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FACTORS CONTRIBUTING TO PERCEIVED STRESS AMONG

DOCTOR OF PHARMACY (PHARMD) STUDENTS


K entya C. F ord , D rPH, CHES
B u suyi S. O lo tu , MS
A ndrew V. T h ach , BS
R ochelle R oberts , P hD
P atrick D avis , P hD

The University of Texas at Austin


Objective: The purpose of this study was to report on perceived stress
levels, identify its contributing factors, and evaluate the association be
tween perceived stress and usage of university resources to cope with
stress among a cross-section of Doctor of Pharmacy (PharmD) students.
Methods: Perceived stress was measured via a web-based survey of
PharmD students. A multiple linear regression was used to assess whether
perceived stress was related to students classification, academic work
load, social support, outside employment, and extracurricular activities.
Results: Survey was completed by 306 students. A majority (69.9%)
reported feeling stressed fairly or very often. Students classification
and academic workload were significantly related to perceived stress
(p<0.001); however, the relationship between perceived stress and the use
of campus resources to cope with stress were not significant (p=0.349).
Conclusion: High levels of perceived stress were found among
PharmD students, which were mostly related to academic workload.
Future research should investigate whether perceived stress is related
to educational outcomes.
Keywords: PharmD students, perceived stress, coping strategies

INTRODUCTION
Stress among college students is a grow
ing public health concern. According to a
recent national survey by the American Col
lege Health Association, 42.8% of college
students reported more than average stress
or tremendous stress within the last 12
months, with another 28.4% of the students
reporting that stress affected their academic
performance (American College Health Asso
ciation, 2013). Research suggests that factors

unique to the college environment such as ac


ademic strain, perceived social norms, cultur
al differences, improper course management,
transitional periods due to distance from
family and support networks, employment,
and other normative experiences associated
with the college environment play a role in
increasing stress among college students
(Stecker, 2004).
While some stress may serve as posi
tive and beneficial motivation for students,

189

190 / College Student Journal


enabling them to work harder or to achieve a
goal (Baum, 1990), students often experience
undesirable outcomes when their stress levels
exceed their ability to cope. In turn, this may
result in negative physical and mental health
consequences, such as feelings of anxiety,
exhaustion, and depression (Aycock, 2011;
E. Chang, F. Eddins-Folensbee, & J. Coverdale, 2012; Jungbluth, Macfarlane, Veach, &
Leroy, 2011; Siqueira Drake, Hafen, Rush,
& Reisbig, 2012; Wei & Sha, 2003). Also,
extreme psychological stress can precipitate
risk for more severe psychological disorders
(e.g., depression) (Bartolomucci & Leopardi,
2009), as well as negative health-compro
mising risk behaviors such as use of alcohol
and tobacco (U.S. Department of Health and
Human Services, 2012).
Within the college environment, research
indicates that students enrolled in advanced
health professional programs, such as in
medicine, nursing, dental, and pharmacy,
appear to be at greater risks for the negative
consequences associated with stress (Dutta,
Pyles, & Miederhoff, 2005). Although stress
can be a major problem for all students
enrolled in rigorous, time-consuming and
demanding health professional programs,
the majority of stress-related research has
targeted dental, medical and nursing students
(Fonseca et al., 2013; Harikiran, Srinagesh,
Nagesh, & Sajudeen, 2012; Kumar et al.,
2009; Manolova et al., 2012; Murdock, Naber, & Perlow, 2010; Neveu et al., 2012; Pau
et al., 2007; Pereira & Barbosa, 2013; Polychronopoulou & Divaris, 2009, 2010; Sedky, 2012; Seyedfatemi, Tafreshi, & Hagani,
2007; Sreeramareddy et al., 2007; Tangade,
Mathur, Gupta, & Chaudhary, 2011; Tempski et al., 2012). In contrast, only a very
few stress-related research with students in
Doctor of Pharmacy (PharmD) programs
have been published (Canales-Gonzales
& Kranz, 2008; Frick, Frick, Coffman, &
Dey, 2011; Gupchup, Borrego, & Konduri,

2004; Hirsch, Do, Hollenbach, Manoguerra,


& Adler, 2009; Marshall, Allison, Nykamp,
& Lanke, 2008; Maynor, 2012). Research
addressing stress and other mental health
indicators are needed among PharmD stu
dents, as higher stress has been found to be
associated with poorer general and mental
health (Gupchup, et al., 2004; Hirsch, et al.,
2009; Marshall, et al., 2008; Maynor, 2012),
and use of negative stress-coping strategies
(Hirsch, et al., 2009).
A small body of research indicate that var
ious factors play a role in the stress perceived
by students during their college years, which
may include examinations and outside-ofclass assignments (Marshall, et al., 2008),
increased academic workload (Fonseca, et
al., 2013; Jungbluth, et al., 2011; Manolova,
et al., 2012; Pickles et al., 2012; Siqueira
Drake, et al., 2012; Walsh, Feeney, Hussey,
& Donnellan, 2010), engagement in extra
curricular activities (Elaine Chang, Flor
ence Eddins-Folensbee, & John Coverdale,
2012; Dumais, 2009), overextension due to
outside employment (Dyrbye et al., 2010;
OConnor & Bevil, 1996; Tucker, Jones,
Mandy, & Gupta, 2006; Weller, Kelder, Coo
per, Basen-Engquist, & Tortolero, 2003),
financial issues (Marshall, et al., 2008), and
lack of social support from friends and fam
ily (Aycock, 2011; Chao, 2012; Lin, 2009;
Reeve, Shumaker, Yearwood, Crowell, &
Riley, 2012; Wei & Sha, 2003). In addition,
pharmacy students may experience stress
due to changing curriculum and models of
practice within schools and colleges of phar
macy, and within advanced practice training
and pharmacy practice sites (Giberson S, Yo
der S, & Lee MP, 2011). Pharmacy students
are exposed to many strenuous endeavors
and rigorous training while preparing to be
come pharmacists; thus, some level of stress
associated with obtaining a PharmD degree
is expected. However, if pharmacy students
stress levels are not addressed and assessed,

Perceived Stress among Doctor of Pharmacy (PharmD) Students /191


there is a strong potential for normal aca
demic pressures to lead to more severe men
tal health indicators and psychosocial risks.
This need for assessment is also encouraged
by the Accreditation Council for Pharmacy
Education (ACPE) which mandated that all
colleges and schools of pharmacy formally
assess students perceived stress levels and
the potential negative health outcomes that
could arise from such stressors (Accredita
tion Council for Pharmacy Education, 2011).
Given the deleterious effects of stress on
academic performance (American College
Health Association, 2013), pharmacy school
administrators should assess the prevalence
and contributing factors of stress among their
students. This information may aid in pro
viding students with the appropriate resourc
es to mitigate the negative effects associated
with stress. Additionally, the availability,
awareness, and use of campus support ser
vices and resources to cope with stress have
been shown to be significantly useful in
helping students manage and cope with their
stressful events (Elaine Chang, et al., 2012;
Gardner & Parkinson, 2011; Matheny et al.,
2002; Simons, Aysan, Thompson, Hamarat,
& Steele, 2002).
The primary purpose of this study was
to report on the perceived academic stress
levels and identify contributing factors for
stress among a sample of PharmD students.
A secondary aim of the study was to evalu
ate the association between stress and usage
of university and/or college of pharmacy
resources in order to cope with stress. This
study differs from previous literature on
stress among PharmD students by surveying
a wider range of PharmD classes (i.e., PlP4) and by utilizing a predictive analytical
strategy (i.e., multiple linear regressions) to
assess the association between stress and its
contributing factors.

METHODS
Study Design and Data Collection
Procedures

This study utilized a cross-sectional,


non-experimental web-based survey design.
The perceived stress items on the survey in
strument were adapted from the previously
validated Perceived Stress Scale (Cohen,
Kamarck, & Mermelstein, 1983). The survey
questions used in this study were part of a
comprehensive annual survey conducted by
the program assessment team as part of the
formal accreditation process and for contin
uous quality improvement at the University
of Texas at Austin College of Pharmacy (UT
CoP). Because the data were de-identified
and originally collected for programmatic
assessment purposes, Institutional Review
Board approval was waived. The survey
was administered to all PharmD students
(i.e., P1-P4) at the end of the 2010 academic
year (i.e., between April-May 2010). A cov
er letter and link to the online survey were
e-mailed to each of the 510 PharmD students.
The students were asked to complete the
survey within 2 weeks and reminder emails
were sent 2 to 3 days ahead of the deadline.
Responses were anonymous and could not
be traced back to the responder, and consent
to participate was assumed if a student re
sponded. In addition, students could have
opted out of the study at any time and were
not compelled to give answers to every sur
vey question, but they were encouraged to
be as truthful and complete as possible. No
incentives were provided for participation.
The six perceived stress items on the
general survey asked students to reflect back
on the last academic year (i.e., 2009-2010)
before responding to the following questions:
During the last academic year, (Ql) how of
ten have you felt stressed? (Q2) how often did
you feel you had too much work and too little
time? (Q3) how often did you have adequate

192 / College Student Journal


social support (i.e., from colleagues, friends,
and/or family members?) (Q4) how often did
you use available university and/or college
resources to help you cope with stress? (Q5)
how often did any outside employment make
you feel overextended? (Q6) how often did
other extracurricular activities (i.e., aside
from work) make you feel overextended?
All variables were measured on a Likert-type
scale that ranged from never (1) to very of
ten (5). Prior to administering the survey to
students, these items were reviewed and mod
ified by members of the program assessment
team, which included administrators, faculty,
and students.
Perceived academic stress is the dependent
or outcomes variable of interest as measured
by the first item (Ql) above. Stress value
ranged from 1 = never stressed, to 5 = stressed
very often. The predictor variables of interest
included students classification (i.e., P1-P4),
academic workload (Q2), social support (Q3),
outside employment (Q5), and extracurricular
activities (Q6). All of the predictor variables,
except student classification, are interval level
data and thus continuous variables.
Data Analyses
Data from the questionnaire were entered
into and analyzed by IBM SPSS Statistics,
version 19.0 (SPSS, Chicago, IL). The pri
mary purpose of this study was to report on
perceived academic stress levels and identify
their contributing factors among a cross-sec
tion of PharmD students. All of the predictor
variables were simultaneously entered into
the multiple linear regression model to pre
dict their association with perceived academic
stress. The secondary aim of the study was to
evaluate the association between perceived
academic stress (Q l) and usage of university
and/or UT CoP resources (Q4) to cope with
stress. A Pearsons correlation was used to
assess this objective. Results are significant
with p-values of less than 0.05.

RESULTS
Data were collected between April and
May 2010 via web-based self-administered
surveys. A total of 306 students completed the
surveys, yielding a response rate of 60%.
Prevalence of Stress
A majority of the students (n = 198,
69.9%) reported feeling stressed fairly or
very often when asked how often they felt
stressed during the last academic year. In ad
dition, P2 students reported feeling stressed
the most (mean SD = 4.52 0.57), followed
by PI students (4.190.83) and P3 students
(3.790.86). P4 students reported feeling
stressed the least (2.981.20).
Factors Contributing to Perceived Stress
One of the main objectives of this study
was to identify the contributing factors of
perceived stress among a cross-section of
PharmD students. The sample size (n = 262)
included in our regression analysis was higher
than the estimated minimum sample size cal
culation of 55, given power (1-P) = 80%, al
pha (a) = 0.05, f2= 0.15 (medium effects size
was assumed), number of predictors = 7, and
two tails distribution (Faul, 1992). The overall
model was statistically significant (F=18.83;
d.f. = 7; p<0.001). This means that at least one
of the independent variables was associated
with the stress. Furthermore, the R-squared
associated with the model was 0.342, indicat
ing that 34% of the variance in the dependent
variable (i.e., perceived academic stress) was
explained by all the independent variables
combined (See Table 1).

Perceived Stress among Doctor of Pharmacy (PharmD) Students /193


Table 1: Factors Contributing to Perceived Stress among PharmD Students (N=262)a
95% C.I. for B
Predictor variable

t-value

p-value

PI

0.996

0.142

7.018

P2

1.326

0.202

P3

0.818

Academic workload

Lower

Upper

0.001'

0.717

1.276

6.557

0.001'

0.928

1.725

0.185

4.429

0.001'

0.454

1.182

0.298

0.067

4.473

0.00T

0.167

0.430

Social support

0.116

0.063

1.832

0.068

-0.009

0.240

Outside employment

0.017

0.052

0.315

0.753

-0.087

0.120

Extracurricular activities

0.021

0.055

0.380

0.705

-0.087

0.128

Students classification11

aN is less than 306 due to missing responses


bReference category: P4 students
'Significance at p < 0.05
Model: F = 18.83, df = 7, p < 0.001; R2= 0.342
Abbreviations: B = Unstandardized coefficients; E = Standard error; C.I. = Confidence Interval

PharmD classification. The regression


analyses showed that students classification
(i.e., P1-P4) was significantly related to per
ceived academic stress. Specifically, when
compared to P4 students, and controlling for
other covariates, perceived academic stress
was highest in P2 students (P=l.326, t=6.56,
p<0.001). They are followed by PI (|3=0.996,
t=7.02, p<0.001) and P3 ((3=0.82, t=4.43,
p<0.001) students, respectively (See Table 1).
Academic workload. There was a signif
icant association between academic workload
and perceived academic stress. Specifically,
for every unit increase in academic workload
experienced by students, the mean perceived
academic stress increased by 0.298, keep
ing all other covariates constant ((3=0.298,
t=4.47, pO.001). In other words, increases
in academic workload were associated with
increases in perceived academic stress.
None of the other variables in the regres
sion model (i.e., social support, outside em
ployment, and extracurricular activities) were
significantly associated with perceived aca
demic stress among students (See Table 1).

Use of Resources to Cope with Stress


There was no significant relationship be
tween perceived academic stress and the use of
available university and/or UT CoP resources
to cope with stress (r=0.056; n=282; p=0.349).
When asked how often they use available uni
versity and/or UT CoP resources to help cope
with their stress, a majority (n = 214, 75.9%)
of the students replied almost never to nev
er having used the available resources. This
means that students are not utilizing campus
resources to help manage their stress despite
the availability of such resources.
DISCUSSION
Most of the students surveyed in our study
reported very high levels of stress, which is
similar to the reported high or above average
levels of stress by PharmD students at other
colleges and schools of pharmacy (Canales-Gonzales & Kranz, 2008; Maynor, 2012).
These findings indicate that, in general, phar
macy students perceive a high level of stress
associated with their program.

194 / College Student Journal


The P2 students in this study reported
the most stress, followed by PI, P3 and P4
students, respectively. In general, PI and P2
students reported higher levels of stress in
our study and in previous studies of stress
among PharmD students (Hirsch, et al., 2009;
Maynor, 2012). The discrepancy in perceived
stress levels among the student classification
is suggested to be due to students transition
ing from a less challenging to a more rigorous
curriculum (Maynor, 2012). At this universi
ty, P2 students transition from a more general,
science-based curriculum of the PI year to
a more demanding curriculum with courses
such as pharmacotherapy, pharmacokinetics,
and patient assessment. These pharmacy-spe
cific courses require more course hours and
additional laboratory time, which may con
tribute to an increase in perceived stress.
Similarly, students in the P 1 year transitioned
from a more general undergraduate education
to a predominately science-based curriculum
which they might find more challenging and
stressful. Both of these transitions could also
be accompanied by changes to sleeping and
eating habits, increased responsibilities, and
distance away from family and friends, which
are known sources of stress for students learn
ing to adjust to new environments (Robotham, 2006; Ross, 1999). In contrast, students
in their later years (i.e., P3 and P4) might
perceive less stress because they might have
learned ways to adjust to the stressful phar
macy curriculum, or learned and mastered
certain strategies to cope with their stress.
It was not surprising that academic
workload was significantly associated with
perceived stress among students. In the liter
ature, coursework, examinations, and outside
of class assignments were significant con
tributors to stress among PharmD students
(Canales-Gonzales & Kranz, 2008; Marshall,
et al., 2008). Moreover, academic workload
has been shown to be an important determi
nant of stress among students in other health

professions (Fonseca, et al., 2013; Jungbluth,


et al., 2011; Manolova, et al., 2012; Pickles, et
al., 2012; Siqueira Drake, et al., 2012; Walsh,
et al., 2010).
However, it was surprising that social sup
port, outside employment, and extracurricular
activities were not significantly associated with
perceived stress. Other studies have shown
that adequate social support from family and
friends was important in helping students cope
with stressful events (Aycock, 2011; Chao,
2012; Lin, 2009; Wei & Sha, 2003), while
stress from outside employment tended to
worsen the stress students experienced as a
result of their academic work (Dyrbye, et al.,
2010; OConnor & Bevil, 1996; Tucker, et al.,
2006; Weller, et al., 2003). On the other hand,
the effects of extracurricular activities on per
ceived stress tend to be mixed, depending on
the type of activity involved (Baker, 2008).
Extracurricular activities such as exercising
and running are effective stress-coping strat
egies that have been employed by college
students in the management of burnouts and
stressful life events (Elaine Chang, et al.,
2012; Marshall, etal., 2008).
It was surprising that despite reporting
high levels of stress, the majority of students
in our program did not see the need to use
available university and/or UT CoP resources
to help them cope with their stress. Many of
these stress-coping resources which include a
free mind-body laboratory for relaxation, and
stress-management classes and groups, re
quire no prior appointments. Future research
should investigate why students do not utilize
such campus resources. Perhaps students are
not willing to seek help even when they know
there are resources to help them with their
problems (Gardner & Parkinson, 2011).
Although one of the strengths of this study
included the use of multivariable analyses and
the inclusion of a wider range of PharmD class
es when compared to previous research, the
findings from this study should be interpreted

Perceived Stress among Doctor of Pharmacy (PharmD) Students /195


in light of several limitations. First, this study
utilized a cross-sectional design and collected
data at the end of the session; thus, it is possible
for students to experience varying degrees of
stressful events throughout the session, and the
relationships expressed among measured vari
ables could have changed over time. Second,
some key demographic variables such as age,
gender, and ethnicity were not collected (due
to confidentiality issues) and therefore could
not be controlled for in the regression analyses.
Future surveys should incorporate these and
other pertinent variables. Third, this study was
conducted at one college of pharmacy. There
may be considerable differences in curricula
at each college and school of pharmacy in the
United States. A final potential limitation may
be the instrument used to assess perceived
stress levels, which was different from the in
struments used in other studies assessing stress
among PharmD students.
This study is one of the few that has used
a multivariate approach to identify factors as
sociated with perceived stress among PharmD
students. Because academic variables such as
grade point average and letter grades were
not included in our survey, further research
should seek to examine the impact of per
ceived stress on these variables. Furthermore,
since students in our program reported high
levels of stress and were not interested in
using the available stress-coping resources,
further studies should examine why students
are not utilizing such resources, including
assessing whether students are aware of said
resources in the first place. Other studies
should also expand the data to include other
comparator groups, within the university and
other colleges and schools of pharmacy.
Several studies have indicated that stu
dents in colleges of pharmacy and other health
professions program perceive a high level of
academic-related stress (Canales-Gonzales &
Kranz, 2008; Fonseca, et al., 2013; Frick, et
al., 2011; Gupchup, et al., 2004; Hirsch, et al.,

2009; Marshall, et al., 2008; Maynor, 2012;


Murdock, et al., 2010; Pereira & Barbosa,
2013; Polychronopoulou & Divaris, 2009;
Seyedfatemi, et al., 2007; Tempski, et al.,
2012). However, this perceived stress is not
limited only to students in pharmacy schools,
but also among licensed pharmacy practi
tioners (Gaither et al., 2008; Yeh, Lin, Lin, &
Wan, 2010). Because of the negative health
outcomes and low productivity that may be
associated with stress among students and
practitioners of pharmacy, pharmacy school
administrators should identify the sources
of stress and assess whether such stressors
affect the proficiency of their students. This
knowledge can aid them in providing students
with the appropriate resources to mitigate the
negative effects associated with stress. Nev
ertheless, since students may not be aware of
the availability of on-campus, stress-coping
resources, it might be necessary for pharmacy
administrators to educate students regarding
the availability of such resources by orga
nizing coping workshops on annual student
orientations sessions (Hirsch, et al., 2009).

CONCLUSION
A majority of students reported feeling
stressed fairly or very often, and P2 students
reported the highest levels of stress. Of the
measured variables, academic workload was
significantly related to perceived academ
ic stress. While a relaxation laboratory and
stress-management classes and groups were
available to help manage stress, students failed
to utilize these free and confidential resources.
Further research is needed across colleges
and schools of pharmacy to assess levels of
stress that may be caused by varying curric
ulum or other factors, such as availability of
appropriate support services for coping with
stress. Additionally, future research should
assess utilization of these support services
and factors that influence students decision
to utilize these resources.

196 / College Student Journal


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