Griffith Research Online
https://research-repository.griffith.edu.au
Person and environmental factors
associated with well-being in medical
students
Author
Rogers, Mary, Creed, Peter, Searle, Judith
Published
2012
Journal Title
Personality and Individual Differences
DOI
https://doi.org/10.1016/j.paid.2011.11.006
Copyright Statement
Copyright 2011 Elsevier. This is the author-manuscript version of this paper. Reproduced in accordance
with the copyright policy of the publisher. Please refer to the journal's website for access to the
definitive, published version.
Downloaded from
http://hdl.handle.net/10072/46351
MEDICAL STUDENT WELL-BEING
1
Title:
Person and environmental factors associated with well-being in
medical students
Authors:
Mary E. Rogers1, Peter A. Creed1, and Judy Searle2
Author Affiliations:
1
Corresponding Author
Dr Mary Rogers
Griffith University
School of Applied Psychology and Griffith Health Institute
Gold Coast Campus, QLD, 4222, Australia.
Griffith University, School of Applied Psychology and
Griffith Health Institute
2
Griffith University, School of Medicine
Telephone:
Facsimile:
Author Email Addresses:
+61 7 5552 8514
+61 7 5552 8291
[email protected]
[email protected]
[email protected]
MEDICAL STUDENT WELL-BEING
2
Person and environmental factors associated with well-being in medical students
Abstract
Medical students are exposed to demanding academic workloads and are often under
considerable psychological strain. This study examined important person and environmental
variables that might predict their psychological well-being. Participants were 755 students in
years 2 - 6 from 11 Australian medical schools. A web-based survey assessed well-being,
personality, professional expectations, lifestyle expectations, barriers, academic stress, and
debt. A hierarchical regression analysis demonstrated that extraversion, conscientiousness,
professional expectations, and lifestyle expectations were positively associated with wellbeing, while academic stress, which was the strongest predictor, neuroticism, and concern
about debt were negatively associated. Medical students who displayed a disposition that was
outgoing, conscientious, and stable, who were less stressed about their academic workload
and their level of debt, and who held higher expectations for their future professional career,
and expectations of a balanced lifestyle, had better well-being. Medical educators should be
aware of these factors and provide support and strategies that promote well-being to students
during medical training.
Key Words: well-being; personality; career expectations; career barriers; academic stress;
concern about debt.
MEDICAL STUDENT WELL-BEING
1. Introduction
During medical school, medical students are exposed to demanding and heavy
workloads. Several studies have shown that these students are under considerable
psychological strain (Biro, Balajti, Adany, & Kosa, 2010; Dahlin, Joneborg, & Runeson,
2005; Radcliffe & Lester, 2003) and that their mental health declines during the course of
their training (Guthrie et al., 1998), although their well-being and well-being trajectory may
not be different from students in other courses (Carson et al., 2000; Singh, Hankins, &
Weinman, 2004).
Well-being can be defined in terms of happiness and overall life satisfaction. People
experience high levels of well-being when they feel pleasant emotions, engage in interesting
activities, and when they are satisfied with their life (Diener, 1984). Some individuals will
experience a high level of well-being despite adverse environmental conditions, while others
will experience low levels despite favourable conditions (Seligman & Csikszentmihalyi,
2000). Well-being theorists suggest that personality, cognitions, goals, and coping efforts all
play a role in influencing well-being (Diener, Suh, Lucas, & Smith, 1999).
Understanding factors that contribute to the well-being of medical students is
important as this might allow appropriate support systems to be implemented. Despite a
strong body of evidence from the international literature investigating medical students’
levels of stress, anxiety, depression, and burnout (e.g., Dahlin et al., 2005; Dyrbye, Thomas,
& Shanafelt, 2005, 2006; Shariati, Yunesian, & Vash, 2007; Tyssen et al., 2007), we know
little about the factors that influence their positive state; that is, what keeps medical students
feeling well.
1.1. Personality and well-being
Personality is regarded as one of the strongest predictors of well-being. Emotional
stability and extraversion are typically associated with happiness, well-being, and positive
3
MEDICAL STUDENT WELL-BEING
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affect, and neuroticism is associated with distress, poor well-being, and negative affect
(Diener et al., 1999). The relationship between neuroticism and vulnerability to stress has
been widely studied; however, the majority of studies specifically focus on medical postgraduate samples (e.g., Firth-Cozens, 2003; McManus, Keeling, & Paice, 2004) rather than
medical students. Tyssen et al. (2007) examined the relationship between extraversion,
neuroticism, and conscientiousness and stress in medical students and found that those high
on extraversion and low on neuroticism and conscientiousness were more protected against
stress.
1.2. Career attitudes and well-being
There is an increased focus on specialty career choice by the medical education
community due to medical students’ career goals changing in response to the changing health
system, labour market (Australian Health Ministers' Conference, 2004), and lifestyle needs
(Dorsey, Jarjoura, & Rutecki, 2005). These changes have significant long-term implications
for career development, lifestyle and quality of life; however, it is only in recent years that
researchers have begun to study well-being in relation to career goals (Lent & Brown, 2008;
Uthayakumar, Schimmack, Hartung, & Rogers, 2010). We aimed to advance this line of
inquiry by examining the relationship between career expectations and well-being, and
between career barriers and well-being.
1.2.1. Career expectations. The outcomes of performing particular behaviours are
dependent on the importance placed on the outcome by the individual (Lent, Brown, &
Hackett, 1994). For example, if an individual believes they are able to attain their goal of
working in a particular medical specialty, they might have positive expectations regarding
achieving a certain amount of professional success and/or leisure time to pursue personal
activities. Thus, expectations serve as a source of satisfaction, personal fulfilment, and
happiness, which are principal elements of well-being (Diener, 1984).
MEDICAL STUDENT WELL-BEING
5
1.2.2. Career barriers. Whilst beneficial conditions, such as a supportive
environment, are assumed to increase the likelihood of enacting goals, perceived
environmental barriers are likely to have a negative effect on setting and pursuing goals, and
limit a person from achieving their potential. Consequently, perceived barriers restrict career
options and impair an individual’s capacity to make optimal career decisions (Lent et al.,
1994). Thus, when goals are thwarted, well-being is affected negatively (Lord, Diefendorff,
Schmidt, & Hall, 2010).
1.3 Academic stress and well-being
Stress associated with the academic learning environment has been linked to
depression, poor health, and poor academic performance. A heavy workload, examinations,
and clinical performance were found to be the most significant causes of stress among
medical students (Saipanish, 2003; Stewart, Lam, Betson, Wong, & Wong, 1999). Saipanish
(2003) reported that medical students worry about their examinations, falling behind in their
learning, and receiving lower than expected marks. In addition to these concerns, Vitaliano,
Russo, Carr, and Heerwagen (1984) found that peer competition, mastering the vast amount
of knowledge, and the long hours of study were also causes of anxiety.
1.4. Debt and well-being
Debt has been found to produce stress and anxiety in medical students and to affect
their well-being and career choices (Morra, Regehr, & Ginsburg, 2008; Shariati et al., 2007).
Students experience increased levels of stress and poor academic performance as a result of
financial debt (Dyrbye et al., 2005), and students who worry about debt are more at risk of
stress and poor performance (Ross, Cleland, & Macleod, 2006).
1.4. Gender and well-being
Studies investigating gender differences in the mental health of medical students have
produced mixed results (see Dyrbye et al., 2006, for a review of US and Canadian literature),
MEDICAL STUDENT WELL-BEING
6
with some researchers finding that psychological distress is higher among female medical
students (Dahlin et al., 2005; Shariati et al., 2007; Tyssen et al., 2007), while others have
found no gender differences (Hojat, Glaser, Xu, Veloski, & Christian, 1999; Richman &
Flaherty, 1990). The vast majority of studies have focused on symptoms of anxiety and
depression in male and female medical students, although few studies have tested potentially
important person and environmental correlates (Dyrbye et al., 2006).
1.5. The present study
The aim of the present study was to identify person and environmental factors that
were associated with optimal psychological functioning of medical students. Based on
previous theory and research, it was hypothesised that well-being would be positively related
to extraversion, conscientiousness, agreeableness, professional expectations, lifestyle
expectations, and gender (being male), and negatively associated with neuroticism, career
barriers, debt, and academic stress. Further research aims were to determine whether there
were relationships between well-being and openness to experience, age, and year level.
2. Method
2.1. Participants
Medical students in years 2 - 6 from 11 Australian medical schools across all
States/Territories participated in the study. These were drawn from approximately 1000
students who were recruited between 2007 and 2009 as part of a wider project tracking the
career choices of medical students and junior doctors.
2.2. Materials
2.2.1. Psychological well-being. This was assessed using the 5-item World Health
Organisation (WHO-5) Well-Being Index (World Health Organization, 1998). The scale
measures positive mood, vitality, and general interest over the past few weeks. Students
responded to items such as, “Over the last two weeks. I have felt cheerful and in good spirits”
MEDICAL STUDENT WELL-BEING
7
/ “I have felt calm and relaxed”, using a 6-point response format with endpoints of 0 (almost
none of the time) to 5 (almost all of the time), with higher scores representing more wellbeing. The WHO-5 has been translated into many languages (World Health Organization,
1998), has been used with adolescents (De Wit, Delemarre-Van De Waal, Pouwer, Gemke, &
Snoek, 2007) and adults (Henkel et al., 2003), and compares favourably with other general
health questionnaires (Bech, Olsen, Kjoller, & Rasmussen, 2003; Henkel et al., 2003).
Internal reliability has been reported at .82 (De Wit et al., 2007) and .84 (Bech et al., 2003).
2.2.2. Personality. The 10-item Big Five Inventory (BFI-10; Rammstedt & John,
2007) was used to assess extraversion, agreeableness, conscientiousness, neuroticism, and
openness. The BFI-10 is a shortened form of the BFI-44 (John & Srivastava, 1999). It
contains two items per scale, each reflecting opposite ends of each personality dimension.
Rammstedt and John (2007) reported a 5-factor structure for the BFI-10 and demonstrated
convergent validity with the BFI-44 and the NEO-PI-R (Costa & McCrae, 1992), external
validity with peer-ratings, and sound test-retest reliability. Items included, “I see myself as
someone who …is reserved” (extraversion) / “…is generally trusting” (agreeableness), with a
5-point response format of 1 (disagree strongly) to 5 (agree strongly).
2.2.3. Career expectations. Participants completed a 12-item scale that assessed
professional and lifestyle expectations relevant to choosing a medical specialty (Rogers,
Creed, & Searle, 2009). Sample items were: “I expect that my choice of specialty will: let me
practice clinical skills that best suit my perceived abilities?” (professional expectations) / “…
allow me to have my desired work/recreational balance?” (lifestyle expectations). Scale
endpoints were 1 (strongly disagree) and 5 (strongly agree). Rogers et al. reported internal
reliability coefficients of .84 and .83 for professional expectations, and .89 and .92 for
lifestyle expectations across two studies of medical students (Rogers, Searle, & Creed, 2010;
Rogers et al., 2009).
MEDICAL STUDENT WELL-BEING
8
2.2.4. Barriers. We assessed career barriers relevant to choosing a medical specialty.
The 14-item barriers scale was developed for the current study and informed by the medical
specialty choice literature, which shows that family and lifestyle considerations, male
domination, hours of work, and number of training positions are factors associated with
selecting medical specialties (Buddeberg-Fischer, Klaghofer, Abel, & Buddeberg, 2006).
The scale contains endpoints of 1 (strongly disagree) to 5 (strongly agree) with higher scores
indicating more perceived barriers. Sample items were: “To what extent do you agree that the
following will be a barrier to pursuing your preferred medical specialty: length of training /
my gender”.
2.2.5. Academic stress. We asked students to complete a 4-item scale assessing
academic workload and performance, which was developed specifically for the study.
Sample items included, “I feel overwhelmed by the amount of work I have to do”, and, “I feel
stressed about how I am performing”. Endpoints were 1 (strongly disagree) to 5 (strongly
agree) with higher scores indicating greater training workload and performance stress.
2.2.6. Concern about debt. Students responded to the question: “At this stage of your
medical education/training, how concerned are you about the level of debt you will have
accrued at the end of your training?”, by selecting between 1 (not at all concerned) and 4
greatly concerned).
2.3 Procedure
Participants were recruited to the larger study through posters, leaflets, and emails
distributed by participating medical schools. A web-based survey was administered in 2010,
and those who returned a completed survey were entered into a draw for the chance to win a
store voucher. Ethics approval was provided by the authors’ university ethics’ committee.
MEDICAL STUDENT WELL-BEING
9
3.0. Results
Participants were 755 medical students aged between 18 and 57 years (M = 24.6, SD
= 5.5). There were 119 in year 2, 251 in year 3, 281 in year 4, 73 in year 5 and 31 in year 6.
The sample was predominantly Caucasian, and 66% were women. Based on participation in
the larger cohort study, the response rate in 2010 was 87%.
3.1. Predicting well-being
A hierarchical multiple regression analysis was conducted to test the relationship
between the person and environmental predictors and the outcome variable of well-being. All
predictors (except agreeableness and openness) were significantly, bivariately correlated with
well-being (see Table 1). Year level and age were not significantly associated with wellbeing, and thus, along with agreeableness and openness, were not included in the analysis.
Gender was entered at Step 1. The person variables of neuroticism, extraversion,
conscientiousness, professional expectations, and lifestyle expectations were entered at Step
2. The environmental variables of career barriers, concern about debt, and academic stress
were entered at Step 3.
Gender at Step 1 was significant, F(1, 753) = 6.01, p < .05, with males reporting
better well-being. At Step 2, the person variables accounted for a further 15.8% of the
variance, FCh(5, 748) = 26.68, p < .001. Significant individual predictors were extraversion,
neuroticism, conscientiousness, professional expectations, and lifestyle expectations.
Students, with higher levels of extraversion, conscientiousness, professional expectations,
and lifestyle expectations, and lower levels of neuroticism, also reported better well-being.
Gender was no longer significant. At Step 3, barriers, concern about debt, and academic
stress accounted for a further 12.7%, FCh(3, 745) = 44.02, p < .001. At this final Step, all
variables accounted for 28.5% of the variance. Students with higher levels of extraversion,
conscientiousness, professional expectations, and lifestyle expectations, and lower levels of
MEDICAL STUDENT WELL-BEING
10
neuroticism, concern about debt, and academic stress also reported better well-being. Career
barriers was not significant. See Table 2.
4.0. Discussion
Identifying the person and environmental factors associated with well-being in
medical students represents an important step in raising awareness of health issues, and
creates the opportunity for providing support to students during medical school. Our findings
supported the hypothesised relationships between well-being and the person variables of
extraversion, conscientiousness, neuroticism, professional expectations, and lifestyle
expectations, and between well-being and the appraised environmental variables of academic
stress and concern about debt. Based on these findings we can identify that medical students
who display a disposition that is outgoing, conscientious, and stable, who have higher
expectations for their future professional career and lifestyle, who are less stressed about their
academic workload, and who are less concerned about their level of debt, experience better
well-being.
The strongest predictor of well-being was academic stress. Considering the complex
information to be learned, the large workload, and the academically stressful and competitive
environment of medical school, this finding may not be surprising. Our results show that
students who appraise their workload as stressful or threatening and worry about their
performance also report lower levels of well-being. Research that can identify the specific
academic stressors that affect health and well-being during medical school is recommended.
Also, it would be helpful if coping strategies that promote an awareness of academic stress
and its consequences be developed and incorporated into medical education and student
counselling services.
In our analysis of the relationship between personality and well-being, we replicated
previous findings by demonstrating positive relationships between extraversion and
MEDICAL STUDENT WELL-BEING
11
conscientiousness and well-being, and a negative relationship between neuroticism and wellbeing (Tyssen et al., 2007). Neuroticism was the second most important predictor after
academic stress. High levels of this trait predispose a person to experience negative emotional
responses that are out of proportion to circumstances and which are detrimental to well-being
(McCrae & Costa, 2003). Medical educators should consider implementing interventions that
target medical students who worry excessively, given the significant association with both
mental and physical heath (Lahey, 2009). In contrast, high levels of extraversion and
conscientiousness were associated with better well-being. Extraverts typically seek social
support, experience more pleasurable events, and are happier people (Costa & McCrae,
1980). Conscientious students tend to be achievement oriented, committed, and cautious in
their approach to work, and, thus, more likely to manage the demands of their studies and to
have better levels of well-being (Hayes & Joseph, 2003).
Concern about debt was the third most important predictor. Given that medical
students usually graduate with a high level of debt in comparison to students in other degrees
(Jolly, 2005), and that previous research demonstrates an association between worry about
financial stress and increased levels of general stress (Ross et al., 2006), it is not surprising
that concern about debt has a negative effect on well-being. Medical educators need to take
this factor into consideration when advising students about fostering and maintaining wellbeing.
Professional expectations and lifestyle expectations were also significant predictors of
well-being. Although these life variables had a small effect, it suggests that aiming for
professional success and a work/life balance is associated with satisfaction and personal
fulfilment. This finding supports the need for delivering career and life planning services that
provide realistic information on the demands and rewards of medical training. This would
MEDICAL STUDENT WELL-BEING
12
enable students to clarify their professional and lifestyle expectations and to plan for their
future.
Whilst the bivariate correlation supported the hypothesis that being male was
associated positively with well-being, this relationship was not evident when tested in the
context of the other variables used in the study. This finding is consistent with others who
found no gender differences on psychological distress during medical school (Hojat et al.,
1999; Richman & Flaherty, 1990). Similarly, while career barriers were negatively,
bivariately correlated with well-being, they were not a significant factor in the model. A
possible explanation for these non-significant findings is that the personality and career
expectations variables may mediate the effect that barriers have on well-being.
4.1. Strengths, limitations, future research, and implications
Our study advances the literature on the well-being of medical students in several
ways. We identified that certain personality traits were associated with the well-being of
medical students, and that there were well-being effects for attitudes and perceptions toward
career and lifestyle factors. While participants were self-selected, the sample was large and
diverse, drawing on students from 11 medical schools across multiple year levels and all
Australian States and Territories.
The cross-sectional, correlational design limits the capacity to identify causality in
relation to well-being, although the causal direction we proposed is consistent with wellbeing theory and longitudinal well-being research (Ryan & Deci, 2001). Additionally, we
used the short BFI-10 inventory to assess personality. Rammstedt and John (2007) reported
8-week, test-retest reliability coefficients ranging from .68 to .83; yet, several of the subscales
in our study had low internal reliability coefficients (e.g., agreeableness = .31). While low
internal reliabilities are to be expected given that each subscale contained two items only, and
the two items represented opposite ends of the personality dimension (i.e., there was broad
MEDICAL STUDENT WELL-BEING
13
coverage of each dimension; see Cortina, 1993), future studies might confirm these results
using longer scales.
We also used specifically devised scales for career barriers, academic stress, and
concern about debt. These scales were associated with other scales in the study in the
expected direction (e.g., career barriers was negatively correlated with professional
expectations and lifestyle expectations, and academic stress and debt concerns were
negatively correlated with well-being), which supports construct validity. However, they
need to be used by future researchers in other settings to confirm their usefulness.
To build on the present findings, researchers also might consider a longitudinal
approach to identify the specific causes of medical student well-being and to ascertain if, and
how, well-being changes over time. Finally, as coping responses can influence an appraisal of
a demanding situation, and are relevant to person-environment models (Edwards, Cable,
Lambert, & Shipp, 2006), we suggest that future researchers include measures of coping and
support when examining student well-being.
Acknowledgement
This study was funded by an Australian Research Council (ARC) Discovery Grant.
MEDICAL STUDENT WELL-BEING
14
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