Analyses of self-care agency and mindset: A pilot study on Malaysian undergraduate medical students

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Submitted: 28 October 2024
Accepted: 16 June 2025
Published online: 7 October, TAPS 2025, 10(4), 35-43
https://doi.org/10.29060/TAPS.2025-10-4/OA3559

Reshma Mohamed Ansari1,2, Chan Choong Foong3, Hidayah Mohd Fadzil4 & Mohamad Nabil Mohd Noor3

1Institute for Advanced Studies, Universiti Malaya, Malaysia; 2Department of Medical Education, International Medical School, Management and Science University, Malaysia; 3Medical Education and Research Development Unit (MERDU), Faculty of Medicine, Universiti Malaya, Malaysia; 4Department of Mathematics and Science Education, Faculty of Education, Universiti Malaya, Malaysia

Abstract

Introduction: Self-care agency, a core concept that helps alleviate the stressors of medical training, is postulated to be practiced by medical students who exhibit a growth mindset. Hence, this pilot study was designed to measure, compare, and correlate the self-care agency and mindsets of undergraduate medical students to assess the potential for scaling to a national survey.

Methods: This cross-sectional study was conducted at one public and one private medical university using a revised version of the Appraisal of Self-Care Agency Scale to measure self-care agency and the Implicit Theories of Intelligence Scale to measure participants’ mindset. Data was analysed using IBM SPSS.

Results: In total, 329 complete responses were obtained. Among the self-care domains, a higher capacity for self-care and a developing capacity for self-care, with a lower ability to indulge in self-care, were reported. Self-care agency showed a significant difference between pre-clinical and clinical students (p = .027; Cohen’s d = .2). Mindset measurements revealed a higher growth than a fixed mindset. The Pearson correlation coefficient showed a weak positive correlation, (r = 0.19) between the means of self-care agency and a growth mindset. Clinical students showed a higher tendency toward self-care than their pre-clinical counterparts in an independent-samples t-test, with no differences between genders and universities.

Conclusion: This pilot study found a positive correlation between self-care agency and growth mindset among undergraduate medical students. Although limited by two prototype universities and response bias, this study provides a solid foundation for future nationwide or cross-country studies.

Keywords:            Self-care Agency, Growth Mindset, Fixed Mindset, Medical Education, Undergraduate Medical Students, Pilot Study

Practice Highlights

  • Undergraduate medical students acknowledge importance of self-care agency and growth mindset.
  • Growth mindset correlates with self-care agency necessitating inculcation of both.
  • Growth mindset combats the stressors of medical training by indulging in proactive self-care.

I. INTRODUCTION

Orem et al. (1995, p. 19) defined self-care as the “practice of activities that individuals start and perform for their benefit, for the maintenance of life, health, and well-being”. Self-care agency, a component of the self-care deficit nursing theory, is “the acquired, complex capacity to meet the requirements to take care of oneself, regulating life processes, maintaining or promoting integrity, structure, and functioning, as well as one’s development and promotion of well-being” (Oliveira et al., 2022, p. 20; Orem et al., 1995). Research has elucidated that the stressors of medical training, which can cause high rates of burnout, anxiety, depression and poor physical health in students (Ayala et al., 2017; Bostock et al., 2018), could be alleviated through self-care (Ayala et al., 2018).

However, during medical training, students find little to no time to engage in self-care; factors such as increased pressure, poor time management, and a negative environment often acting as barriers (Ayala et al., 2017; Ayala et al., 2018). Guldner et al. (2020) suggested that mindset is a predictor of depression and burnout among medical residents, highlighting the relationship between mindset and poor psychological well-being, alleviated by self-care practices (Carter et al., 2025).

Carol Dweck coined the terms “growth mindset” and “fixed mindset” as part of the implicit theories of intelligence, in which individuals could view intelligence as fixed (entity theory) or as a dimension that can be improved with effort (incremental theory) (Cook et al., 2018; Dweck, 2013). The mindset theory, when applied to the medical education context, suggests that a growth mindset views effort as a means to develop abilities (Theard et al., 2021). In contrast, a fixed mindset could lead to poorer outcomes in a high-pressure educational environment (Bostock et al., 2018) and resultant poor psychological well-being (Root Kustritz, 2017).

Studies have measured participants’ mindsets and correlated them with scales measuring anxiety or overall well-being (Guldner et al., 2020; Root Kustritz, 2017; Wolcott et al., 2021). One of the reasons for a growth mindset to aid students’ well-being is by allowing them to place greater value on health and fitness and exhibit health-seeking behaviours (Orvidas et al., 2018; Thomas et al., 2019).

Adding on, identification of stressors, the burnout caused by them, mental health issues, active self-care seeking behaviours including coping strategies are associated with a growth mindset (Burnette et al., 2020). Nursing students who were exposed to structured activities fostering a growth mindset, reported indulging in student-preferred strategies such as viewing obstacles from a newer perspective, working for competency, and indulging in self-care practices, thus directly relating a growth mindset to better self-care agency (Carter et al., 2025).

Medical students in Malaysia, akin to their global counterparts have reported increased levels of stress and psychological distress (Masilamani et al., 2020), due to stringent admission processes, higher cognitive load, and an assessment-based curriculum (Yusoff et al., 2013). Studies across four public medical schools in Malaysia have shown that students tend to alleviate stress through religious activities, active coping strategies, positive reinterpretation, acceptance, and planning (Yusoff et al., 2011), which could be viewed as a subtle expression of a growth mindset. Despite the postulation that a growth mindset accentuates self-care agency, there is a dearth of studies on the self-care agency of Malaysian medical students and its correlation with mindset.

Hence, this pilot study was conducted with the objective of measuring, comparing, and correlating self-care agency and the mindsets of Malaysian undergraduate medical students to gauge the feasibility of a nationwide survey (Lowe, 2019).

II. METHODS

This cross-sectional pilot study was conducted at a public and a private medical university in Malaysia. which were accessible to researchers. The selected public university is a prototype of Malaysian public universities characterised by highly qualified students with excellent examination results paying subsidised fees, as the operation of the university is funded by the government (Wan, 2007). The selected private university is representative of Malaysian private universities, which primarily provide an alternate pathway for the high school students who are not placed in public universities. Being self-funded, the fees are relatively higher, and the students are typically of paying capacity (Wan, 2007).

Permission to conduct this study was obtained from the ethics committees of both the public and private universities (UM.TNC2/UMREC_2872 and RMC/SEP/2023/EC02, respectively). Generally, although every medical school in Malaysia is homegrown and has variations in its curriculum, both the universities chosen for this study had a similar integrated curriculum spanning over five years for the Bachelor of Medicine, Bachelor of Surgery (MBBS) program, with two years of pre-clinical and three years of clinical studies.

The study instrument consisted of three sections. Data collection was anonymous, and the first section recorded the details of the participants’ age, gender, institution of study, and year of study. Section two included the revised version of the Appraisal of Self-care Agency Scale (ASAS-R), used to measure self-care agency (Oliveira et al., 2022). The ASAS is a 24-item scale developed by Evers et al. in 1986 (Evers, 1989) and modified by Sousa et al. (2010) into a 15-item scale that can be applied to adults aged over 18 years.

The three domains of ASAS-R holistically measure the three types of personal trait components that characterise the concept of self-care agency (Oliveira et al., 2022). The responses were ranked on a 5-point Likert scale (1 = totally disagree; 5 = totally agree). The total scores ranged from 15 to 75, with higher scores indicating greater self-care agency (Oliveira et al., 2022).

Sousa et al. (2010) divided the items into the following domains: Domain I: having the capacity for self-care (items 1, 2, 3, 5, 6, and 10; maximum domain score = 30); Domain II: developing the capacity to self-care (items 7, 8, 9, 12, and 13; maximum domain score = 25); and Domain III: inability to self-care (items 4, 11, 14, and 15; maximum domain score = 20), with acceptable Cronbach’s alpha values of 0.86, 0.83, and 0.79, respectively. The instrument has been validated among the general population in countries such as China, Spain, and Brazil, and among medical students in Portugal (Alhambra-Borrás et al., 2017; Guo et al., 2017; Oliveira et al., 2022; Yuan et al., 2021).  

Section three consisted of the Implicit Theories of Intelligence Scale (ITIS), adopted from the published version of the ITIS by Cook et al. (2017), to measure the mindset of medical students. The ITIS is an eight-item instrument with four items related to incremental beliefs (1, 2, 3, and 4) and four items related to entity beliefs (5, 6, 7, and 8) regarding intelligence and ability. Responses were based on a 6-point Likert scale (1 = strongly disagree; 6 = strongly agree) (Cook et al., 2017). For each domain, the scores ranged from 4 to 24.

A confirmatory factor analysis of the ITIS scores demonstrated an overall acceptable model fit; an exploratory factor analysis confirmed a two-factor structure (Cook et al., 2017), with the Cronbach’s alpha ≥ 0.77 for each domain (Cook et al., 2018).

The sample size of the study was calculated using Raosoft online software (http://www.raosoft.com/samplesize.html).

With an approximate total population of 1300 (public university = approximately 900; private university = approximately 400), based on a confidence level of 95%, a response distribution of 50%, and a margin of error of 5%, the sample size was determined to be 297. A quota sampling technique was applied to ensure adequate sample representation for each university: 204 from the public university and 93 from the private university.

The questionnaire items were entered into a Google Form, and the link was distributed to all the students of both the universities where they were asked to answer the questionnaire after reading the participant information sheet and providing informed consent.

The data were collected over four weeks, starting on November 1 – November 30, 2023, which was two months from the start of the new semester (September 2023) in both universities which gives ample time for the students to experience the learning environment and respond to the questionnaire. A reminder was provided two weeks after the start of data collection, and data collection ended two weeks after the reminder. The students were informed of the closure of data collection.

The data were analysed using the IBM Statistical Package for Social Sciences (SPSS) v.26 via descriptive and inferential tests. The normality of the data distribution was screened. Pearson’s product-moment correlation was used to analyse the relationship between self-care agency and mindset, whereas independent-samples t-tests were used for comparative analyses between gender and years of study.

III. RESULTS

A. Participants’ Characteristics

A total of 329 valid responses were received. The participants’ demographic characteristics are presented in Table 1.

The distribution of the participants according to their year of study followed the same pattern in both universities, with more female than male respondents and more pre-clinical than clinical students, implying that the sample was representative of the population.

Age

Range (years)

Mean

 

 

18–28

20.8

 

Year of study

Private university

n (%)

n=118

(35%)

Pre-clinical

n (%)

68

57.63%

Year 1

n (%)

n=31

45.5%

Year 2

n (%)

n=37

54.5%

Clinical

n (%)

50

42.37%

Year 3

n (%)

n=28

56%

Year 4

n (%)

n=12

24%

Year 5

n (%)

n=10

20%

Public university

n (%)

n=211

(65%)

Pre-clinical

n (%)

127

60.2%

Year 1

n (%)

n=78

61.4%

Year 2

n (%)

n=49

38.6%

Clinical

n (%)

84

39.8%

Year 3

n (%)

n=20

23.8%

Year 4

n (%)

n=8

9.5%

Year 5

n (%)

n=56

66.7%

Gender

Male

n (%)

 

n=112

34.1%

 

Private university

n (%)

n=38

33.9%

 

Public university

n (%)

n=74

66.1%

Female

n (%)

 

n=217

65.9%

Private university

n (%)

n=80

36.9%

Public university

n (%)

n=137

63.1%

Table 1. Participants’ demographic characteristics (N = 329)

B. Descriptive Statistics

The key descriptive statistics and reliability indices of the ASAS-R are presented in Table 2.

Item No.

Itemsa

Minimum

Maximum

Mean (SD)

 

 

ASAS-R Cronbach’s alpha

.841

ASAS-R total score Mean (SD)

55.74 (8.10)

Domain I: Having the capacity for self-care (items 1, 2, 3, 5, 6 & 10 of ASAS-R)

 

Domain total score (SD)

 

 

 

24.14 (4.17)

 

Domain Cronbach’s alpha

 

 

 

.875

Domain II: Developing the capacity for self-care (items 7, 8, 9, 12 & 13 of ASAS-R)

 

Domain total score (SD)

 

 

 

19.69 (3.61)

 

Domain Cronbach’s alpha

 

 

 

.762

Domain III: Inability to self-care (items 4, 11, 14 & 15 of ASAS-R)

4

* I often lack energy to care for myself in the way that I know I should.

1.00

5.00

3.09 (1.18)

 

11

* In my daily activities I seldom take time to care for myself.

1.00

5.00

2.82 (1.19)

14

* I seldom have time for myself.

1.00

5.00

2.82 (1.18)

15

* I am not always able to care for myself in a way I would like.

1.00

5.00

3.15 (1.20)

Domain total score (SD)

11.90 (3.63)

Domain Cronbach’s alpha

.761

*Negatively worded items; the answers were reversely scored.

a5-point Likert scale: 1 (totally disagree) to 5 (totally agree).

 Table 2. ASAS-R and its scores

The domain scores for Domains I (M = 24.14, SD = 4.17) and II (M = 19.69, SD = 3.61; maximum scores = 30 and 25, respectively) were higher than those for Domain III (M = 11.90, SD = 3.63; maximum score = 20). The items of Domains I and II showed mean scores varying from 3.7 to 4.1, indicating global positive scores for one’s self-perception of having and developing self-care abilities. The mean scores of the items of Domain III varied from 2.8 to 3.15, suggesting that the students acknowledged a lack of means to self-care (all four items were reversely worded) (Damásio & Koller, 2013).

Table 3 presents the key descriptive statistics and reliability indices of the ITIS questionnaire. The maximum score for each domain was 24. The score for the incremental domain (Min: 1.00 and Max: 6.00; M = 18.49, SD = 4.13) was higher than that for the entity domain (Min: 1.00 and Max: 6.00; M = 12.33, SD = 5.24), indicating that the students were more aligned toward a growth mindset than a fixed mindset (Sun et al., 2021). The mean of the items indicating a fixed mindset (entity domain) showed a range of 2.8 to 3.3, compared with the mean of the items indicating a growth mindset (incremental domain), which showed a range of 4.5 to 4.7 (Hong et al., 1999).

ITIS Cronbach’ alphaa

.724

Domain: Entity (items 1, 2 3 & 4 of ITIS)

Domain total score Mean (SD)

12.33 (5.24)

Domain Cronbach’s alpha

.930

Domain: Incremental (items 5, 6, 7 & 8 of ITIS)

Domain total score Mean (SD)

18.49 (4.13)

Domain Cronbach’s alpha

.907

a6-point Likert scale: 1 (strongly disagree) to 6 (strongly agree).

Table 3. ITIS and its scores

C. Correlational Analysis

For inferential statistics, the total score of self-care agency and the mindset domains were subjected to tests of normality using the applied statistical methods of skewness and kurtosis; z-values were not considered as the sample size was greater than 300 (Kim, 2013). The resultant absolute skew values were less than 2, and the absolute kurtosis values were less than 7. Hence, the data were considered to be normally distributed, and parametric tests were applied (Hair et al., 2006; Kim, 2013). All values were considered significant if the p value was less than 0.05.

The relationship between self-care agency (total score) and growth mindset (domain score) was investigated using Pearson’s product-moment correlation coefficient. There was a significant positive correlation between the two variables (r = .19, n = 329, p < .01 (two-tailed)), indicating that self-care agency behaviour is associated with a growth mindset. In contrast, the Pearson correlation between self-care agency (total score) and a fixed mindset (domain score) was not significant (r = .060, n = 329, p = .278 (two-tailed)). Pearson’s correlation did not show significant correlations between the domains of growth and a fixed mindset with the individual domains of capacity for self-care, developing capacity for self-care, and inability to perform self-care.

D. Comparative Analysis

An independent-samples t-test was performed to compare the self-care agency (total score) between pre-clinical and clinical students. The analysis showed a significant difference in the total scores of pre-clinical (M = 54.92, SD = 8.86) and clinical students (M = 56.93, SD = 6.71; t (329) = -2.22, p = .027, two-tailed). Though the magnitude of the differences in the means (mean difference = -2.00, 95% CI: -3.78 to -.23) was small (Cohen’s d = .2), it implicates that the factors that hinder self-care could be further explored and mindset interventions could be targeted for pre-clinical students. However, the independent-samples t-test performed to compare the domain scores of fixed and growth mindsets did not show any significant difference between pre-clinical and clinical students (t (329) = -1.668, p = .096, two-tailed) and (t (329) = .216, p = .829, two-tailed), indicating that their mindsets did not differ in this population. 

An independent-samples t-test performed to compare the means of self-care agency, fixed mindset, and growth mindset among private and public university students exhibited no significant differences (t (329) = .772, p = .441, two-tailed), (t (329) = -.916, p = .360, two-tailed), (t (329) = -.252, p = .801, two-tailed) indicating that similar stressors and barriers to self-care agency existed in both types of institutions.

An independent-samples t-test was performed to compare the means of self-care agency, fixed mindset, and growth mindset among genders; no significant differences were found (t (329) = -.58, p = .954 two-tailed), (t (329) = .936, p = .350, two-tailed), (t (329) = .052, p = .959, two-tailed) suggesting that both the genders had similar views on the problems encountered in medical schools which could hinder self-care despite possessing a growth mindset. A one-way ANOVA was performed to compare the means of self-care agency, growth mindset, and fixed mindset with respect to the year of study (Year 1–Year 5). The post-hoc Tukey test also did not reveal any significant differences.

IV. DISCUSSION

The total ASAS-R score in this pilot study is comparable to Guo et al.’s (2017) study of older Chinese individuals (55.29 ± 5.22) and Schönenberg et al.’s (2022) study of adults with at least one chronic disorder (52.81 ± 8.39). A study conducted in Brazil among fibromyalgia patients showed similar baseline total scores of 51.9 ± 9.7 and 53.5 ± 11.0 in two samples (Yuan et al., 2021). Oliveira et al. (2022) did not report the total ASAS-R score among Portuguese medical students, but the higher means of Domains I and II and the lower mean of Domain III in this pilot study resonated with their findings which could be further explored by qualitative research. Despite that, Portuguese medical students reported higher mean with Domain II rather than Domain I unlike participants of the current pilot study. This indicates that Portuguese students though lack self-care currently, are positive to be able develop self-care abilities in future. On the other hand, Malaysian students are quite satisfied with their current self-care abilities rather than develop the abilities (Oliveira et al., 2022). The factors for this difference of opinion could be that the Portuguese respondents were of higher age (Mean = 22) and possible cultural factors which could be explored by research as well.  

Two items in Domain III (items 11 and 14) scored the lowest in this pilot study and can be likened to the study by Guo et al. (2017) who reported that item number 15 in Domain III “I am not always able to care for myself in the way I would like” scored the lowest (2.83 ± 0.93). The opinion that our students also agree that they lack time and energy for self-care are similar to a study conducted at Yale University, and in the United States of America (USA), where medical students neglected self-care and attributed it to lack of time and high stress levels in their academic journey (Ayala et al., 2018; Gold et al., 2015). Similar factors including organisation for self-care, attributable to an intense medical curriculum were voiced out by Portuguese and Malaysian medical students alike (Oliveira et al., 2022; Yusoff et al., 2013). A worldwide analogous opinion among medical students should be taken into account by medical educators to act on easing the academic journey through early detection and targeted interventions.

In this pilot study, there was no difference in gender in the self-care agency domain, which differs from a study conducted by Ayala et al. (2018), who reported higher stress and self-care activities among female students. However, nursing students in Turkey reported a more optimistic approach to stress management by male students, which correlated with self-care agency among them as well (Komser & Özakgül, 2023). The difference in study results pertaining to gender necessitates a multi-institutional future study with a robust sample size to yield comparable outcomes.  Higher self-care agency among clinical students reported in this study is similar to another Malaysian study by Aida et al (2014). Clinical students initially sought predominantly informal ways (peers, friends, and parents) for health seeking rather than formal channels (counselling and psychiatrists) (Aida et al., 2014). Active coping strategies, reframing (focusing on the process not results, viewing failures as opportunities) and planning as means of self-care was also reported by clinical students (Masilamani et al., 2020).  Students have reported struggle in self-care behaviours within the first 12 weeks of medical school training regardless of their gender in USA as they struggle with poor sleep and physical activity (Boyd et al., 2023). Though it can be hypothesised that older students with more experience and maturity learn self-care behaviours along their student journey, it is still open to research. Since there is no difference in self-care agency between public and private universities similar to other studies, (Ayala et al. 2018), we can deduce that the factors for poor self-care are alike across different institutions.

In this pilot study, more medical students were found to exhibit a growth mindset rather than a fixed mindset with comparable means with a study among international students in USA, where the growth mindset score was 19.51 ± 1.362, and the fixed mindset score was 14.34 ± 1.557 (Winfrey, 2020) comparable to clinical veterinary students (Guldner et al., 2020; Whittington et al., 2017). There was no difference between fixed and growth mindsets between genders in this pilot study. However, Bostock et al. (2018) reported that more females had a fixed mindset and poorer mental health than their male counterparts. There was no difference in mindset among the students of different years of study in this pilot study. This finding differs from the results of Root Kustritz (2017), who reported that year–two veterinary students showed a more growth-oriented mindset, while Bostock et al. (2018) reported that year–four students had a higher growth-oriented mindset.

Studies that establish a link between psychological distress and mindset predict overall psychological well-being and better mental health in people with a growth mindset due to their adjustment skills (Whittington et al., 2017). Although there have been limited studies directly correlating growth mindsets and self-care, Orvidas et al. (2018) reported that mindsets lead to self-regulatory actions to help people engage in exercise and healthy eating habits, which are attributed to two of the ten domains of self-care by Ayala et al. (2017). This is due to the fact that growth mindsets are important for increasing the capacity to engage in activities even when challenges arise, as it enables understanding of the value and self-relevance of such activities (Ayala et al., 2017). 

Individuals with a growth mindset have intrinsic motivation and show resilience, which translates into self-care abilities during periods of distress (Alatorre et al., 2020; Root Kustritz, 2017). Additionally, growth-mindset individuals value personal growth, autonomy, purpose in life, and self-acceptance, which could explain their self-care abilities and psychological well-being (Whittington et al., 2017). Individuals with a fixed mindset are more prone to stress and unhealthy perfectionism, which are linked to suicidal behaviours (Dweck, 2013). A fixed mindset does not believe in change, and self-care to bring about positive change may not be appreciated (Root Kustritz, 2017). A meta-analysis conducted by Burnette et al. (2020) concluded that there is a negative relationship between growth mindset and psychological distress, but a positive correlation with active coping and treatment values, indicating that a growth mindset places value on self-care (Burnette et al., 2020).

Selection, complexity, reliability and generalisability biases could occur with quota sampling employed in this study. Selection bias was mitigated by calculating the sample size based on the population in the respective medical schools and complexity was avoided by including two protype schools only. The alpha values for the data ensured reliability. Since this was a pilot study the findings were not generalised but were intended to gauge the logistic and statistical feasibility of a nationwide study. Although respondents were informed of their anonymity prior to answering the questionnaire to minimise bias, some respondents might have wanted to demonstrate their positive side and, therefore, present themselves as having self-care abilities and a growth mindset, giving rise to response bias.

V. CONCLUSION

The findings of this pilot study indicate that although students are in favour of self-care capacity and its development, they lack of self-care ability in practice, factors of which could be explored qualitatively in future research. The positive correlation between a growth mindset and self-care ability could be utilised in medical curricula by integrating mindset training to enhance self-care capacity among the students. This pilot study also provides justification for a nationwide, multi-institutional global research.

Notes on Contributors

RMA was involved in literature search, data acquisition and analysis, manuscript preparation and revision.

FCC was involved in the study conception and design, data analysis, manuscript editing, and review.

HMF was involved in the study conception and design and manuscript review.

MNMN was involved in data acquisition and manuscript revision.

All the authors approved the final version of the manuscript and its revised versions.

Ethical Approval

Ethical approval was obtained from the research ethics committees of both the public and private universities, (UM.TNC2/UMREC_2872 and RMC/SEP/2023/EC02, respectively) in accordance with the Declaration of Helsinki.

Data Availability

As per the requirements of the local ethics committees, data will be stored in an enclosed and dedicated facility in the faculty building. The datasets used and/or analysed in the current study are available from the corresponding author upon reasonable request. 

Acknowledgement

The authors express their sincere gratitude to all the students who participated in this study.  

Funding

The authors declare no sources of funding.

Declaration of Interest

The authors declare that they have no competing interests.

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*Foong Chan Choong
Medical Education and Research Development Unit,
Faculty of Medicine, Universiti Malaya, Malaysia
+0060 12-419 1248
Email: foongchanchoong@um.edu.my

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