Objective: To find out the correlation between levels of stress and self-regulated learning skills in medical students.
Methods: The quantitative correlational study was conducted in January 2018 at the University College of Medicine and Dentistry, Lahore, Pakistan, and comprised regular medical students enrolled in first to fifth year. Data was collected using Perceived stress scale-14 and Self-regulated learning perception scale questionnaires to identify the levels of stress and self-regulated learning skills. Data was collected at one point of time and analysed using SPSS 25.
Results: Of the 350 students approached, 295(84%) filled in the questionnaire. Of them, 118(62.4%) were females and 111(37.6%) were males. No significant differences were found between the scores of male and female students (p>0.05). There was a moderate positive correlation between stress and self-regulated learning skills (p<0.05).
Conclusion: Self-regulated learning skills can play a vital role in coping with stress and identifying a goal.
Keywords: Stress, Self-regulation, Medical education, Challenges, Strategies, Coping, Students (JPMA 70: 447; 2020).
Medical students all over the world come across challenges. Feelings of incompetence along with cultural and social issues further complicate the situation. It has been observed that stress at personal level results in impaired academic performance, suicidal thoughts and abrasion from profession.1 On a professional level, studies have suggested that stress can lead to pessimism, which negatively affect a student's ability to care for patients, their rapport with the staff and eventually the culture of medical profession.2 In our country the resources are limited, and, as a result, the sources of stress in the life of a Pakistani medical student differ from those in other countries. The aim of medical education is to accommodate doctors who can aid society to the best of their ability. Consequently, the responsibility of the medical institution involves being able to identify stress and support their students individually on how to manage stress effectively throughout their academic and professional years.3 A number of researchers have proposed different programmes for managing stress that is aimed at helping the students.4-7 An effective strategy that can help medical students cope with stress is self-regulation.8 Research also proves that promoting the use of self-regulated learning skills can improve the students' academic achievements, clinical performance and mental well-being.8 The current study was planned to assess the correlation between levels of stress and self-regulated learning skills in medical students.
Subjects and Methods
The quantitative correlational study was conducted in January 2018 at the University College of Medicine and Dentistry (UCMD), Lahore, Pakistan, and comprised regular medical students enrolled in first to fifth year. UCMD is affiliated with the University of Lahore. After gaining approval from the institutional review board, a pilot study was done on a group of 19 students representing all five years to address any issue related to ''item language and its understanding'' and ''time taken to complete the questionnaire''. The data from the pilot study was not included in the results. The sample size was calculated through OpenEpi online software,9 using confidence interval (CI) of 95% and margin of error 5%. Any threats towards internal validity of the study were identified and handled accordingly. Data was collected by using Perceived Stress Scale-14 (PSS-14)10 and Selfregulated Learning Perception Scale (SRLPS)11 after their validity and reliability were established. The questionnaire consisted of three sections designed on Google forms (Annexure 1).
Students signed informed consent before they completed the questionnaire.
The PSS-14 scale consists of 14 questions with a range of options (never, almost never, sometimes, often, very often) on Likert scale from 0 to 4 for each item. These items inquire about the events that occurred one month prior to the survey. Items number 4,5,6,7,9,10 and 13 are positively stated questions. Therefore, their score is calculated as reversed (0=4, 1=3, 2=2, 3=1, and 4=0). The final score ranges between 0 and 56. High scores signify high level of stress, while low scores indicate lower level of stress. The range of PSS-14 scores were divided into stratified quartiles. The upper two and lower two quartiles were combined (28 being the operational cut-off value for the upper bound) and were labelled as severe stress, moderate stress, mild stress and no stress respectively. This cut-off value was set in accordance with similar studies in the region.12-14 The SRLPS incorporates 41 items with a range of options (never, almost never, sometimes, often, very often) on Likert scale from 1 to 5 for each item. The minimum possible score for SRLPS is 41 and the maximum 205. Data was collected at one point of time and analysed using SPSS 25. Pearson's correlation was used in order to determine the relationship between the students' stress levels and the self-regulated learning skills. P< 0.05 was taken as significant.
Of the 350 students approached, 295(84%) filled in the questionnaire. Of them, 118(62.4%) were females and 111(37.6%) were males. No significant differences were found between the the scores of male and female students (p>0.05). Mean PSS-14 score was 29.87±1.59 in females and 29.75±1.99 in males, whereas the mean SRLPS score was 114.66+26.49 in females and 117.91±28.31 in males. On the important factor of motivation to study MBBS, SRLPS score was higher in students 129.98±33.26 studying out of their own choice, and mean SRLPS score was lower in students 115.6±2.89 who were studying MBBS due to parental pressure. However, the mean PSS-14 score of students with personal interest 30.35±2.1 and those under parental pressure 29.36±1.2 was not significant (Table 1).
The highest SRLPS score was seen in final year students 121.78 ±32.61 followed by third year 120.03 ±29.68, first year 115.04 ±25.64, fourth year 112.65±26.00 and second year 109.14±20.12. PSS-14 scores ranged 21-34 SRLPS ranged 82-172 (Table- 2).
Pearson's correlation indicated moderate positive c or relation between stress and S RLS (Figure).
The fact that no statistically significant differences were found between PSS-14 scores of female and male students was not unexpected.15,16 The total SRLPS scores calculated between male and female students showed little variation which was in contrast with a study.17 One possible reason for it could be the "private" study setting. Given that a majority of the medical students were from a higher socioeconomic class, it is assumed that their stress and self-regulation levels were not affected by gender.16,18 Personal interest is an intrinsic motivator, which helps to identify goals and to make plans to achieve them.19-21 Therefore, it was no surprise that PSS-14 score was lower and SRLPS was higher in students who were studying MBBS with their own personal interest. A number of studies have proved that self-regulation skills are refined over time and are usually highest in final/fifth year.22-24 But the fact that self-regulation skills are second most developed in third year was unexpected. One possible explanation to this finding can be the type of curriculum the students are following. The students of fourth and final years studied the traditional curriculum divided as first two years for Basic Sciences and the last three years for Clinical Sciences. In contrast, the current first, second and third year are exposed to an integrated problem-based learning (PBL) curriculum. As third year students have been learning to apply integration for almost three years, their self-regulation skills improve a lot.25-27 In our study a moderate positive correlation between stress and self-regulated learning skills was observed which was contradictory to previous studies.8,28 One way to explain this finding is the possibility that some amount of stress is natural part of medical education and might be a motivator for some students.29 Looking at the total scores of PSS-14, out of 295 students, 90 scored a maximum of 26 that fall in the lower quartile of stress.12,13,14 Since majority of the medical students fall in the lower quartile of stress, it is assumed that mild stress can direct students towards self-regulation. It is a positive sign that the students care about their learning and take stress to make plans accordingly. On the bright side, it can be considered that students are dealing with stress through self-regulation. As our study was conducted at a single centre, its scope is restricted. Another limitation was related to PSS-14 that can only evaluate the level of stress during the preceding month. Longitudinal surveys should be used to measure stress throughout an entire academic year. A final concern was regarding the total scores obtained through the questionnaires. It might be a possibility that students under- or over-estimated their stress levels and selfregulated skills. In future studies it will be prudent to compare selfregulated learning scores of two medical colleges; one following the traditional, and the other following an integrated curriculum.
Stress and self-regulation were found to be independent of gender but self-regulated learning skills played a vital role in coping with stress and identifying a goal. Although stress can be a motivator for some medical students, only low levels of stress helped students to remain focussed.
Disclaimer: The text is part of a Masters in Medical Education thesis.
Conflict of Interest: None.
Source of Funding: None.
1. Osama M, Islam MY, Hussain SA, Masroor SM, Burney MU, Masood MA, et al. Suicidal ideation among medical students of Pakistan: a cross-sectional study. J Forensic Leg Med 2014;27:65-8.
2. Rennie SC, Rudland JR. Differences in medical students' attitudes to academic misconduct and reported behaviour across the years-a questionnaire stud y. J Med Ethics 2003;29 :97-102.
3. Brydges R, Butler D. A reflective analysis of medical education research on self-regulation in learning and practice. Med Educ 2012;46:71-9.
4. Chang E, Eddins-Folensbee F, Coverdale J. Survey of the prevalence of burnout, stress, depression, and the use of supports by medical students at one school. Acad Psychiatry 2012;36:177-82.
5. Fares J, Saadeddin Z, Al Tabosh H, Aridi H, El Mouhayyar C, Koleilat MK, et al. Extracurricular activities associated with stress and burnout in preclinical medical students. J Epidemiol Glob Health 2016;6:177-85.
6. Nelson NG, Dell'Oliver C, Koch C, Buckler R. Stress, coping, and success among graduate students in clinical psychology. Psychol Rep 2001;88:759-67.
7. Shaikh BT, Kahloon A, Kazmi M, Khalid H, Nawaz K, Khan N, et al. Students, stress and coping strategies: a case of Pakistani medical school. Educ Health (Abingdon) 2004;17:346-53.
8. Van Nguyen H, Laohasiriwong W, Saengsuwan J, Thinkhamrop B, Wright P. The relationships between the use of self-regulated learning strategies and depression among medical students: an accelerated prospective cohort study. Psychol Health Med 2015;20:59-70.
9. Dean AG, Sullivan KM, Soe MM. OpenEpi: Open Source Epidemiologic Statistics for Public Health, Version 3.01. [Online] 2 01 3 [Ci ted 20 18 Feb ru ar y 1 0 ]. Avai lable from UR L: www.OpenEpi.com
10. Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. J Health Soc Behav 1983;24:385-96.
11. Turan S, Demirel O, Sayek I. Metacognitive awareness and selfregulated learning skills of medical students in different medical curricula. Med Teach 2009;31:e477-83.
12. Thangaraj S, D'souza L. Prevalence of stress levels among first year medical undergraduate students. Int J Interdiscip Multidiscip Stud 2014;1:176-81.
13. Amr M, Hady El Gilany A, El-Hawary A. Does gender predict medical students' stress in mansoura, egypt? Med Educ Online 2008;13:12.
14. Örücü MÇ, Demir A. Psychometric evaluation of perceived stress scale for Turkish university students. Stress Health 2009;25:103-9.
15. Yusoff MS, Abdul Rahim AF, Yaacob MJ. Prevalence and Sources of Stress among Universiti Sains Malaysia Medical Students. Malays J Med Sci 2010;17:30-7.
16. Waqas A, Khan S, Sharif W, Khalid U, Ali A. Association of academic stress with sleeping difficulties in medical students of a Pakistani medical school: a cross sectional survey. PeerJ 2015;3:e840.
17. Cleary TJ, Durning SJ, Artino AR, Jr. Microanalytic Assessment of Self-Regulated Learning During Clinical Reasoning Tasks: Recent Developments and Next Steps. Acad Med 2016;91:1516-21.
18. Muzafar Y, Khan HH, Ashraf H, Hussain W, Sajid H, Tahir M, et al. Burnout and its Associated Factors in Medical Students of Lahore, Pakistan. Cureus 2015;7:e390.
19. Ertmer PA, Newby TJ. The expert learner: Strategic, self-regulated, and reflective. Instr Sci 1996;24:1-24.
20. Sitzmann T, Ely K. A meta-analysis of self-regulated learning in work-related training and educational attainment: what we know and where we need to go. Psychol Bull 2011;137:421-42.
21. Zimmerman BJ. Investigating self-regulation and motivation: Historical background, methodological developments, and future prospects. Am Educ Res J 2008;45:166-83.
22. Cho KK, Marjadi B, Langendyk V, Hu W. Medical student changes in self-regulated learning during the transition to the clinical environment. BMC Med Educ 2017;17:59.
23. Dunlap JC. Problem-based learning and self-efficacy: How a capstone course prepares students for a profession. Educ Technol Res Dev 2005;53:65-83.
24. Regehr G, Eva K. Self-assessment, self-direction, and the selfregulating professional. Clin Orthop Relat Res 2006;449:34-8.
25. Fisher M, King J, Tague G. Development of a self-directed learning readiness scale for nursing education. Nurse Educ Today 2001;21:516-25.
26. Stentoft D, Duroux M, Fink T, Emmersen J. From cases to projects in problem-based medical education. Journal of Problem Based Learning in Higher Education 2014;2:45-62.
27. Thomas L, Bennett S, Lockyer L. Using concept maps and goalsetting to support the development of self-regulated learning in a problem-based learning curriculum. Med Teach 2016;38:930-5.
28. Jouhari Z, Haghani F, Changiz T. Factors affecting self-regulated learning in medical students: a qualitative study. Med Educ Online 2015;20:28694.
29. Al-Basri SF, Al-Afari R, AlHibshi AM, Al-Sayes F, Soo PY, Tekian A. Readiness for self-directed learning among King Abdulaziz University medical students. Int J Res Med Sci 2017;5:xxx-xx.