Table 1. Demographic of respondents and average PSS-10 score

Table 2. Mean score for PSS-10 items by programme of study

A. Exploratory Factor Analysis on PSS-10

Using the final year medical and health sciences student data for EFA (Table 3), the KMO measure for PSS-10 was 0.823, indicating sampling adequacy. The scale had a p-value of <0.001 for the Bartlett’s Test of Sphericity, confirming variability in the data was sufficient. The factor loadings of varimax rotated solution and the eigenvalue of the two factors identified (Perceived Helplessness and Perceived Control) are shown in Table 3. The cumulative variances explained were 61.386%.

 B. Reliability

Cronbach’s alpha for the two factors were 0.865 and 0.796 respectively, which indicates good internal consistency reliability (Table 4). To determine the robustness of the analysis, each item was deleted in turn from the calculation and the resulting Cronbach’s alpha remained high (0.724-0.859). Corrected item-total correlations showed satisfactory correlation for all items and their respective subscale (range from 0.539 to 0.748) (Table 4). Items with the highest corrected item-total correlation were item 2 (“felt that you were unable to control the important things in your life”), item 3 (“felt nervous and ‘stressed’”), and item 10 (felt difficulties were piling up so high that you could not overcome them). Both tests supported the PSS-10 as a two-factor scale.

Table 3. Factor loadings by exploratory factor analysis for PSS-10

Table 4. Corrected Item-Total Correlation

IV. DISCUSSION

A. Exploratory Factor Analysis

Exploratory factor analysis for PSS-10 revealed a two-factor structure, which was consistent with the findings in the original study (Cohen, 1988) and other validation studies (Andreou et al., 2011; Chaaya et al., 2010; Lesage et al., 2012; Leung et al., 2010; Örücü & Demir, 2009; Siqueira et al., 2010; Wongpakaran & Wongpakaran, 2010). The two factors identified in our study were related to the concept of control and ability to cope, as reflected in the positively-worded items, and the concept of helplessness, as reflected in negative items, respectively. The three items that loaded most heavily on the helplessness factor related to a lack of control (item 2), anxiety (item 3) and feeling overwhelmed (item 10).

 B. Locus of Control

It was evident that feeling unable to control important things in life (Item 2) greatly contributed to perceived stress of students. (Table 4) External locus of control, where people believe external factors control success or failure, is associated with higher stress (Linn & Zeppa, 1984) and understandable for healthcare students. For example, the teaching timetable is often changed at the last minute as the teachers might have urgent clinical duties or they may be expected to do more self-directed learning in which the breadth or depth of the learning may not be made clear. The expectations for clinical skills in clinical settings are often different from what was taught in school (Gibbons et al., 2008). The uncertainty of the curriculum, progress and assessment also contribute to stress in healthcare students (Elzubeir et al., 2010). Moreover, as the most junior member of the healthcare team, students have no decision-making capacity and may feel helpless when confronted with situations beyond their expertise or observe actions contrary to their personal views (Jennings, 2009).

C. Anxiety

Feeling nervous (item 3) was another contributing factor for perceived stress (Table 4). Medical and health sciences students are required to sit high-stakes examinations in order to be promoted to the next year of study or to graduate, where test anxiety is understandably prevalent (Encandela et al., 2014). Clinical competency exams such as OSCEs are particularly anxiety-provoking (Muldoon et al., 2014). This is especially relevant to the final year students in this study, as the final summative exams in all programmes are intense. In particular, the written final Bachelor of Medicine and Bachelor of Surgery (MBBS) exam covers material from the whole year and all disciplines including medicine, surgery, psychiatry, obstetrics and gynaecology, paediatrics, orthopaedics, and family medicine, and also includes a clinical competency test in each discipline. This final exam constitutes the licensing exam to become a doctor in Hong Kong.  

In addition, the vast majority of students admitted to undergraduate healthcare professions studies in Hong Kong are secondary school graduates. The age-related level of maturity may affect their ability to cope with a strenuous, content-rich curriculum as well as the pressures of clinical practicums and clerkships. Students have raised concerns about exam-induced anxiety and the heavy academic workload and in fact, the most common reason for students to seek counselling support at our institution is because of academic-related stress or psychological distress.

Working in the clinical environment also produces anxiety, especially when starting a new rotation in a new discipline when students often lack clinical experience, are unfamiliar with the ward, encounter difficult patients, and have a fear of making mistakes (Sharif & Masoumi, 2005). The hierarchical medical culture is more pronounced in healthcare settings and can be intimidating for undergraduate healthcare professions students who are seen as the lowest rung on the ladder. Other situations where the students are singled-out, such as during simulations, being observed, evaluated or video-recorded, also increases anxiety (Nielsen & Harder, 2013) especially as these teaching sessions are done in small groups. The style of learning for our students in these clinical years also require a more proactive, interactive and self-reliant style of learning. In addition to scheduled bedside teaching with a clinician, students have to seek out patients to clerk in order to hone their clinical skills and gain clinical experience. This may be an adjustment to students used to a more traditional classroom style and textbook learning.

D. Overwhelmed

The third most important item contributing to high perceived stress was the feeling of being overwhelmed with the workload and difficulties (item 10) (Table 4). Healthcare studies are well-known for being content heavy. Students have a heavy workload including long hours of lectures, tutorials, laboratories and clinical attachments, and are also expected to spend substantial time on independent study. Because most healthcare professions students in Hong Kong are admitted to such programmes directly upon completion of secondary education, higher diploma or associate degree, the curricula are even more packed with basic foundational as well as profession-specific advanced content.

Students in their final year of study have to contend with clinical experiential learning but must also further develop their knowledge base. This entails acquiring a huge volume of factual content as well as applying concepts to clinical scenarios. Students must work more independently in clinical attachments and may have some responsibility for patient care or administrative work. For example, nursing students’ progress from having practicums in small groups to shadowing a practising nurse, and working as a member of the nursing team in the ward in their senior years.

In addition, clinical teaching settings in Hong Kong, can be challenging learning environments especially the tertiary care teaching hospitals where much of the training takes place. The business of routine patient care already involving a multitude of staff makes it a daunting place for healthcare professions students who have to compete with each other for the opportunity to clerk patients.

In the clinical environment, students also come face-to-face with difficult situations and experience feelings that they may have difficulty resolving. This may include having problems communicating communication with patients or their families, struggling with ethical dilemmas such as witnessing a medical error, or experiencing the illness experience of patients and the helplessness of not being able alleviate their suffering. Medical students can be overwhelmed by the burden of suppressing their own natural emotions when facing the pain and suffering of their patients (Jennings, 2009). Likewise, nursing students also expressed that workload from clinical work and their own studies exceeded their physical and emotional capacity (C. K. Chan et al., 2009).

E. Limitations

At the time of data collection, no data were collected for other scales of similar or opposite construct. Hence no convergent or divergent validity could be calculated. Also, test-retest reliability could not be done as this was a one-off cross-sectional survey. Despite these limitations our data supported a two-factor structure of the PSS-10, consistent with the original and other previous studies.

 V. CONCLUSION

Demonstrating good construct validity and internal consistency, PSS-10 is a valid measure for assessing self-reported stress in medical students as well as in health sciences students. Longitudinal studies on student stress using this measure will help to assess the extent and patterns of stress in a high-risk population in order to develop timely interventions.

Notes on Contributors

JY Chen and JPY Tsang reviewed the literature, designed the study, performed data collection and data analysis, and developed the manuscript. WY Chin, A Tiwari, J Wong, ICK Wong, A Worsley, Y Feng, MH Sham and CS Lau advised on the study design, facilitated data collection and gave critical feedback on the manuscript. All authors have read and approved the final manuscript.

Ethical Approval

Ethical approval of this study was granted by the Institutional Review Board of the University of Hong Kong/Hospital Authority Hong Kong West Cluster (Reference No.: UW 14-472). All participants have given written consent for their data to be used in the research and for publication.

Acknowledgements

We would like to thank the students of HKUMed for participating in the study, and the administrative staff of Li Ka Shing Faculty of Medicine, School of Nursing, School of Chinese Medicine, Department of Pharmacology and Pharmacy, and School of Biomedical Sciences for helping with the logistical arrangement of the questionnaire administrations.

Funding

This work was supported by a Teaching Development Grant funded by the University of Hong Kong.

Declaration of Interest

The authors declare that there is no conflict of interest.

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