University education is often a time of life synonymous with stress, sleep deprivation, and tears (along with all the youthful upsides). While this can be true for many disciplines in the world of tertiary education, our budding health professionals seem are known to have some of the most difficult courses to undertake in their careers. It is not for nothing, as during those important years (decades) of education they develop the knowledge and skills that enable them to provide the highest level of care possible. Still, it is no surprise that this process is classically a high stress environment.
Although it is important to learn how to cope under pressure, especially when entering challenging careers, excessive stress is not always conducive to the best learning environment. High levels of stress and burnout are known to have a negative impact on academic success, quality of life, and psychological and physical wellbeing. While increasingly, society has started to take note of the signs and symptoms of severe stress in recent years, which may in part be due to the rising incidence of mental health issues among university students, research on chiropractic students in particular has been scarce.
Studies looking into the stress and burnout prevalence across medical disciplines have revealed high levels of depression and anxiety, with psychological distress prevalence levels well over that found in the general population. Literature on complementary and alternative medicine education is scarcer, although it has been shown that chiropractic programs are demanding, and have a considerable impact on the well-being of chiropractic students when compared to the general student population.
Therefore, managing students’ stress and allowing them to gain knowledge in an optimal environment is a discussion well worth having.
What does the new study say?
A recent study published in the Journal of Chiropractic Education aimed to quantify the prevalence of stress and burnout in chiropractic students from European chiropractic colleges. It also aimed to compare the results with findings in other health professions. Two questionnaires were utilised to establish the prevalence of stress and burnout; the Maslach Burnout Inventory – Student Survey (MBI-SS) and the Perceived Stress Scale (PSS-10).
The study included only European chiropractic colleges with a five-year curricular program. All universities were contacted via email and four out of a potential nine colleges participated. Of the colleges that were not included; three colleges could not participate due to time constraints and other circumstances, one was excluded due to major differences in chiropractic curriculum, and one withdrew before handing out the surveys.
MBI-SS is a questionnaire specifically designed to assess burnout in college students. It only takes about ten minutes to complete and focuses on three core aspects of burnout, namely exhaustion, cynicism, and a lack of academic efficacy. These areas are assessed across 16 questions which are each scored on am eight-point Likert scale ranging from 0 (never) to 7 (everyday). The psychometric properties, also referred to as its validity and reliability as a psychological tool, has been researched in recent years. It has demonstrated an adequate internal consistency in Dutch, Spanish, Portuguese, Brazilian, and Chinese samples.
It is important to mention that in this recent literature, one of the items for cynicism tends to be excluded. The item “when I’m in class or I’m studying I don’t want to be bothered” is typically viewed as ambivalent, however the current study uses and refers to the MBI manual as a guideline, and this guide includes all original 16 items of the questionnaire. The statistical analysis method utilised was method two, according to the MBI manual guidelines, where an average for each subscale of the MBI was obtained. Each subscale is calculated and interpreted individually, but when taken together provide a 3-dimensional perspective on burnout.
The PSS-10 questionnaire consists of 10 questions that assess an individual’s perception of stress. Each item is scored on a five-point Likert scale where the occurrence of stress is rated from 0 (never) to 4 (very often). A higher score constitutes a higher level of perceived stress. The psychometric properties of the PSS are widely accepted as a valid instrument, with high internal consistency. An overall score of 0-10 on the PSS indicates low stress, 11-15 indicates mild stress, 15-20 indicates moderate stress, and a score about 20 indicates severe stress.
Participation in the study was voluntary across all colleges, and no monetary compensation was provided. Surveys were sent out in the mid semester period (November for our European friends) to ensure data collection would not fall during exam periods. Collecting responses during this time may have altered the results of the PSS and MBI, potentially demonstrating a higher level of both stress and burnout than is normally experienced during the year. Surveys were left open for a two-week period for students to submit responses, and multiple reminders were sent before closing the questionnaires.
What did they find?
From the results collected across the four colleges:
- Females had a higher participation rate
- Most responses were from students aged 18-25
- The percentages of responses from working and non-working students were similar
- MBI-SS had a response rate of 30%
- PSS had a response rate of 34%
The MBI-SS results revealed that in the general chiropractic student population;
- 26.4% presented with high emotional exhaustion
- 18.2% presented with high cynicism
- 43.8% low academic efficacy
The results from the PSS showed “moderate” levels of stress across the study population.
When the authors compared the results of the current study with results from literature centred on medical students, they found chiropractic students presented MBI subscale results similar to those of medical students, with high levels of emotional exhaustion and depersonalisation/cynicism. Interestingly though, while chiropractic and medical students seem to reflect each other in these areas, chiropractic students presented lower scores for academic efficacy/personal accomplishment. PSS scores showed chiropractic students have an increased perception of stress compared to the general population. It should also be noted that although the difference was small, when results from the chiropractic students were compared with results from physical therapy and pharmacology students obtained from literature, chiropractic students presented higher perceived stress scores.
The main significance of these results is that they are in line with recent literature identifying a growing trend of students in health professions who suffer from moderate to high levels of stress and burnout.
The main takeaways:
- Chiropractic and medical students have similarly high levels of exhaustion, cynicism, and lack of academic efficacy.
- Burnout is prevalent in the field of chiropractic.
- Examining the scope of stress and burnout is necessary to aid in the development of future curriculums, reduce the burden on students, and prevent them from suffering burnout by the time they get into practice.
While this study provides valuable scope and support for the issue of high stress in chiropractic courses, and more broadly health sciences, there are some things to consider. The study is cross-sectional and therefore cannot determine any casual relationships. This being said, now we know there is a problem we have the basis to investigate where the problem has arisen from, and where it may be being perpetuated.
This opens the door to improved courses and enhanced education for future generations, allowing them to reach further and forward the knowledge and skills of the chiropractic profession. As the study utilised questionnaires there is the potential for both recall and reporting bias to influence the results obtained. There was also an overall low response rate.
The study being conducted with only European colleges reduces the generalisability of the findings, as this sample is not representative of the broader chiropractic student population.Future research could include a wider and more diverse sample that looks into the source of stress, and how stress coping mechanisms can be effectively promoted in colleges.
While yes, this is a European Study, it should bear thinking about across all educational institutions. As we nurture the next generation of chiropractors and equip them to deal with the trauma, toxins and stress of their future practice members, it seems that step number one is to make sure they are equipped to deal with their own.
- Rank MP, de la Ossa PP. Stress and burnout in chiropractic students of European chiropractic colleges. J Chiropr Educ. 2021;35(1):14-21. doi:10.7899/JCE-19-7