ORIGINAL ARTICLE

Volume 6 Issue 4 2014

DOI:10.5959/eimj.v6i4.276
www.eduimed.com

Recognition of stressors in postgraduate students of a teaching University in Pakistan

Darayus P.Gazder1, Annie Adnan Ali1, Durre Fatima Naqvi1, Nosheen Zehra2, Irum Memon1,
Abdul Rafay1
1 2
Medical Students, Department of Community Health Sciences, Ziauddin University, Karachi, Pakistan.

ARTICLE INFO ABSTRACT

Received : 16/06/2014
Accepted : 03/11/2014 Objective: To recognize postgraduate stressors and their intensity among
Published : 01/12/2014 doctors doing post-graduation in the fields of academic and clinical
medicine, using the Postgraduate Stressor Questionnaire (PSQ). Methods:
A cross sectional study was conducted where the target population were
KEYWORD postgraduate students. The PSQ was administered, a twenty-eight item
Postgraduate students questionnaire to identify and measure intensities of stressors. Questionnaires
Stressors were administered to ninety post-graduate students, forty-five from each
Academic medicine field. Data was entered on SPSS version 20. After descriptive analysis and
Clinical medicine checking the data for normality independent sample t-test and ANOVA
were applied for numerical data, and chi square was applied for categorical
data. Results: The mean age of the students was 30.97 (SD=6.52) years.
Majority of the students were females. It was seen that academic related
stressors were greatest among the two fields of medicine. Higher levels of
stress were seen in students who were training in clinical medicine
(mean=13.30, SD=4.84) than academic medicine (mean=12.27, SD=5.47).
Conclusion: Postgraduate medical training is a highly stressful environment
encountered by students. Academic related stressors were found to have its
greatest impact in both the fields of medicine; this stress arises from
scholastic, academic or educational events. Highest amounts of stress were
seen in students enrolled in clinical medicine.

© Medical Education Department, School of Medical Sciences, Universiti Sains Malaysia. All rights reserved.
CORRESPONDING AUTHOR: Darayus P.Gazder, Medical Students, Department of Community Health
Sciences, Ziauddin University, Karachi, Pakistan. Email: [email protected]

Introduction Pakistan’s society is a conservative one, the

society gives great respect and admiration to
Stress can be defined as “A psychological doctors and hence the medical profession is
condition or emotional strain or suspense” [1]. looked upon with awe in our society. Doctors are
Stress can occur in two dimensions it may have a looked upon as “Healers.” There is a lot of
positive or negative impact. When stress leads to competition to enter medical school and the
a positive track it enhances performance, gives transition from school/college to a medical
confidence and gives excellent end results. But university is a big jump. Therefore, the struggle
when stress moves in a negative direction, it can to enter a medical school, he/she has an
cause physical and psychological destruction [2]. enormous amount of complex materials to learn
and they face competition against other brighter

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students. The duration of medical education and available data is scarce particularly in Pakistan.
training is also a factor that contributes to stress Thus, the purpose of this study is to try and
in medical trainees. Medical school training in evaluate different stressors affecting
Pakistan is relatively long. It requires 5 years of postgraduate students and which stressor group
schooling after completing 12 years of secondary has its maximum effect and intensity on students
and 1 year of house job [3]. Stress and emotional in different fields of post-graduation in
disturbances among students are relatively medicine.
common, and seemingly, this is a worldwide
problem [4]. Studies indicate that specific stress Method
factors related to medical school may induce
mental health problems, and a decrease in life A cross sectional study was conducted on
satisfaction among students [5]. Distress may postgraduate medical students studying and
affect their performance as students and later as a working in Ziauddin University. It was a one
caregiver for patients [6]. Bridging the gap year project. A total of 90 postgraduate medical
between graduation from medical school and students were chosen and divided into two
being board eligible in a medical specialty is a groups with forty-five students from each
lengthy and arduous process. program of academic and clinical medicine
respectively. Simple random sampling technique
Postgraduate medical training has always been was employed for collection of data. The nature
regarded as a highly stressful environment to of survey, applicability of results and
students [7]. Stress is a factor that generally confidentiality were explained to the
results in negative thoughts and perceptions that, participants. Completion of questionnaire was
in turn, may adversely affect the performance of voluntary and affirmed that it would not affect
an individual [8]. the progression of their course. The
questionnaire was self-administered. The
Medical students after graduation pursue their students were informed to follow the
career in either Academic (MPhil/PhD) or instructions. Filling of questionnaires took
Clinical (Physician) medicine. High levels of approximately 15 minutes and students were
stress are augmented once they enter into advised to return it on the same day. The
different programs. There may be intense questionnaire contained questions which were
competition in the selection of a field of their likert-type responses, multiple choice questions
choice, associated with long working hours and open ended questions were filled by the
[8-9]. This could affect the overall performance students. Clearance was taken from the ethical
of the individual and that in turn may lead to a review board prior to the start of study. The
cascade of events at both personal and study was done with the perusal of the head of
professional levels [10]. the institution and then informed consent was
taken from participants.
Personal and environmental events that cause Data was collected using a questionnaire
stress are known as stressors [11]. Sources of consisting of two parts: (i) socio-demographic
stress among postgraduate generally can be questions and (ii) questions designed to elicit
grouped into seven groups: academic, poor information about the sources and levels of
relationship with superiors, bureaucratic stress.
constraints, work-family conflicts, poor
relationship with colleagues, performance Postgraduate Stressors Questionnaire (PSQ)
pressure and poor job prospects related stressors
[12]. This section dealt with seven stressors affecting
students, it was a 28 item questionnaire [15]. The
Sources of stress among undergraduate medical seven stressors analyzed were Academic related
students are well established in Pakistan [13-14]. stressors (ARS), Poor relationship with superior
However, for postgraduate medical trainees the related stressors (PRRS), Bureaucratic

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constraints related stressors (BCRS), Work- Demographic Profile
family conflicts related stressors (WFRS), Poor
relationship with colleagues related stressors Ninety postgraduate medical students
(PCRS), Performance pressure related stressors participated in this study, consisting of forty-five
(PPRS), Poor Job prospects related stressors students from Academic (MPhil/PhD) and
(PJRS). Clinical (Medicine/Surgery) programs. The
demographic profile of the overall sample is
The Postgraduate stressor questionnaire was shown in Table 1. About 67.8% of the medical
developed to identify the stressors affecting trainees were females, as 32.2% were male.
postgraduate students as well as measure the 51.1% of the trainees were married, 46.7% were
intensity of stress caused by the stressors. single and 2.2% were divorced. Mean age of the
students was 30.97 and standard deviation 6.52.
The reliability analysis showed that the Eighty-one of the postgraduate students were
Cronbach’s alpha value for the PSQ was 0.95. working as paid employees, as the other 9 were
Whereas, the Cronbach’s alpha values for working voluntarily with no profit. It was also
academic, poor relationship with superior, seen that while 66.7% of students pursuing
bureaucratic constraints, work-family conflicts, academic medicine work an average of 5 to 10
poor relationship with colleagues, performance hours per day, as for 48.9% of students pursuing
pressure, and poor job prospect domains were clinical medicine maintain similar average
0.63, 0.84, 0.81, 0.65, 0.73, 0.78, and 0.70 working hours. On the other hand, it was found
respectively. For each potential stressor 5 that 31.1% of students pursuing clinical medicine
categories were placed and classified as causing actually work an average of 15 to 20 hours per
no stress at all, causing mild stress, causing day, while only 2.2% of students pursuing
moderate stress, causing high stress, causing academic medicine maintain such lengthy
severe stress to indicate intensity of stress average working hours (Figure 1).
caused by these items. Recommended scoring
method of zero for least intensity of stress versus Table 1: Demographic Conclusion
maximum of four for most intensity of stress was
used that is scale of 0, 1, 2, 3, 4 was utilized as Program Postgraduate Students, n Total
has been done by previous studies. Ethical Male Female
consent was taken from the students before Academic 14 31 45
administration. Data was entered on SPSS Clinical 15 30 45
version 20. Mean and standard deviation was 90
taken out for stressor scores. P value less than
0.05 were taken as significant.

Figure 1: Percentage of work done by postgraduate students, in hours per day

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Result whose mean falls at 2.14. This stress arises from
scholastic, academic or educational events.
Based on our study and observation of Performance pressure related stressors were the
postgraduate medical training it was found to be next major stressor and stands at a mean of 2.08-
a highly strenuous environment to students. All 7 it means that postgraduate students have a short
of the stressors were found to directly impact the duration given to complete high risk tasks where
students. Lists of all the stressors are given in any mistake can lead to disastrous consequences
Tables 2 and 3. The intensity of stress is and are generally burdened by work. This was
diagrammatically represented on a bar graph followed by work family related stressors at a
(Figure 2) respectively. Results show that mean of 1.93. It can be described as stress arising
academic related stressors were the primary when one’s life is centred on work events
stressor affecting postgraduate medical students leading to misery and distress feelings.

Table 2: Manifestation of stress among postgraduate students

Stressor Group Mean Standard

deviation
ACADEMIC RELATED STRESSORS 2.14
Tests/Examinations 2.42 0.99
Lack of time to review what has been learnt 2.37 1.02
Difficulty understanding content 1.50 1.01
Large amount of content to be learned 2.26 0.99
PERFORMANCE PRESSURE RELATED STRESSORS 2.08
Time pressures and deadlines to meet 2.07 0.97
Work overload 2.24 1.15
Fear of making serious mistakes 1.93 1.24
My work is mentally straining 2.09 1.17
WORK FAMILY RELATED STRESSORS 1.93
Work demands affect by personal life 2.29 1.27
Advancing a career at the expense of home life 2.23 1.25
My life is too centered on my work 1.81 1.26
Absence of emotional support from family 1.37 1.26
BUREAUCRATIC CONSTRAINTS RELATED STRESSORS 1.82
Lack of authority to carry out my job duties 1.83 1.27
Unable to make full use of my skills and ability 1.99 1.27
Cannot participate in decision making 1.73 1.30
Having to do work outside of my competence 1.73 1.29
POOR RELATIONSHIP WITH SUPERIOR RELATED STRESSORS 1.67
Lack of support from superiors 1.88 1.28
Difficulty in maintaining relationship with superior 1.60 1.28
My beliefs contradict with those of my superior 1.42 1.14
Unfair assessment from superiors 1.78 1.32
POOR RELATIONSHIP WITH COLLEAGUES RELATED STRESSORS 1.56
Working with uncooperative colleagues 1.80 1.24
Working with incompetence of colleagues 1.71 1.14
Relationship problems with colleagues 1.46 1.18
Competition among colleagues 1.29 0.95
POOR JOB PROSPECTS RELATED STRESSORS 1.56
Feeling insecure in my job 1.18 1.22
Society does not think highly of my profession 1.10 1.31
Lack of promotion prospects 1.74 1.34
Feeling of being underpaid 2.20 1.47

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Table 3: Stressors in academic and clinical programs affecting postgraduate students

Stressor Academic, mean + SD Clinical, mean + SD Overall stress, mean + SD

ARS 2.10 + 0.797 2.17 + 0.72 2.14 + 0.76
PRRS 1.52 + 1.10 1.82 + 0.93 1.67 + 1.02
BCRS 1.72 + 1.11 1.92 + 1.00 1.82 + 1.05
WFRS 1.97 + 1.14 1.88 + 0.84 1.93 + 1.00
PCRS 1.37 + 0.92 1.76 + 0.84 1.56 + 0.90
PPRS 2.08 + 0.96 2.09 + 0.78 2.08 + 0.87
PJRS 1.51 + 1.02 1.61 + 1.07 1.56 + 1.04
Academic related stressors (ARS), Poor relationship with superior related stressors (PRRS), Bureaucratic constraints related
stressors (BCRS), Work-family conflicts related stressors (WFRS), Poor relationship with colleagues related stressors
(PCRS), Performance pressure related stressors (PPRS), Poor job prospects related stressors (PJRS).
SD = Standard Deviation

Figure 2: Overall Stressors (Bar chart)

KEY:*
I = Academic related stressors (ARS), II = Performance pressure related stressors (PPRS), III = Work-family conflicts
related stressors (WFRS), IV = Bureaucratic constraints related stressors (BCRS), V = Poor relationship with superior
related stressors (PRRS),), VI = Poor relationship with colleagues related stressors (PCRS), VII = Poor Job prospects
related stressors (PJRS).

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To measure the intensity of stress among the two seen in a previous study [14]. An alarming
groups. Mean and standard deviation were number of postgraduate students are depressed
calculated of the stressors; as they are events that due to lack of time in reviewing what has been
cause stress. Highest amounts of stress were learnt, and application of knowledge in tests and
attributed in postgraduate students who had examinations. In the US, Collier et al (2002)
enrolled in clinical programs, followed by the noted an alarming number of postgraduate
academic program. (Shown in Table 4) trainees who were depressed and showed
increased level of cynicism and decreased levels
Table 4. Levels of stress in the three programs of humanism. The authors attributed this to
calculated by stressors increases in their educational debts [23]. Similar
observations were made in Canada [24-25].
Program N Mean Standard
deviation
Academic 45 12.27 5.47 Postgraduate medical training is extremely
Clinical 45 13.30 4.84 taxing on the students, both mentally and
physically. This result is consistent with previous
research, that postgraduate student’s
Discussion performance is affected by mentally straining
work which they experience [26]. Work overload
Stress amongst postgraduate students is a well- and pressure to complete given tasks, mostly
known fact. Postgraduate trainee doctors are within tight timelines contribute to high levels of
receiving increasing attention, as it is perceived stress. Bansal et al (2010) stated that 66.7% of
that excessive levels of stress may cause the postgraduate students felt that high levels of
dissatisfaction, low morale and poor work stress were contributed due to work overload
performance [16]. It is known that doctors do [27]. Stress due to work demands cause
suffer from high levels of psychological emotional disturbances to a person, this is
disturbance. The level of reported minor attributed by work overload, short duration given
psychiatric morbidity ranges from approximately to complete a given task and doing high risk
one-third for medical students and postgraduate tasks.
trainee doctors entering their training programs,
to over half for doctors who have become A limitation of this study was its small sample
medical consultants and general practitioners size and its cross-sectional design. Despite
[17-21]. assuring anonymity and confidentiality of their
responses underreporting of diverse group of
The results of our study confirmed the stressors might be an issue. However, our study
observations of others as it indicated that was the first to describe stress been faced by
postgraduate students are under considerable postgraduate medical students in Pakistan. The
stress. Firth (1986) noticed that medical residents major stressors that have been faced by the
had higher stress levels than other groups in the students were related to academic and
general population in the UK [22]. It was also performance pressure. Further studies must be
seen that postgraduate students who were carried out to identify the risk factors involved
enrolled in clinical medicine experienced higher and its effects. Our use of valid stress scales
levels of stress than acceptable, (Table 4) than increases the validity of our results and the
students who took academic medicine. This generalizability of our results to other institutions
maybe because of the long working hours, in Pakistan.
demanding schedules, night duties compounded
by exposure to different patients. Conclusion

Our results suggested that major stressors From the above study, one can comprehensively
affecting postgraduate students were due to conclude that postgraduate medical training is
academic and performance related pressures also highly demanding in every aspect, requiring a

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