 years. demographics of the student population are detailed in Table 1.
Quantitative results
In general, the results show that all students reported feeling some level of stress and burnout in their responses. The results of the paired t-tests used to answer the first research question (Was there a difference in perceived stress and burnout over time?) is presented in Table 1. CSE scores showed the greatest mean changes from T1-T2 and T1-T3, however these differences were not significant (Table 2). MBI-GS (S) mean scores identified that PE changes were greatest from T2-T3 and T1-T3, however were likewise not significant (Table 1).
Table 1: Cohort median and paired samples t-test results for CSE Total scores and MBI scores
Outcome measure
|
Median (range)
|
Total/Subscale
(Time point)
|
Mean difference
|
(95% CI)
|
Paired diff.
p-value
|
T1 CSE
|
170.0 (79.0-254.0)
|
CSE –Total (T1–T2)
|
-9.2
|
(-27.9, 9.5)
|
0.318
|
T2 CSE
|
165.5 (88.0-258.0)
|
CSE – Total (T2-T3)
|
0.6
|
(-11.9, 13.2)
|
0.914
|
T3 CSE
|
162.5 (95.0-260.0)
|
CSE – Total (T1-T3)
|
-8.8
|
(-27.5, 9.9)
|
0.330
|
T1 MBI CYN
|
1.0 (0.0-4.0)
|
CYN T1-T2
|
-0.5
|
(-1.1, 0.2)
|
0.135
|
T2 MBI CYN
|
2.0 (0.0-4.0)
|
CYN T2-T3
|
0.7
|
(-0.0, 1.3)
|
0.055
|
T3 MBI CYN
|
1.0 (0.0-6.0)
|
CYN T1-T3
|
-.02
|
(-1.0, 0.6)
|
0.628
|
T1 MBI EX
|
4.0 (1.0-5.0)
|
EXH T1-T2
|
-0.2
|
(-1.0, 0.6)
|
0.565
|
T2 MBI EX
|
4.0 (0.0-6.0)
|
EXH T2-T3
|
1.1
|
(0.1, 2.1)
|
0.040
|
T3 MBI EX
|
3.5 (0.0-6.0)
|
EXH T1-T3
|
-0.2
|
(-1.1, 0.8)
|
0.682
|
T1 MBI PE
|
5.0 (2.0-6.0)
|
PE T1-T2
|
1.3
|
(-2.5, 5.2)
|
0.482
|
T2 MBI PE
|
5.0 (0.0-6.0)
|
PE T2-T3
|
4.7
|
(-1.5, 10.8)
|
0.128
|
T3 MBI PE
|
4.0 (0.0-6.0)
|
PE T1-T3
|
3.1
|
(-1.8, 8.0)
|
0.194
|
|
|
|
|
|
|
|
Key: CSE, Coping Self Efficacy Scale; MBI-GS (S), Maslach Burnout Inventory – General Survey (Students); T1, time point 1 start of course; T2, time point 2 prior to clinical placement; T3, time point 3 immediately post placement; CYN, Cynicism subscale; EXH, Exhaustion subscale; PE, Professional Efficacy subscale. Note: significance p-value≤0.017 (accounted for multiplicity 0.05/3). Negative mean differences indicate smaller scores at the corresponding time point.
In relation to the second research question (Did sex influence the amount of stress and burnout experienced?), the median age of female participants was 23 (20-38) and for males was 26.5 (21-36) years, with strong evidence for significance between groups (p=0.012) [Table 2]. There was no statistically significant difference between groups in relation to their previous degree [Table 2].
Table 2. Demographic information and descriptive data for student CSE and MBI scores in relation to sex
Characteristic
|
Females (n=22)
|
Males (n=16)
|
p-value
|
Age (years), median (range)
|
23.0 (20.0-38.0)
|
26.5 (21.0-36.0)
|
0.012
|
Qualification, n (%)
Bachelor
Masters
|
18.0 (81.8%)
4.0 (18.2%)
|
15.0 (93.8%)
1.0 (6.3%)
|
0.370
|
T1 CSE
|
157.0 (79.0-220.0)
|
171.5 (97.0-254.0)
|
0.256
|
T2 CSE
|
159.0 (88.0-254.0)
|
177.5 (128.0-258.0)
|
0.185
|
T3 CSE
|
155.0(95.0-222.0)
|
167.0 (125.0-260.0)
|
0.370
|
T1 MBI CYN
|
1.0 (0.0-4.0)
|
1.0 (0.0-4.0)
|
0.193
|
T2 MBI CYN
|
1.0 (0.0-3.0)
|
2.0 (0.0-4.0)
|
0.185
|
T3 MBI CYN
|
1.0 (0.0-5.0)
|
1.0 (0.0-6.0)
|
0.955
|
T1 MBI EX
|
4.0 (0.0-5.0)
|
3.5 (0.0-5.0)
|
0.427
|
T2 MBI EX
|
4.0 (1.0-6.0)
|
4.5 (0.0-6.0)
|
0.950
|
T3 MBI EX
|
4.0 (0.0-5.0)
|
3.0 (0.0-6.0)
|
0.392
|
T1 MBI PE
|
5.0 (2.0-6.0)
|
5.0 (4.0-6.0)
|
0.581
|
T2 MBI PE
|
5.0 (3.0-6.0)
|
5.0 (0.0-6.0)
|
0.415
|
T3 MBI PE
|
4.0 (0.0-6.0)
|
4.0 (0.0-6.0)
|
0.955
|
Key: CSE, Coping Self Efficacy Scale; MBI-GS (S), Maslach Burnout Inventory – General Survey (Students); T1, timepoint 1 at the start of the first semester; T2, timepoint 2 refers to semester two, when the students were finalizing coursework subjects on campus, immediately prior to engaging in their first clinical placement; T3, timepoint 3 immediately after the completion of the first two consecutive five-week placement blocks; CYN, Cynicism subscale; EX, Exhaustion subscale; PE, Professional Efficacy subscale. Note: significance: p-value≤0.05
Differences between sexes were observed across CSE scale and MBI-GS (S) subgroups, however these differences did not reach significance (Table 2). Highest median CSE scores for both males and females were seen at T1, and lowest scores at T3 (Table 1). The highest MBI-GS (S) Cynicism subscale median scores were reported at T2, Exhaustion subscale at T1 and T2, and professional Efficacy subscale at T1 and T2 (Table 1).
Of the 51 total responses across timepoints for the MBI-GS (S) question “I feel depressed by my studies”, 44 (86%) gave scores greater than zero, indicating that at some point during the timepoints, students have felt depressed by their studies.
Qualitative results
Participants provided responses to the open-ended questions at each of the three timepoints T1 27/27, T2, 26/30 and T3 19/20 participants respectively). Answering the third research question (What were the coping mechanisms utilized by pre-registration DPHTY students?), the thematic analysis revealed common stress and burnout influencers and common coping strategies [Table 3]. Thematic analysis revealed seven organizing themes across the three timepoints including: curriculum coursework, clinical placement, transition periods, work-life balance, coping behaviors, financial pressures, and course survival tips.
Table 3: Thematic Analysis
Organizing Theme
|
Basic theme and time point prevalence
|
Exemplar Quotations
|
1. Curriculum coursework
|
functioninga
challenges
T1, T2
|
“Workload stress [leads to] feeling pressure/stress regarding amount of work to review and get done.”
“I feel there aren’t enough hours in the day. We spend hours in class and then are expected to go home and study/do work. I feel stressed and overwhelmed when I don’t have enough time to go for a run or do something for myself.“
|
1.2 Examination stress
T1, T2, T3
|
“During the exam period where we had 3 exams in 3 days which were quite different from each other, week prior to the week of exams, after the exams where we are waiting for results of exams/ assessment.”
“Exams were really stressful and overwhelming, I found my mental health deteriorated and I felt so much pressure to do well and know what I how much to study, I broke down a couple of times in the week or two leading up to the written exam.”
|
2. Clinical placement
|
2.1 Placement duration
T3
|
“Having the placements before our holiday break was very helpful to solidify our learning. I loved the 10-week block of placements. I feel it will be nicer to have shorter blocks at class and then placements back to back, 10 and 10 is great. It's a very stressful course.”
“I feel it may be useful to have a few days break in between placements to have a good mental/physical break prior to starting the next block.”
|
2.2 Placement stress
T3
|
“I felt extremely stress on my first 5 weeks of my clinical placement. My educator hardly gave any immediate feedback and it made me very anxious as to knowing whether I was doing well or not. I got very unwell in my second block of my placement and I was physically/mentally exhausted making it difficult to perform to the best of my abilities.”
“Being on placement, coming home and preparing an in-service presentation and reflection - very overloaded at end each time.”
|
3. Transition periods
|
3.1 Relocation adjustment
T1, T3
|
“First week of class, it was a big adjustment moving from home and disruption of routine.”
“The biggest stressor has been missing family and friends back home at the end of the semester.”
|
3.2 Transition to academic life
T1
|
“During the first week of classes it was overwhelming to be back at school again after 2 years, but I adapted quickly.”
“During exam periods having back to back exams trying to balance sleep and stress of studying. Initially starting uni at bond.”
|
3.3 Transition to placement T3
|
“Transitioning from placement 1 to 2 over a short period of time was quite stressful mentally and emotionally.”
|
3.4 Transition doubt
T3
|
“[I’m] questioning if this is really what I want to do because I haven’t enjoyed much of the course.”
|
4. Work-life balance
|
4.1 Lack of time management skills
T1, T2
|
“Constantly thinking about how much I have to get done. Leads to anxiety attacks and poor sleep.”
“How little time off I would have. How much university would cut into my social life.”
|
4.2 Health impact and wellbeing
T1, T2, T3
|
“I've been burnt out from last semester, which made me ill with the flu and I've had lingering flu ever since leaving me extra upset about situations and it has been affecting my relationship and my strong mindset.”
|
5. Coping
Behavioursa
|
5.1 Study skill social supportb
T1, T2
|
“Being with friends from cohort, discussing any uncertainties regarding study or content with friends, calling my family members regularly.”
“Studying on campus rather than at home. Studying with others at times but also studying on my own at times.”
|
5.2 Exercise/recreational activities
T1, T2, T3
|
“I get up at 5.30am every morning to exercise as I feel this is personal time for me to destress and do something for myself.”
“I tried to maintain my exercise regime, but I believe it made me even more exhausted after really long days.”
“Listen to music/podcast (not physio related)”
|
5.3 Maladaptive behaviours
T1, T2, T3
|
“Excessive drinking [alcohol]”
“Stress eating to the extreme which has been unsuccessful”
|
5.4 Mindfulness and positive self-talkb
T1, T3
|
“Trying to have positive thoughts on what I achieved so far and trusting ill get 'through' this”
“Focus on end goal and the impact I can make in end”
|
5.5 Religion/spiritualb
T3
|
“Pray and calm down mind”
“Attending church every weekend to reignite my spirit”
|
5.6 Psychological intervention
T1, T3
|
“Saw psychologist week 6. Not feeling myself, felt brain couldn't concentrate or process”
“I visited a psychologist a few times whilst on placement and I believe this helped me to develop some coping strategies”
|
6. Financial pressures
|
6.1 Curriculum costs
T1, T2, T3
|
“The travel to each of my placements was also very stressful as I was unable to afford extra accommodation in [X location] as I rent with my [name] on the [Y location]. It was 2.5 hours each way every day”
“Main periods of stress have been reassuring myself I can do what I want with this degree, that it’s not a waste of time/money and it was the best decision for me”
|
7. Course survival tips
|
7.1 Curriculum details
T1, T2, T3
|
“I wish I knew what a typical day as a Bond University physiotherapy student looked like”
“The amount of content that was going to be covered in a short period of time”
“How much travel I would need to do for clinic”
|
|
7.2 Self-management techniques
T2, T3
|
“Take time for yourself so you don’t burn out. Learn as the semester goes.”
“Best strategies for dealing with homesickness. Best way to focus on work is thinking about how close I was to going home. A little more about how working in a hospital really feels.”
|
Key: aA priori themes from the Social and Academic Functioning (SAF) Scale, b A priori themes from the CSE scale
Theme 1: Curriculum Coursework
Curriculum coursework was an organizing theme that resonated across all timepoints. The basic theme ‘academic functioning challenges’ was evident throughout responses during T1 and T2. Students report not knowing where to focus or prioritize study, for example finding balancing study and study topics challenging. Another academic functioning challenge reported by students related to a lack of accent training and language barriers. For students on the DPHTY program English may be a second language, thus dialects and accents may add additional challenges to learning. Examination stress also appeared to be a prevalent basic theme where participants described increased stress especially with completing three exams in three days (Table 3).
Theme 2: Clinical Placement
In general, students described the 10-week clinical placement block as “enjoyable”, with reports that a few days break between the clinical placement block may be beneficial. Due to these responses arising in T3, potentially, students were less focused and less stressed about clinical placement during the earlier aspect of the program. Students reported feeling stressed about professional behaviours – receiving feedback, performance standards, self-directed learning and professional development (Table 3).
Theme 3: Transition Periods
Transitions to university life, clinical placement and relocating were reported by students in both T1 and T3, including difficulty with being away from friends and family, and difficulties with cohort cohesion. Students also reported doubts and questioning whether they want to continue the program due to not currently enjoying the course.
Theme 4: Work-Life Balance
Work-life balance featured in students’ responses across all timepoints, specifically relating to difficulty finding the right balance between university life and having time for themselves. Students reported a lack of time management and guilt when doing activities other than study. Difficulties maintaining relationships and having time to be involved in social activities were also reported (Table 3).
Theme 5: Coping Strategies
Both positive and maladaptive coping strategies were evident across all three timepoints. Successful coping strategies commonly reported included social support coupled with study skills, exercise/recreational activities, and mindfulness and positive self-talk (Table 3). Whilst some students openly reported seeking psychological intervention in order to cope, others reported adopting maladaptive coping mechanisms including excessive alcohol consumption, excessive eating, and gaming.
Theme 6: Financial Pressures
Financial burden was reported across all three timepoints. Difficulties were reported especially whilst on placement, due to travel requirements and having to source accommodation (often resulting in paying multiple rent). Sourcing part-time work was reported to be difficult for students due to time pressures and course intensity (Table 3).
Theme 7: Course Survival Tips
Students consistently reported that they wish they had known more curriculum details and self-management techniques throughout all three timepoints. They wish they had known more information on content delivery along with a typical day as a DPHTY university student. Participants also reported that they needed to take time to themselves so to avoid burnout, with other reports stating that they wish they had known the best strategies for dealing with homesickness (Table 3).