Quality of Medical Students’ Learning Environment

Introduction

Stress refers to a person’s mental, emotional, and physical reaction to environmental challenges or threats that can cause stress.¹Particularly, stress may be a problem in the educational environment. A little stress can be normal and increase productivity for some people. However, excessive stress can cause serious mental and physical problems.^2,3

Students have always found tertiary education to be stressful. Medical education adds to the already stressful environment.^4,5Medical students face many stressors on their path to achieving their goals.⁵These include a complex medical curriculum, information overload and long study hours.³Numerous studies have shown that medical students in India are subject to moderate to severe stress levels, with India at 91.1%.⁶Pakistani: 84.5%⁷Thailand: 83.5%⁸Malaysia: 49%⁹Saudi Arabia’s Imam Abdulrahman Bin Fisal University, Dammam reported stress at 67.9% for 2018.⁵In Rabigh Medical College Jeddah at 59.2% for 2015³Umm Al-Qura University (UQU), Makkah, 70.9% for 2015¹⁰King Saud University in Riyadh, at 63% for 2011.¹¹ A previous study performed at UQU suggests the causes of distress to be the following factors: large volumes of information that must be retained, students’ academic competition, grade point average (GPA), and fear of failure. These factors may be more prominent in the preclinical years when courses are more theoretical.¹⁰Another UQU study found that most students dissatisfied by the passive, lecture-based teaching method and wanted to see active learning and effective studying habits.^10,12

The Medicine and Bachelor of Surgery (MBBS), at UQU, was therefore updated in 2016. The University College London, one of the most prestigious medical schools in the United Kingdom, helped to create the new curriculum. The MBBS program was revised in content, learning style and teaching and assessment methods.¹³This update transformed the educational experience for all staff members, students, and lecturers. It brought new challenges to the medical education experience.

It became especially important to recognize stress and stressors among medical students after this curriculum update. Our understanding of the matter helps us to implement strategies to reduce the incidence of stress and prevent its adverse effects on the students’ health, their academic performance, and their subsequent careers. Our theory is that students are more responsible and therefore more stressed with the new curriculum. Although stress and depression were studied in medical students, these studies were done in the context of traditional education.^6–11This study is different because it was conducted to assess the quality of the learning environment after the new MBBS curriculum was implemented. This study was designed to fill in the gaps regarding the impact of the curriculum changes on stress among medical students. It also sought to identify the source of stress and its effect on quality of life.

Methods

Research Design, Population and Sample Size Determination

This study was designed as a descriptive cross-sectional research. It was done using an online questionnaire, which was self-administered between August 22, 2020 and September 6, 2020. Ethical approval was obtained from the Biomedical Ethics Committee of the Faculty of Medicine at UQU, Makkah, Saudi Arabia (approval number HAPO-02-K-012-2020-08-430), and we conducted it in accordance with the Declaration of Helsinki. The targeted population is medical students in years 2 to 5 (batch of 2019–2016) who passed the first academic year and are following the updated MBBS curriculum. The foundation year is the first academic calendar. It is designed to prepare students for the MBBS (including an intensive English language course and basic science). We excluded students who have studied at UQU before UQU, as well as sixth-year students who are still studying traditional MBBS curriculum. OpenEpi version 4.0 was used to calculate the required sample size.¹⁴We used a population of approximately 1300 students as a basis for our design. The confidence interval (CI), level at 95%, and the expected frequency percentage of 50% were all considered. These factors gave rise to a sample of 297 participants. The total required sample size was 340 participants in case of data loss. The final data collected included 572 students.

Questionnaire Structure

We created an online questionnaire with Google Forms, and distributed it on different social media platforms in English. The questionnaire was modified to conform to previously published studies.^{10,12,15–18}Three experts in family medicine, medical education and public health reviewed the questionnaire’s format and content to determine its relevance, clarity, adequacy, and relevancy. There are five main sections. The first asks participants to describe their demographic characteristics. This includes gender, age and year of study. The second part is the Kessler Psychological Distress Scale (K10), which assesses the students’ stress levels.^16; It involves 10 questions on emotional states, each with a five-level response scale (from one being “never” to 5 being “always”). The third part evaluates the sources of stress. This includes academic, psychological and health-related stress. The fourth part examines the effects of this stress. Finally, the fifth part discusses students’ suggestions and solutions for stress. The questions in the third, forth, and fifth parts were composed of different statements inspired by previous studies.^{10,12,15–18}A panel of experts comprising three assistant professors in family medicine, medical education and public health reviewed the draft for accuracy, relevance, clarity and adequacy. The participants’ opinions of these questions for each section were measured using a 3-point Likert scale (“disagree,” “natural,” and “agree”). The reliability of the questionnaire items was tested using Cronbach’s test and they were observed to be reliable, with a minimum reliability score of 0.68 for “(nominate a question)” and a maximum of 0.82 for “(nominate another question).”

Statistical Analysis

After collecting data from those who met the eligibility criteria, we coded the data to feed it into IBM SPSS version 22. Microsoft Excel was used to create graphs. All statistical analyses were done using two-tailed tests with an alpha error 0.05. P 0.05 was considered statistically significant. Frequency and percentages were used to describe the frequency distribution of students’ demographic data, stressors, stress levels, impacts, and suggestions to minimize stress. To assess stress levels, the K10 score was used. The sum of the scores for each of the 10 items was used to determine the level of stress. It can be either a minimum of 10 or a maximum score of 50. Low scores can indicate low levels of psychological distress and vice versa. The overall score is categorized as normal (10–19 points), mild stress (20–24), moderate stress (25–29), and severe stress (30–50). Cross-tabulation was done between various student-related factors and stress levels to identify the most significant stress determinants. This was done using the Pearson chi-square or exact probability tests (for small frequencies).

Results

Participant Characteristics

Table 1 shows participant characteristics. The survey included 572 medical student who completed the questionnaire. Their ages ranged from 18 to 25, with a mean age of 21.9 ± 3.5 years. 52.1% of respondents were females. 36% of respondents were in their second year, with 24.7% in the first year, 29.4% the fourth year and 10% in fifth year. Participants had an average monthly income of 84.3%.

Table 1Saudi Arabia: Undergraduate Medical School Student Characteristics

K10 Questionnaire and Stress Presence

We performed the stress assessment (Table 2) using the Kessler10 Psychological Distress instrument. Of the students, 98.6% felt nervous during MBBS courses; 108 students reported this feeling as “always” occurring, 191 students reported it as occurring “most” of the time, and only 80 students reported it “seldomly.” Of the students, 94.8% felt tired for no good reason, including 57 students who reported this fatigue as “always” occurring, 180 students who reported it “most” of the time, and 109 students who reported it “seldomly.” Of the participants, 93.7% felt that everything was an effort, 90.4% felt restless or fidgety, 88.3% felt depressed, 81.5% felt so sad that nothing could cheer them up, 79.2% felt so nervous that nothing could calm them down, and 68.7% felt worthless. 18.9% had mild stress, 17.1% had medium stress, and 46.5% had serious stress.

Table 2Stress Level Assessment for Bachelor of Medicine and Master of Surgery Students

Stress Management: Personal Sources

The most commonly cited academic sources of stress are (Table 3Self-study strategy problems (58.4%), difficulty in reading textbooks (58%), dissatisfaction at exam performance (50.5%), concern about future career prospects (49%). The most common psychological stressors were lack of time management (56.5%), dissatisfaction with exam performance (50.5%), and inability to overcome distractions (36.4%). As for health-related stress sources, 51.7% reported difficulty sleeping. This was followed by depression (43.2%) as well as poor food quality (29.2%) and chronic health problems (16.3%). Uncomfortable classroom chairs were the most popular environmental source (61.4%). This was followed by unclean classrooms (33.5%), overcrowded classrooms (39.5%), and poor ventilation (34.3%).

Table 3Personal Stress Sources for Bachelor of Medicine and Master of Surgery Students

Stress has a negative impact

The most commonly reported stress-related effect is (Figure 1Anxiety (62.9%) was followed by mood swings (60%), impaired educational performance (51.9%) and insomnia (35.8%), thoughts about changing specialties (27.3%) and bioconcentration (27.1%). The least reported was developing mental disorders (4.7%).

Figure 1Stress can have a negative effect on the performance of Bachelor of Medicine and Bachelor of Surgery Students

Suggested Solutions

Table 4Shows the solutions students suggested to manage stress during the MBBS program. A mere 71.9% of students considered creating a supportive learning environment acceptable or excellent for stress management. 76% also suggested that struggling students be identified and given individual support. Additionally, 79.9% of students considered it acceptable or excellent for teachers for creating a supportive learning atmosphere. 73.6% suggested teaching stress management skills to students and promoting self-awareness. 72.2% suggested encouraging students and their families to get enough sleep and regular exercise.

Table 4Stress Management: Suggestions and solutions

Association between Stress and Study Variables/Somodemographic Data

Table 5 Figure 2During the MBBS course, the determinants behind stress in medical school were demonstrated. The statistical significance of the findings (P = 0.001) was that severe stress was detected in 60.7% of female students, and 31% among male students. The most severe stress levels were found in students who did not have sufficient learning resources (68.8%), followed closely by those who complained about the difficulty of learning strategies, teaching, and assessment strategies (64.1%) and those who had difficulties with the teaching style (57.4%). Students who were assigned tasks with statistically significant differences (P = 0.011) had the lowest levels of stress. Other associations between variables can be seen in Table 5. As shown in, there are no significant associations between stress levels (P = 0.085), and other sociodemographic data (P = 0.156). Table 5.

Table 5The Determinants of Stress in Bachelor of Medicine and Bachelor of Science Students

Figure 2Distribution of severe stress levels among most-reported stressors

Discussion

Stress levels

According to the K10 scores, nearly half (46.5%) were severely distressed. Previous studies have shown that medical students experience high levels of stress, especially in their first year. However, this decreases over time.^2,5Our results were similar (48.6%) to those of a Malaysian university.¹⁷However, it showed lower stress levels that local universities: King Saud University Riyadh 78.7%).¹¹Imam Abdulrahman Bin Faisal University Dammam (82.6%).⁵This could be because of the different stress-assessment methods used or because UQU is higher up in ranking than UQU. Students may feel more pressure to maintain high rankings and reach their goals. The high levels of stress among UQU medical students may be related to the university’s recent changes in applying the new MBBS curriculum, teaching, and assessment methods. This update has made the educational experience more enjoyable for students, lecturers, staff, and lecturers. However, it also brought new challenges that could increase stress. Stress could be caused by the new MBBS curriculum which consists of integrated modules that are taught in different departments. This structure encourages students to be more independent in their studies and in linking medical information together, increasing the student’s workload. This is in line with previous studies that investigated the impact of curriculum changes on medical students’ stress.^18,19Continuous training workshops in learning and studying skills can help students to acquire the skills they need and reduce stress.

Stress Relief: Personal Sources

The students revealed stressors regarding self-study strategy issues, followed by difficulty in reading textbooks; therefore, a learning skills course should be developed to address students’ needs and prepare them for new environments and challenges. A UQU College of Medicine study found that most students understand the importance of taking a learning skill course to help them navigate university life.¹⁰The present study adds some environmental stressors to the mix, such as uncomfortable chairs and unclean and poorly ventilated classrooms. Recent systematic reviews have shown that stress is linked to a less positive learning environment.²⁰UQU College of Medicine should therefore use techniques to address these problems. Developing and enhancing the college building may decrease students’ stress. Many studies have also shown that stress can cause psychological and health problems such as sleeplessness and depression.^11,15,21,22

Predictors of stress

Our study found a statistically significant correlation between severe stress levels and female gender. This is consistent with other studies that have shown that female medical students are more likely to experience high levels of stress.^{11,12,15,23,24} This might be due to the effect of gender differences in perceived stress and coping, as the genders are physiologically different.²⁵However, other studies did not show a significant association between stress levels and gender.^2,26,27This disagreement could be due to differences in stress assessment methods or learning environments. However, more research is needed to examine this relationship. The current study found no significant relationship between stress levels and income or age. This is in line with other studies that found no significant association between stress levels and income levels of medical students.^2,27,28,29This is in contradiction with other studies that have shown that financial status and age can influence stress severity.^30–32 This disagreement might be explained by the fact that most participants in the present study are from a younger-generation age group (19–25 years) and about 84% of them are on an average monthly income.

The most stressful aspects of the MBBS curriculum were found to be related to a lack of learning resources. This was followed by unclear teaching, learning and assessment strategies. The lack of clarity and guidance can explain our findings. One reason is the focus of the new curriculum, which encourages medical students to use textbooks and understand the information without “spoon feeding.” It is worth mentioning that a previous study, conducted at UQU College of Medicine in 2010 during the period of the traditional curriculum, showed that medical students ranked peer competition (followed by poor English language skills) as the most difficult aspect during the MBBS course.¹⁰These factors are not causing stress at the moment, as English language teaching has improved.

The current study found that fifth-year students were more likely to experience severe stress levels in MBBS courses (batch36, 2016) than second-years (batch39, 2019). A study in the United States showed that third-year students were at greater risk for depression and perceived stress than first-year students.¹¹A second study by the College of Medicine of King Saud University showed that stress levels declined as students progressed through the academic year.²This discrepancy could be explained by several factors. First, our study was completed during the coronavirus pandemic (COVID-19), which saw school suspend at the beginning and end of the second semester. Hence, second-year students did not complete the entire year’s experience and the comprehensive exams. The fifth-year students were also the first to learn the new MBBS curriculum at UQU College of Medicine. This added pressure on them. The second-year students, on the other hand, are the fourth batch to learn the new curriculum. The fifth-year students are close to graduation, so they are more likely work hard on the requirements for the Saudi Commission for Health Specialties. This adds to their pressure to get accepted for postgraduate programs.

Stress has a negative impact

Our study shows that anxiety was the most prevalent stress symptom among medical student (62.9%). Next were mood swings (60%), impaired performance (51.9), insomnia (35.5%), thoughts about changing specialties (27.3%), poor concentration (27.1%). These results are similar to many other studies.^32,33Studies by Lakhiar et. al.³⁴ Yadav et al³⁵Inam et.al³⁶It was found that medical students have higher levels of anxiety than students of other specialties. A study in India found that medical students with high levels of stress have low concentration (86%) as well as mood changes (80%). These statistics are much higher than ours.³⁷This could be due to differences between the study curriculum and their lifestyles. A Riyadh study found that medical students are highly stressed. There was also a significant correlation between high stress levels and low GPAs (P = 0.01).²⁷Another study from Rabigh showed similar results: Students with high stress scored lower than those with low stress.³In Pakistan, a study that looked at stress and academic performance showed an inverted correlation. Higher stress equals lower academic performance.³⁶This could be because stress can lead to overthinking, which can affect preparation and concentration during study, and decrease sleep quality. Almojali and colleagues found that stress levels were associated with poor quality sleep, which was correlated with lower GPA.²⁶ Unfortunately, there is no specific study focused on medical students’ thoughts on changing specialties, but a similar study, involving medical students and residents, found that 12.1% of participants thought about withdrawing from medical school.³⁷

Limitations, Strengths and Recommendations

This study examines stress and learning environment among medical students in UQU’s new MBBS program from novel and multifaceted perspectives. Our study has some limitations. First, it is possible that the shared-method bias was present because medical students were the only reporters of all study variables. A self-report survey, however, was the only data collection tool. The second is that the present study’s data is perception-based and was collected during the COVID-19 epidemic, which poses more challenges for medical students. Despite these limitations, our study’s findings emphasize the presence of high stress levels among medical students at UQU and clarify the aspects needing improvement within the learning environment. It also sheds light upon the problems students face in medical school and suggests solutions. We recommend that further research be done on female medical students in order to identify possible causes of their stress levels. To understand the causes of the severe stress levels observed in fifth-year medical students and to plan interventions to help them cope with future challenges, further follow-up studies are needed. The COVID-19 pandemic could have influenced students’ responses. Therefore, future investigations should be conducted in more favorable circumstances.

Conclusion

According to the current study, medical students are subject to high levels of stress. This can lead to a decrease in resilience, academic burnout, and maladaptive stress coping mechanisms. Professors and universities need to be aware of potential stressors and offer support to students in overcoming them. Students can also benefit from counseling services offered by universities. Another solution to this problem is to make stress-management training a mandatory part of the medical curriculum that students cannot skip due to academic pressure. It might be worth considering extracurricular activities like arts and music or physical activities.

Changes to the MBBS curriculum may be responsible for stress levels rising. The current study found a statistically significant relationship between severe stress levels and a dearth of learning resources, along with complaints about unclear teaching. It may be worth considering orientation programs for staff and students each year to increase their knowledge and awareness about the program structure, assessment methods, learning styles, and resources. In addition, improving the learning resources—particularly the library services—will help students see their accomplishments in a more positive light and help protect them from academic burnout.

Data Sharing Statement

The article includes the original contributions made to the study. You can contact the corresponding author for further inquiries.

Ethical Approval

Ethical approval was obtained from the Biomedical Ethics Committee of the Faculty of Medicine at Umm Al-Qura University (approval number HAPO-02-K-012-2020-08-430) and was conducted in accordance with the Declaration of Helsinki. Before each participant answered the questionnaire, they were required to provide electronic informed consent. Participants were protected from any unauthorized access. Participants were not asked for their names or telephone numbers.

Acknowledgment

We would like to express our gratitude to the Umm Al-Qura University medical students who generously answered the study’s questionnaire.

Contributions from Authors

All authors made significant contributions to conception, design, acquisition of or analysis and interpretation data.

Disclosure

This work is free of conflicts of interest according to the authors.

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