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Assessment of the reliability and validity of a stress questionnaire for pharmacy administration graduate students.

The purpose of this study was to test and assess the reliability and validity of a modified stress scale in a sample of pharmacy graduate students. The modified stress scale was used as part of a larger, nationwide, study whose aim was to investigate the association of stress, perceived academic success and health-related quality of life among pharmacy administration graduate students in U.S. colleges of pharmacy. A usable response rate of 46.5% (172/370) was obtained. A principal components analysis with varimax orthogonal rotation resulted in a 29-item, eight component solution (accounting for 66.2% of the explained variance).The eight components were named: 1) fear of failing stress, 2)academic stress, 3) world stress, 4) time stress, 5) stress about feedback, 6) student-faculty interaction stress, 7) economic stress and 8) environmental stress. The Cronbach coefficient alpha value of .90 for the 29-item scale indicated high reliability and internal consistency. The predictive validity results were significant and in the expected direction providing evidence of the validity of the modified stress scale. The modified stress scale is a reliable and valid measure of assessing stress in pharmacy administration graduate students and may be useful in identifying areas of stress that may be present in graduate students from other disciplines.

INTRODUCTION

Students may experience high stress at predictable times each semester due to academic commitments, financial pressures, and lack of time management skills. When stress is perceived negatively or becomes excessive, it may affect health and academic performance (Misra, McKean, West, & Russo, 2000). Doubts about being in the right academic program, concerns about faculty/advisor relations and concerns about time to attain degree are some of the areas which may constitute stressful experiences of being in graduate school.

Many stress scales have been developed and used to study stress among college students (Gadzella, 1991; Kohn & Frazer, 1986; Towbes & Cohen, 1996), health sciences programs students (Heins, Fahey, & Leiden, 1984; Toews et al., 1997; Vitaliano, Russo, Carr, & Heerwagen, 1984), and graduate students (Cahir & Morris, 1991; Hodgson, 1991; Rocha-Singh, 1992). Using previously developed and validated stress scales, studies have been performed to assess stress among bachelor of pharmacy students (Henning, Ey, & Shaw, 1998) and Doctor of Pharmacy (Pharm.D.) students (Dutta, 2001; Gupchup, Borrego, & Konduri, 2004). However, published studies utilizing a validated stress scale to explore the effect of stress among pharmacy graduate students (masters and doctoral level) are lacking.

Given the rigor of masters (M.S.) or doctoral (Ph.D.) level graduate programs in pharmacy, we hypothesize that stress may be an important determinant of whether a student completes their course of study in a timely manner, or even at all. Having a valid and reliable stress scale to identify potential stressors encountered by pharmacy graduate students would be important for graduate program coordinators. Graduate program coordinators could use such a scale to identify potential sources of stress within their graduate students and in turn use the results of such a scale to develop stress awareness and reduction programs. Subsequently, this may help their students deal with their potential stressors and help them succeed.

The purpose of this study was to test and assess the reliability and validity of a modified stress scale in a sample of pharmacy graduate students in U.S. colleges and schools of pharmacy.

Methods

Questionnaire modification

Among the scales available to assess stress in graduate students and health sciences students, the stress questionnaire developed by Heins et. al (1984) was selected for use (after modification) in our study population of pharmacy graduate students (Heins et al., 1984). This questionnaire was developed for the medical education field and has been used to assess stress among medical, law and science graduate students. Some of the original item wording from this stress questionnaire were slightly modified in our study to be applicable to pharmacy graduate students. New items pertaining to environmental stress (moving to new city/country, finding roommates, etc.) were added to the modified stress questionnaire after a literature review of other stress questionnaires (Hodgson, 1991 ; Rocha-Singh, 1994). Stress questionnaire items related to terrorism, nuclear war and the world situation were added because our research team believed that they were important in light of the world's current political scenario.

In summary, the modified stress questionnaire section contained 39-items, each containing a four-point, Likert-type scale response format (1 = not a stress, 2 = slight stress, 3 = moderate stress, 4 = severe stress). The modified stress questionnaire addressed the following stress categories: 1) academic stress [e.g.: stress about classes, examinations, faculty members], 2) time stress [e.g.: long hours in class, time spent in studying, no time for self], 3) fear of failing stress [e.g.: poor grades, failing out of the program], 4) classroom stress [e.g.: lack of positive feedback, being 'put down' by a professor], 5) economic stress [e.g.: inflation, student loans], 6) world stress [e.g.: terrorism, nuclear war], and 7) environmental stress [e.g.: moving to new city/country, looking for roommate]. Seven questions which did not fit in any of the above mentioned categories were classified under the "miscellaneous" category (e.g.: frequent exams, fight with significant other, etc.).

Study sample

The modified stress questionnaire was subsequently pilot tested among a sample of seventeen pharmacy graduate students specializing in pharmacy administration at two U.S. schools of pharmacy. Pharmacy administration involves the study of the social and administrative aspects of the practice of pharmacy. Pilot schools participating in the pilot test included the University of Arizona College of Pharmacy, Tucson, AZ and The University of New Mexico College of Pharmacy, Albuquerque, NM. The purpose of the pilot study was to evaluate face and content validity of the questionnaire and identify any unclear questionnaire items. Respondent comments from the pilot study were used to make changes to the questionnaire.

The final modified stress questionnaire was used as part of a larger study whose aim was to investigate the association of stress, perceived academic success and health-related quality of life among pharmacy administration graduate students (Konduri, 2003). The modified stress questionnaire was sent out nationwide to colleges or schools of pharmacy containing pharmacy administration graduate programs at twenty-seven universities for distribution to pharmacy administration graduate students through their respective graduate program coordinators.

Data Analysis

Appropriate descriptive statistics were calculated to characterize the sample. A principal components analysis (PCA) with varimax orthogonal rotation was performed for the 39-item modified stress questionnaire to identify the latent components. Four criteria were used to identify the components: 1) Kaiser's rule of an eigenvalue of at least 1.0 to retain the component (Anastasi, 1976); 2) items had to have loadings of 0.40 and above to be retained (Hair, Anderson, Tatham, & Black, 1995); 3) items with cross-loadings (loadings on more than one component) of 0.40 and above were deleted (Zelnio & Simmons, 1981), and 4) components with two items or less were deleted as their interpretation is considered to be risky even under the most exploratory factor analytic techniques (Tabachnick & Fidell, 2001).

After applying criteria mentioned above, PCA with varimax orthogonal rotation was again performed on the remaining set of items. The criteria described above were again applied until there were no more cross loadings. Subsequently, items were grouped within their respective components and the components were assigned names based on their content. The data were analyzed using the Statistical Package for Social Sciences (SPSS for Windows Version 11.0) software.

Reliability estimates were determined for the modified stress questionnaire. Internal consistency reliability estimates were calculated using Cronbach's coefficient alpha for the overall modified stress questionnaire and for the individual identified components. To assess the predictive validity of the modified stress questionnaire, Pearson's product moment correlations were calculated between the overall stress score and the mental and physical components of health-related quality of life. Health-related quality of life (HRQOL) was measured with the widely used SF-12 health survey which consists of 12 items and yields two summary HRQOL scores: the mental component summary (MCS) score and the physical component summary (PCS) score (Ware, Kosinski, & Keller, 1996). Additionally, the scores for each component of the modified stress questionnaire were correlated with the SF12 HRQOL MCS and PCS scores. We expected that higher scores on the stress questionnaire would be negatively related to HRQOL scores.

The overall stress score and the individual component stress scores were correlated with a modified perceived academic success scale score (M-PASS). The M-PASS was developed by taking Hodgson's (1991) original six-item 'perceived academic success scale' and adding six new items that were deemed relevant measures of perceived academic success (Konduri, 2003). The M-PASS has a high Cronbach's alpha reliability coefficient of 0.90 (Konduri, 2003). We expected that scores on the stress questionnaire would be negatively correlated to perceived academic success scores. Finally, we performed correlations between self-reported grade point average (GPA), the overall stress score and the individual component stress scores. We expected that scores on the stress questionnaire would be negatively correlated to self-reported GPA.

Results

Demographic characteristics

A total of 370 questionnaires were mailed to graduate program coordinators for distribution to pharmacy administration graduate students. Usable responses were received from 172 pharmacy administration graduate students, resulting in a 46.5% usable response rate after two mailings. More than half the sample were females (n = 89, 52.4%). The mean age of the graduate students in the sample was 28.6 years (SD = 4.8) with a range of 22 to 47 years. Nearly 63% of the sample were single (n = 107), 33.3% were married (n = 57) and 2.9% were divorced/separated (n = 5). Almost two-thirds of the sample were foreign citizens (n = 101, 59.8%). A majority of the students received financial assistance for their graduate studies (n = 157; 92.4%). The mean number of semesters completed for the graduate students in the sample was 4.8 (S.D. = 4.9) and the mean self-reported grade point average was 3.75 on a 4.0 scale (SD=0.25). Two-thirds of the sample were enrolled in a Ph.D. program (n = 110; 64.3%) and nearly one-third (n = 61; 35.7%) of the sample were enrolled in a M.S. degree program. Additional demographic characteristic results are shown in Table 1.

Identification of Questionnaire Components (Domains)

The initial principal components analysis (PCA) with varimax orthogonal rotation conducted on the 39-item modified stress questionnaire resulted in an 11-component solution. After applying the four criteria used to retain components delineated in the methods section, 30 items remained. These 30 items were again subjected to a PCA with varimax rotation and the four criteria described earlier were applied. This resulted in an 8-component solution with the retention of 29 items. The eight components accounted for 66.2% of the explained variance. The eight components were named based on their content as follows: 1) Fear of failing stress [eigenvalue = 8.12, 5 items]; 2) Academic stress [eigenvalue = 2.30, 6 items]; 3) World stress [eigenvalue = 2.22, 3 items]; 4) Time stress [eigenvalue = 1.64, 3 items]; 5) Stress about feedback [eigenvalue = 1.45, 3 items]; 6) Student-faculty interaction stress [eigenvalue = 1.30, 3 items]; 7) Economic stress [eigenvalue = 1.12, 3 items]; 8) Environmental stress [eigenvalue = 1.05, 3 items]. Table 2. presents the item loadings on each component for the 29 items in the modified stress questionnaire, and the explained variance associated with each component. The item loadings ranged from 0.42 to 0.88. None of the items had cross-loadings (loadings on more than one component) above 0.38. Therefore, a fairly clean component solution was obtained.

The Cronbach coefficient alpha values for the total scale, as well as each component are shown in Table 3. The Cronbach coefficient alpha value for the total modified stress questionnaire (29 items) was 0.90, indicating a high internal consistency. The internal consistency (Cronbach's alpha) did not improve with the deletion of any item from the scale. The Cronbach coefficient alpha values for the eight stress components ranged from 0.54 (environmental stress) to 0.86 (world stress). Cronbach coefficient alpha values for the respective components did not improve with the deletion of any item within the respective component. The means, standard deviations and possible range of scores for the total stress scale and each component are presented in Table 3. These scores were calculated by summing the scores for each item in the total scale and for each respective component. Higher scores on the total scale and each component indicate higher stress.

The predictive validity results are presented in Table 4. The total stress score for the modified stress questionnaire was negatively and significantly related to the SF-12 HRQOL Mental Component Summary (MCS) score and the modified perceived academic success scale (MPASS) score (r = -0.31, p<0.01; and r = -0.20, p<0.01, respectively). This indicates that graduate students who had higher stress scores had lower mental component HRQOL scores and lower perceived academic success scores. These results were in the expected direction and provide evidence of validity of the stress questionnaire in pharmacy administration graduate students. Additionally, the academic stress component [component two] was negatively and significantly related to both the SF-12 HRQOL MCS (r = -0.23, p<0.01) and modified perceived academic success score (r = -0.23, p<0.01). The stress about feedback component [component five] was negatively and significantly related to the SF-12 HRQOL MCS score (r = - 0.24, p<0.01), and the student-faculty interaction stress component [component six] was negatively and significantly related to perceived academic success (r = -0.26, p<0.01). All of the correlation analyses findings were in the expected direction and provide some evidence of the validity of the overall modified stress questionnaire and of the individual components comprising the modified stress questionnaire.

Self-reported grade point average (GPA) was negatively and significantly related to the overall stress score (r = - 0.29, p<0.01); the fear of failing stress component [component one], (r = -0.36, p<0.010); the academic stress component [component two], (r = -0.30, p<0.01) and the student-faculty interaction stress component [component six], (r = -0.19, p<0.05). These findings indicate that students reporting a lower GPA have higher overall stress, fear of failing stress, academic stress and student-faculty interaction stress scores. Additionally, self-reported GPA was positively and significantly related to the modified perceived academic success scale (M-PASS) score (r = 0.17, p & indicating that as self-reported GPA increases, students' perceived academic success scale scores increase.

Discussion

The purpose of the current study was to modify an existing stress questionnaire for use in a sample of pharmacy administration graduate students. The original stress questionnaire developed by Heins et al. (1984) for medical students identified six components: academic stress, time stress, fear of failing stress, classroom stress, economic stress and world stress. In our study, we identified eight components in the modified stress questionnaire. The newly identified components were named: fear of failing stress, academic stress, world stress, time stress, stress about feedback, student-faculty interaction stress, economic stress and environmental stress. These new components suggest that certain aspects of stress from the perspective of pharmacy administration graduate students are different from those of medical students.

The two largest factors identified from the modified stress questionnaire were fear of failing stress and academic stress. Together they accounted for 36% of the explained variance. The identification of an academic stress component in our study is consistent with other studies (Kohn & Frazer, 1986; Misra et al., 2000). However, the fear of failing stress component identified in our study appears unique to pharmacy graduate students as other stress scales do not contain fear of failing as a major component (Cahir & Morris, 1991; Hodgson, 1991). Four items in the fear of failing stress component consist of items related to graduate study: 1)concern about failing out of the program, 2) afraid that I might be asked to repeat a course or the year, 3) being placed on academic probation, and 4) getting poor grades. The fifth item of this component, "fight with significant other" was an unusual item which loaded in this component suggesting that graduate students who may be in a relationship may experience fear that stress in their relationship may contribute to failure. The world stress component accounted for 7.6% of the explained variance. This was expected since the study was conducted in an era of terrorism and conflict between nations around the world. The original stress questionnaire developed by Heins et al. (1984) has no reported or published Cronbach coefficient alpha value. In our study, the Cronbach coefficient alpha value for the modified stress questionnaire was 0.90, indicating that this questionnaire was a reliable measure of self-reported stress for graduate students. The Cronbach coefficient alpha values for the eight stress components ranged from 0.54 to 0.86. A Cronbach coefficient alpha value of 0.70 is considered acceptable when developing instruments (Nunnally, 1978). However, Ware et al. (1998) have suggested that scales with reliabilities of 0.50 to 0.70 are considered sufficiently reliable for use in group comparisons (Ware et al., 1998).

The predictive validity results obtained for the modified stress questionnaire and the components were promising. The total stress score as well as the academic stress component were negatively related to the mental component of HRQOL and perceived academic success. The stress about feedback component was negatively related to the mental component HRQOL score and the student-faculty interaction component was negatively related to perceived academic success. Additionally, the total stress score, the fear of failing, academic stress, and student-faculty interaction stress components were negatively and significantly related to self-reported GPA. These correlations were in the expected directions. Though the current study was performed in pharmacy graduate students, the results obtained are consistent with previous studies performed in other student groups. Gupchup et al. (2004) showed that stress among professional pharmacy students was negatively related to the mental component of HRQOL, while Damush et al. (1997) and Hudd et al. (2000) reported that stress among college students was negatively related to mental health and self-esteem, respectively. Additionally, previous studies have shown that stress negatively affects academic success among graduate students and medical students (Hodgson, & Simoni, 1995; Blumberg, & Flaherty, 1985).

Although this study provided useful results about the reliability and validity of the modified stress questionnaire, there are some limitations that need to be considered for future use of the modified stress questionnaire. This study was conducted in a sample of pharmacy graduate students representing only one area of specialization, namely, pharmacy administration. There are several other graduate areas of specialization within pharmacy such as medicinal chemistry, pharmacology, and pharmaceutics (the study of the manufacture of medications). It is unclear whether the psychometric properties of the modified stress questionnaire will vary in these other areas of specialization. With slight modifications, the content of the modified stress questionnaire may also be applicable to, and used in, other health sciences related graduate programs. The use of the modified stress questionnaire in other health sciences related graduate programs could be the focus of future studies.

In this study the useable response rate obtained was 46.5%. It is unclear whether the reliability and validity coefficients would be any different among the non-respondents. If stress levels were different in the respondents than the non-respondents, there is a possibility of non-response error. However, when early and late responders were compared they did not differ significantly on either the total stress score or any component score.

Perceived academic success was used as an indicator of academic success in this study. Most studies use GPA as an indicator of academic success. However, GPAs for graduate students are notoriously high, with little variation. The mean GPA reported by the respondents in this study was 3.75 (SD = 0.25). The questionnaire used to measure perceived academic success, the MPASS, had a high Cronbach coefficient alpha reliability of 0.90 (Konduri, 2003). Moreover, as indicated by the low correlation between self-reported GPA and MPASS scores (r = 0.17, p<0.05), the MPASS captures several issues other than GPA that are perceived by pharmacy graduate students to be important to their academic success (Konduri, 2003). Therefore, we considered it appropriate to use the MPASS as an indicator of academic success.

This study was cross-sectional in nature and therefore the capacity of the modified stress questionnaire to document changes in stress levels over time needs to be evaluated in future studies. Additionally, the capability of the questionnaire to differentiate among graduate students who have benefited from stress management programs also needs to be investigated. Nonetheless, we believe that the modified stress questionnaire is a useful, reliable and valid instrument for identifying areas of stress that may be present in a group of graduate students. The information and results obtained from the administration of the modified stress questionnaire may be used in planning strategies that might alleviate stress; thereby improving HRQOL and academic success.

Conclusions

The modified stress questionnaire is a reliable and valid measure of assessing stress in pharmacy administration graduate students. Future research will need to be performed to establish the reliability and validity of the modified stress questionnaire for graduate students from other disciplines.

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NIRANJAN KONDURI, B.S. PHARM, M.S. (1)

GIREESH V. GUPCHUP, B.S. PHARM, PH.D. (2, 3)

MATTHEW E. BORREGO, PH.D. (4)

MARCIA WORLEY-LOUIS, PH.D. (5)

(1) Loma Linda University, School of Public Health, Loma Linda, CA 92350

(2) Southern Illinois University-Edwardsville, School of Pharmacy, Edwardsville, IL 62026

(3) To whom correspondence should be addressed

(4) University of New Mexico Health Sciences Center, College of Pharmacy, Albuquerque, NM 87131

(5) University of Minnesota-Duluth, College of Pharmacy, Duluth, MN 55812
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Author:Konduri, Niranjan; Gupchup, Gireesh V.; Borrego, Matthew E.; Worley-Louis, Marcia
Publication:College Student Journal
Geographic Code:1USA
Date:Mar 1, 2006
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