factors contributing to perceived stress among

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FACTORS CONTRIBUTING TO PERCEIVED STRESS AMONG DOCTOR OF PHARMACY (PHARMD) STUDENTS

K e n t y a C. F o r d , Dr PH, CHES

B u s u y i S. O l o t u , MS

A n d r e w V. T h a c h , BS

R o c h e l l e R o b e r t s , Ph D

P a t r ic k D a v i s , Ph D

The University o f Texas at Austin

Objective: The purpose o f 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 crosssection of Doctor o f Pharmacy (PharmD) students.

Methods: Perceived stress was measured via a webbased 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


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190 / College Student Journal

enabling them to work harder or to achieve agoal (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. Cover-

dale, 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 inmedicine, 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, Na-

ber, & Perlow, 2010; Neveu et al., 2012; Pau

et al., 2007; Pereira & Barbosa, 2013; Poly-

chronopoulou & Divaris, 2009, 2010; Sed-

ky, 2012; Seyedfatemi, Tafreshi, & Hagani,

2007; Sreeramareddy et al., 2007; Tangade,

Mathur, Gupta, & Chaudhary, 2011; Temps-

ki 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-of-

class 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 extracurricular activities (Elaine Chang, Flor

ence Eddins-Folensbee, & John Coverdale,

2012; Dumais, 2009), overextension due to

outside employment (Dyrbye et al., 2010;

O’Connor & 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,


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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 forstress 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., Pl

P4) and by utilizing a predictive analytical

strategy (i.e., multiple linear regressions) toassess the association between stress and its

contributing factors.

METHODS

Study Design and Data Collection

Procedures

This study utilized a crosssectional,

nonexperimental webbased 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 acomprehensive 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 deidentified

and originally collected for programmatic

assessment purposes, Institutional Review

Board approval was waived. The survey

was administered to all PharmD students(i.e., P1P4) at the end of the 2010 academic

year (i.e., between AprilMay 2010). A cov-

er letter and link to the online survey were

emailed 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., 20092010)

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


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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 tostudents, 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 (Q l) 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 primary 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 o f 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 (Ql) and usage of universityand/or UT CoP resources (Q4) to cope with

stress. A Pearson’s 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 addition, P2 students reported feeling stressed

the most (mean ± SD = 4.52 ± 0.57), followed

by PI students (4.19±0.83) and P3 students

(3.79±0.86). P4 students reported feeling

stressed the least (2.98±1.20).

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 ofPharmD 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


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Table 1: Factors Contributing to Perceived Stress among PharmD Students (N=262)a

95% C.I. for BPredictor variable B E t-value p-value ■

Lower Upper

Students’ classification11

PI 0.996 0.142 7.018 0.001' 0.717 1.276

P2 1.326 0.202 6.557 0.001' 0.928 1.725

P3 0.818 0.185 4.429 0.001' 0.454 1.182

Academic workload 0.298 0.067 4.473 0.00T 0.167 0.430Social 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

aN is less than 306 due to missing responses bReference category: P4 students'Significance at p < 0.05Model: F = 18.83, df = 7, p < 0.001; R2= 0.342Abbreviations: B = Unstandardized coefficients; E = Standard error; C.I. = Confidence Interval

PharmD classification. The regressionanalyses 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


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The P2 students in this study reportedthe 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,

sciencebased curriculum of the PI year to

a more demanding curriculum with courses

such as pharmacotherapy, pharmacokinetics,

and patient assessment. These pharmacyspe-

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 educationto a predominately sciencebased 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 (Roboth

am, 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

(CanalesGonzales & Kranz, 2008; Marshall,

et al., 2008). Moreover, academic workload

has been shown to be an important determi-

nant o f 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; O’Connor & 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 exercisingand running are effective stresscoping 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 stresscoping resources which include a

free mindbody laboratory for relaxation, and

stressmanagement 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 o f the strengths of this study

included the use o f 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


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in light of several limitations. First, this studyutilized 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 inusing 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 pharmacyadministrators 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 o f stress. Of the

measured variables, academic workload wassignificantly 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 withstress. Additionally, future research should

assess utilization of these support services

and factors that influence students’ decision

to utilize these resources.


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C o p y r i g h t o f C o l l e g e S t u d e n t J o u r n a l i s t h e p r o p e r t y o f P r o j e c t I n n o v a t i o n , I n c . a n d i t s

c o n t e n t m a y n o t b e c o p i e d o r e m a i l e d t o m u l t i p l e s i t e s o r p o s t e d t o a l i s t s e r v w i t h o u t t h e

c o p y r i g h t h o l d e r ' s e x p r e s s w r i t t e n p e r m i s s i o n . H o w e v e r , u s e r s m a y p r i n t , d o w n l o a d , o r e m a i l

a r t i c l e s f o r i n d i v i d u a l u s e .

factors contributing to perceived stress among

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