Assessment of stress in physician assistant students.

Twenty-seven full-time students within the Physician Assistant Studies Program at The University of Texas--Pan American were anonymously surveyed to determine their levels of stress while enrolled in their first semester. The majority of respondents reported that their stress levels at this point in the program tell within the moderate to considerable range. Most indicated that their stress was induced by the academic demands of the program and their financial obligations. In an attempt to manage their stress, the majority of those surveyed indicated they employed passive techniques.

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An under-recognized variable to academic success within physician assistant training programs is the student's ability to manage stress. The faculty of The Physician Assistant Studies Program (PASP) at The University of Texas--Pan American (UTPA), looking to enhance student academic performance, recognized that stress levels tend to be heightened while in the program. Consequently, they were concerned about the impact of stress upon the student's physical, emotional, and academic well being. Within the program, the faculty has become aware of the fact that several students have sought medical treatment for stress-induced or stress-related health conditions. In order for the student to adequately cope with these stress-related conditions, the authors felt that the sources of stress must first be identified, followed by the development of an intervention plan that could be successfully implemented.

Review of Literature

A review of literature indicated a dearth of material as to stress related factors associated with physician assistant training. However, the academic demands of physician assistant programs are closely related to medical school and residency programs. In this regard, there is a significant amount of information on the effects of stress associated with the training of medical students and residents (Lee & Graham, 2001; Levey, 2001; Michels, Probst, Godenick, & Palesch, 2003; Rosenthal, Rosenthal, & Edwards, 1990: Shapiro, Shapiro, & Schwartz, 2000; Stewart, Lam, Betson, Wong, & Wong, 1999: Vitaliano, Maiuro, Russo, Mitchell, Carr, & Van Citters, 1988). Medical education necessitates its students perform well under stressful conditions. While espousing strength and self-sufficiency, medical training programs consequently cultivate cynicism and depersonalization among its medical trainees. This behavior further compounds an increased feeling of both powerlessness and helplessness (Michaels et al.). Consequently, medical education does not adequately prepare its students or professionals to manage and cope with the effects of stress. Thus the medical field is afflicted with fi-equent burnout of its professionals (Michaels et al.).

Medical students are inundated with stress from the start of their medical training as they attempt to adjust to lifestyle changes and increasing hassles incurred by the demands of medical education (Lee et al., 2001 : Rosenthal et al., 1990). Characteristics commonly associated with medical training and identified as situational or professional stressors include: variable hour shifts, sleep deprivation, cumbersome administrative responsibilities, poor administrative support, and curriculum overload (Lee et al.; Levey, 2001 : Enns, Cox, Sareen, & Freeman, 2001). Additional characteristics are: perceived lack of professional knowledge and skills (Sheu & Hwang, 2002), health care policy changes, difficult patients, patient care, life and death situations, and unexpected shill in academic performance (Lee; Levey; Enns). Further stressors mentioned in the literature include family responsibilities, incurring financial debt, decreased chances for social, leisure, or physical activities, decreased support network due to relocation, cultural and minority issues, and inadequate coping skills (Lee, Michels et al.2003; Enns, 2001).

The documented consequences of stress on medical trainees include: alcohol and drug abuse, interpersonal relationship difficulties, depression, anxiety, and suicide (Levey, 2001: Michels et al., 2003; Shapiro el al, 2000; Vitaliano et al., 1988: Givens & Tjia, 2002). Other studies have also shown stress can be detrimental to the medical trainees' or professional's academic achievement (Stewart, 1999), effectiveness in delivering health services by decreasing attention span, concentration, decision-making skills, and ability to establish physician-patient relationships (Shapiro, 2000). In addition to affecting psychological and emotional well being, stress can also result in a decrease in physical health, such as the development of hypertension, heart disease, and immune deficiency disorders (Lee 2001: Vitaliano et al.: Fontana, 1998). Due to the overall significance of stress upon the individual, it is essential that this particular variable be scrutinized within the parameters of PA education.

Method

Twenty-seven full-time students within the Physician Assistant Studies Program at The University of Texas--Pan American were anonymously surveyed to determine their levels of stress while enrolled in their first semester. All students had been in the 24 month program for a period often weeks. Prior to filling out the survey, all students were asked to complete a voluntary, consent form. Written surveys were administered to the group within a classroom setting. The survey was composed of both qualitative and quantitative items. The survey was constructed by two UTPA-PASP faculty members. The questions were constructed in as unbiased a manner as possible with no leading questions. A copy of the survey questions is listed in the appendix. Most students completed the survey within a half hour period. Descriptive analysis of the survey using SPSS 11.0 was conducted to develop preliminary baseline data for the projected longitudinal design of this study.

Results

Of the students surveyed, 16 were males and 11 were females. The ethnicity of the subjects surveyed was 17 Hispanic, two African-American, two Asian, four Caucasian, and two other. Most students had a bachelor's degree with a few indicating an associate's and one a master's. Five students had no degree at this time but were nearing completion of a bachelor's degree (Figure 1). Nineteen responded having a biological science degree. Of the remaining students, only two had degrees outside of a science major Additionally, students indicated that prior to entering the UTPA-PASP, most had experience in the medical field. Examples of this experience included: medical assistant, licensed vocational nurse, emergency medical technician, respiratory therapist, surgical assistant, and laboratory technologist. Of the students surveyed, 11 were married, 14 were single, one was separated, and another was divorced. Nineteen students were 20-30 years of age, 5 were 31-40, and 3 were over 40 years old.

Over 70% of respondents identified changes in their eating and sleeping habits in response to their participation in the first semester of the PA program. Forty-one percent of respondents stated the PASP induced a moderate to significant amount of stress contributing to changes in their relationships. Nearly 68% of students reported financing their PA training through student loans while 48.1% of students utilized personal savings. While student loans and personal savings represent the most common sources of financial support, 15% of students reported using current employment earnings to pay for the program. Of those students employed while attending the PA program, three reported working between 1-20 hours per week and one student reported working 30 or more hours. The majority of students (18.5%) reported their employment affected their PA studies to a small degree while 11% stated their employment moderately affected their studies.

Despite the financial hardships and stress placed upon their personal relationships, students indicated the reason they chose this particular career path was to make a difference by caring for others and making an impact upon those in need.

Major contributors to the subjects' stress level included examinations and total course load requirements (Figure 2). As depicted in Table 1,58% of students identified the program's course load requirements induced a moderate level of stress while 41% of students cited course examinations as an inducer of considerable stress. Other contributors mentioned were academic and clinical assignments, although the students had not been placed in clinical rotations at the time of the survey (Table 1). In addition to the categorized sources mentioned above, other factors inducing considerable stress in PA students include information overload, financial worries, relevancy of course lectures, and lack of time management and organizational skills (Table 1).

Respondents indicated that their stress levels affected the following areas of their personal behaviors: 20 students reported that they were aware of changes in their sleeping habits. 19 in their eating habits, and 11 in their relationships (Figure 3). Contrary to the literature concerning medical students. the subjects did not indicate any significant increase in the use of alcohol or tobacco (Levey, 2001: Michels et al., 2003; Shapiro et al., 2000: Vitaliano et al., 1988). Because the survey was administered early in the course of the PASR it could be speculated that there had not been sufficient time for these behaviors to manifest.

When asked as to the techniques employed in managing their stress levels, students provided a variety of answers. For example, most students resorted to passive outlets such as spending time with family members and friends, watching movies or television, listening to music, or seeking peer support or spiritual involvement. Exercise was mentioned by some, but not as a significant coping technique for stress reduction (Figure 4). Most students, when asked about using campus resources, were either unaware of such resources or they did not access them. A significant number of participants were not aware of any resources on the UTPA campus that could help manage their stress. In this regard, respondents did not utilize campus resources such as the fitness center facilities, counseling center, or consultation with a faculty member. Overall, 15 of the subjects rated the effectiveness of their stress management as only minimally to moderately effective. Only 12 indicated that they considered their stress management techniques highly effective (Figure 5).

A number of respondents reported that their expectations of workload and stress levels within the PASP would be different than those of an undergraduate program. When asked about the differences, the students answered that they expected the program to be more difficult and demanding. They also expected greater amounts of required work, along with more stringent academic expectations of content mastery, time management, and professionalism. The authors speculated that the students were somewhat aware that their stress levels would be elevated beyond what they experienced as a pre-PA student. However, many respondents indicated they did not have realistic expectations as to the amount of work, preparation, changes in study habits, personal sacrifices, financial strain, and time constraints for outside interests that would be demanded of them by the UTPA-PASP.

Discussion

Responses from this preliminary data collection indicate students perception of moderate to considerable stress associated with the UTPA Physician Assistant Studies Program. These responses support other studies cited in the literature review. Additional data will be collected on these students toward the end of their first year within the PASP and again prior to graduation. These preliminary data indicate potential sources of stress and that students entering the program could be counseled about such stressors, advised about differing stress reduction techniques, informed about campus resources for assistance, and advised to actively participate in stress reduction efforts.

APPENDIX

The PA Student Stress Questionnaire

Age

                           -- <20 years old
                           -- 20-30 years old
                           -- 31-40 years old
                           -- >40 years old

Gender                     -- Male
                           -- Female

PASP Classification        -- Junior
                           -- Senior

Ethnicity                  -- Hispanic or Latino/Latina
                           -- White or Caucasian
                           -- Black or African American
                           -- Asian
                           -- American Indian or Alaska Native
                           -- Native Hawaiian or Pacific Islander
                           -- Other, please specify:

Degree(s) earned prior to starting the UTPA-PASP?

                           -- Associates
                           -- Bachelors
                           -- Masters
                           -- Doctorates
                           -- Foreign Medical Graduate
                           -- No degree

What was your major in college?

                           -- Biological sciences (biology,
                              microbiology, physiology,
                              etc.)
                           -- Physical science (chemistry, physics,
                              math, etc.)
                           -- Social and behavioral sciences
                              (sociology, psychology, etc.)
                           -- Allied health sciences (medical
                              technology, OT, PT, etc.)
                           -- Nursing
                           -- Education
                           -- Other, please specify:

What hands on health care experience did you have (prior to entering
UTPA-PASP)?

-- Medical Assistant      -- EMT                      -- Foreign
                                                      Medical Graduate
-- LVN                    -- Paramedic                -- Other, please
                                                         specify
-- BSN                    -- Occupational Therapist   -- None
-- Medical Technologist   -- Physical Therapist

How many years of medical experience did you have in the above areas?

                           -- Less than 1
                           -- 1-3 years
                           -- 3-5 years
                           -- Greater than 5 years
                           -- None

Are you fluent in Spanish?

                           -- Yes, I am fluent
                           -- No, I am not fluent

If you are not fluent in Spanish, how great an impact did your lack of
language skills have on your educational experience while enrolled in
the UTPA-PASP?

                           -- None
                           -- Very little
                           -- Moderate amount
                           -- Significant amount

Indicate the size of the community in which you were reared.

                           -- Large city (population >500,000)
                           -- City of moderate size (population
                              50,000-500, 000)
                           -- Small city (population 10,000-50,000)
                           -- Town (population 2,500 - 10,000)
                           -- Small town (population <2,500)
                           -- Rural/unincorporated area

What is your marital status?

                           -- Single
                           -- Engaged
                           -- Married
                           -- Separated
                           -- Divorced
                           -- Widowed

What impact did the PASP have on your relationship with your spouse
and/or significant other and family?

                           -- None
                           -- Very little
                           -- Moderate amount
                           -- Significant amount

How many children do you have?

            --0      --1        --2       --3       --4 or more

What were their ages when you started the PASP?

Have you had a change in this area while in the UTPA-PASP? If so, what
impact did that have on your studies?

                           -- No change
                           -- Yes (please explain)

How are you paying for your degree?

                 -- Scholarships            -- Others
                 -- Loans                   -- Working while in school
                 -- Savings

How many hours per week did you work while in the PASP?

                           -- I did not work while in the PASP.
                           -- 1-10 hours/week
                           -- 11-20 hours/week
                           -- 20-30 hours/week
                           -- 30 or more hours/week

How did this affect your studies?

                           -- None
                           -- Very little
                           -- Moderate amount
                           -- Significant amount

Why did you choose this profession?

Did you shadow PA's prior to starting the PASP (total number of hours)?

                           -- No
                           -- 1-20 hours
                           -- 21-40 hours
                           -- 41-60 hours
                           -- Greater than 60 hours

What were your expectations of the curriculum coming into the PASP?
(For example, the amount of work or the amount of stress) What are
your expectations now?

What stress management techniques do you employ? (mark all that apply)

                           -- Exercise
                           -- Spending time with family or friends
                           -- Watching television or a movie
                           -- Other, please specify:

How effective are your stress management techniques?

                           -- Not at all effective
                           -- Minimally effective
                           -- Moderately effective
                           -- Highly effective

Compare your level of stress to that of other PA students in the
UTPA-PASP. Rate your level of stress using the following scale:

                           1 = I feel no stress at all.
                           2 = I feel very little stress.
                           3 = I feel a moderate amount of stress.
                           4 = I feel a considerable amount of stress.
                           5 = I feel overwhelmed by the amount of
                               stress I am experiencing.

What about the UTPA-PASP is stressful? Please explain.

                           -- Total course load
                           -- Course assignments
                           -- Examinations
                           -- Clinical assignments
                           -- Faculty
                           -- Other, please specify:

Have you noticed any personal behavior changes since starting the
UTPA-PASP? Please explain.

                           -- Changes in eating
                           -- Changes in sleeping habits
                           -- Changes in your relationships
                           -- Changes in alcohol consumption
                           -- Changes in tobacco use
                           -- Other, please specify:

What type of support systems do you have in place?

                           -- Peers
                           -- Friends
                           -- Family
                           -- Other, please specify
                           -- No support systems

How effective are your support systems?

                           -- Not at all effective
                           -- Minimally effective
                           -- Moderately effective
                           -- Highly effective

Are there any resources within the UTPA-PASP to help you manage your
stress? Please list.

How effective are these resources?

                           -- Not at all effective
                           -- Minimally effective
                           -- Moderately effective
                           -- Highly effective

Table 1
Sources of Stress Within The UTPA-PA Studies Program

Source of Stress        N          None           Mild

Total Course Load      19           0.0%         10.5%
Course
Assignments             6          16.7%          0.0%
Examinations           22           0.0%          4.5%
Faculty                 5          20.0%         20.0%
Other (financial
worries,
information
overload, etc)          8          0.0%          12.5%

                         Degree of Stress
Source of Stress     Moderate   Considerable   Overwhelmed

Total Course Load     57.9%        26.3%          5.3%
Course
Assignments           50.0%        16.7%         16.7%
Examinations          50.0%        40.9%          4.5%
Faculty               20.0%        20.0%         20.0%
Other (financial
worries,
information
overload, etc)        37.5%        50.0%          0.0%

Figure 1.
Degree Prior To Entering UTPA-Physician Assistant Studies
Program

No Degree                  19%
Associate's                11%
Bachelor's                 63%
Master's                    7%

Note: Table made from pie chart.

Figure 2.
Percent Distribution of Student Stress Attributed to Various
Components of the UTPA-PASP Program

Other                    29.6%
Faculty                  14.8%
Examinations             81.5%
Course Assignments       18.5%
Total Course Load        70.4%

Note: The percent distribution was attained by dichotomizing
the items pertaining to stress attributed to various program
components (i.e. What about the UTPA-PASP is stressful? Total
course load, course assignments, examination, faculty, and
other) into 0 = no stress level indicated and 1 = stress level
indicated.

Note: Table made from pie chart.

Figure 3.
Behavioral Changes Attributed to Participation in the UTPA
Physician Assistant Studies Program

Sleeping Habits          74.1%
Eating Habits            70.4%
Relationships            40.7%
Tobacco Use              11.1%
Alcohol Use               3.7%

Note: Table made from bar graph.

Figure 4.
Stress Management Methods Utilized By UTPA-PASP Students

Spend Time With          70.4%
Family and Friends

Watch TV or Movies       70.4%

Exercise                 44.4%

Other (Listening to      40.7%
Music, Spiritual
Involvement)

Note: Table made from bar graph.

Figure 5.
Degrees of Effectiveness of Stress Management Techniques
Utilized By UTPA-PASP Students

Not Effective             0.0%
Minimally Effective      25.9%
Moderately Effective     51.9%
Highly Effective         22.2%

Note: Table made from bar graph.

References

Enns, M.W., Cox, B.J., Sareen, J., Freeman, P. (2001). Adaptive and maladaptive perfectionism in medical students: a longitudinal investigation. Medical Education, 35, 1034-42.

Fontana, A., McLaughlin, M. (1998). Coping and appraisal of daily stressors predict heart rate and blood pressure levels in young women. Journal of Behavioral Medicine, 24(1), 5-17.

Givens, J.L., Tjia, J. (2002). Depressed medical students' use of mental health services and barriers to use. Academic Medicine, 77(9), 918-21.

Lee, J. & Graham, A.V. (2001). Students' perception of medical school stress and their evaluation of a wellness elective. Medical Education, 35, 652-9.

Levey, R.E. (2001). Sources of stress for residents and recommendations for programs to assist them. Academic Medicine, 76, 142-50.

Michels, P.J., Probst, J.C., Godenick, M.T., Palesch, Y. (2003) Anxiety and anger among family practice residents: A South Carolina family practice research consortium study. Academic Medicine, 78(1), 69-79.

Rosenthal, T.L., Rosenthal, R.H., Edwards, N.B. (1990). Case history and shorter communication: Students' self-ratings of stress in medical school: A replication across 20 months. Behaviour Research Therapy, 28(2), 171-3.

Shapiro, S.L., Shapiro, D.E., Schwartz, G.E.R. (2000) Stress management in medical education: a review of the literature. Academic Medicine, 75(7), 748-59.

Sheu, S., Lin, H.L., Hwang, S. (2002). Perceived stress and physio-psycho-social status of nursing students during their initial period of clinical practice: The effect of coping behaviors. International Journal of Nursing Studies,39, 165-75.

Stewart, S.M., Lam, T.H., Betson, C.L., Wong, C.M., Wong, A.M.P. (1999). A prospective analysis of stress and academic performance in the first two years of medical school. Medical Education, 33, 243-50.

Vitaliano, P.P., Maiuro, R.D., Russo, J., Mitchell, E.S., Carr. J.E.. Van Citters, R.L. (1988). A biopsychosocial model of medical student distress. Journal of Behavioral Medicine (4), 311-31.

Lisa Kuhn, PA-C, MMS, Assistant Professor, Physician Assistant Studies Program; Peter L. Kranz, PhD., Assistant Professor, Counselor of Education Program, Department of Educational Psychology: Felix Koo, Ph.D., M.D., Clinical Instructor, Physician Assistant Studies Program; Griselda Cossio. MA, The University of Texas --Pan American. Nick L. Lund, Ph.D., Executive Director, Northern Arizona University--Yuma.

Correspondence concerning this article should be addressed to Lisa Kuhn, PA-C. MMS, Assistant Professor, Physician Assistant Studies Program, 1201 West University Drive, Edinburg. TX 78539; Email: [e-mail].