essay on university stress

Stress in College Students: What to Know

Strong social connections and positive habits can help ease high levels of stress among college-age adults.

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From socializing to working out, here's how college students can better manage stress.

From paying for school and taking exams to filling out internship applications, college students can face overwhelming pressure and demands. Some stress can be healthy and even motivating under the proper circumstances, but often stress is overwhelming and can lead to other issues.

"Stress is there for a reason. It's there to help mobilize you to meet the demands of your day, but you're also supposed to have times where you do shut down and relax and repair and restore," says Emma K. Adam, professor of human development and social policy at Northwestern University in Illinois.

Chronic and unhealthy levels of stress is at its worst among college-age students and young adults, some research shows. According to the American Psychological Association's 2022 "Stress in America" report , 46% of adults ages 18 to 35 reported that "most days they are so stressed they can't function."

In a Gallup poll that surveyed more than 2,400 college students in March 2023, 66% of reported experiencing stress and 51% reported feelings of worry "during a lot of the day." And emotional stress was among the top reasons students considered dropping out of college in the fall 2022 semester, according to findings in the State of Higher Education 2023 report, based on a study conducted in 2022 by Gallup and the Lumina Foundation.

As students are navigating a new environment and often living independently for the first time, they encounter numerous opportunities, responsibilities and life changes on top of academic responsibilities. It can be sensory overload for some, experts say.

“Going to college has always been a significant time of transition developmentally with adulthood, but you add to it everything that comes along with that transition and then you put onto it a youth mental health crisis, it’s just compounded in a very different way," says Jessica Gomez, a clinical psychologist and executive director of Momentous Institute, a researched-based organization that provides mental health services and educational programming to children and families.

Experts say college students have experienced heightened stress since the COVID-19 pandemic, a trend likely to continue for the foreseeable future.

“What some of our research at Gallup has shown is that we had a rising tide of negative emotions, not just in the U.S. but globally, in the eight to 10 years leading up to the pandemic, and of course it got worse during the pandemic," says Stephanie Marken, senior partner of the education research division at Gallup who conducted the 2023 study. “For currently enrolled college students, there’s so many contributing factors.”

Adam notes that multiple factors combine to contribute to heightened stress among younger adults, including the nation’s racial and political controversies, as well as anxiety regarding their futures fueled by climate change, global unrest and economic uncertainty. Female students reported higher levels of stress than males in the Gallup poll, which Marken says could be attributed to several factors like increased internal academic pressure, caregiving responsibilities and the recent uncertainty regarding abortion rights following the reversal of Roe v. Wade.

All of this, plus the residual effects of pandemic learning, has contributed to rising stress for college students, Marken says.

"We need to give them a lot of credit," she says. "They had the most challenge in remote learning of all the learners that have come before them. Many of them had to graduate high school and study remotely, or were a first-year college student during the pandemic, and that was incredibly difficult."

The challenges that came with that learning environment will likely affect students throughout college, she says, as well as typical stressors like discrimination, harassment and academic challenges.

"Those will always be present on college campuses," she says. "The question is, how do we create a student who overcomes those challenges effectively?"

Experts suggest a range of specific actions and positive shifts that can help ease stress in college students:

• Notice the symptoms of heightened stress.
• Build and maintain social connections.
• Sleep, eat well and exercise.

Notice the Symptoms of Heightened Stress

College students can start by learning to identify when normal stress increases to become unhealthy. Stress will appear differently in each student, says Lindsey Giller, a clinical psychologist with the Child Mind Institute, a nonprofit focused on helping children and young adults with mental health and learning disorders.

"Students prone to anxiety may avoid assignments as well as skip classes due to experiencing shame for being behind or missing things," she says. "For some, they may also start sleeping in more, eating at more random times, foregoing self-care, or look to distraction or escape mechanisms, like substances, to fill time and further avoid the reality of workload assignments."

Changes in diet and sleeping are also telling, as well as increased social isolation and pulling away from activities that once brought you pleasure is also a red flag, Gomez says.

She warns students to watch for signs of irritability, a classic indicator of increased stress that can often compound issues, especially within interpersonal relationships.

"Your body speaks to you, so be in tune with your body," she says.

Build and Maintain Social Connections

Socializing can help humans release stress. Experts say having fun and finding joy in life keep stress levels manageable, and socializing is particularly important developmentally for young adults. In the 2023 Gallup poll, 76% of students reported feeling enjoyment the previous day, which Marken says was an encouraging sign.

But 39% reported experiencing feelings of loneliness and 36% reported feeling sad. “We are in the midst of an epidemic of loneliness in our country, where we are noticing people don’t have the skills to build friendships,” Gomez says.

Discover six

Talking about feelings of stress can help college students cope, which is why the amount of students feeling lonely is concerning, Marken says. If students don't feel like they belong or have a social network to call on when feeling stressed, negative emotions are compounded.

“I think we’re more connected, and yet we’re more isolated than ever," she says. "It feels counterintuitive. How can you be more connected to your network and campus than ever, yet feel this lonely? Just because they have a device to connect with each other in a transactional way doesn’t mean it’s a meaningful relationship. I think that’s what we’re missing on a lot of college campuses is students creating meaningful connections about a shared experience."

Setting boundaries on social media use is crucial, Gomez says, as is getting plugged in with people and organizations that will be enriching. For example, Gomez says she joined a Latina sorority to be in community with others who shared some of her life experiences and interests.

Sleep, Eat Well and Exercise

Maintaining healthy habits can help college students better manage stressors that arise.

"Prioritizing sleep, moving your body, getting organized, and leaning on your support network all help college students prevent or manage stress," John MacPhee, CEO of The Jed Foundation, a nonprofit that aims to protect emotional health and prevent suicide among teens and young adults, wrote in an email. "In the inevitable moments of high stress, mindful breathing, short brain breaks, and relaxation techniques can really help."

Experts suggest creating a routine and sticking to it. That includes getting between eight and 10 hours of sleep each night and avoiding staying up late, Gomez says. A nutrient-rich diet can also go a long way in maintaining good physical and mental health, she says.

Getting outdoors and being active can also help students limit their screen time and use of social media.

“Walking to campus, maybe taking that longer walk, because your body needs that to heal," Gomez says. "It’s going to help buffer you. So if that’s the only thing you do, try to do that."

Colleges typically offer mental health resources such as counseling and support groups for struggling students.

Students dealing with chronic and unhealthy stress should contact their college and reach out to friends and family for support. Reaching out to parents, friends or mentors can be beneficial for students when feelings of stress come up, especially in heightened states around midterm and final exams .

Accessing student supports and counseling early can prevent a cascading effect that results in serious mental health challenges or unhealthy coping mechanisms like problem drinking and drug abuse , experts say.

"Know there are lots of resources on campus from academic services to counseling centers to get structured, professional support to lower your workload, improve coping skills, and have a safe space to process anxiety, worry, and stress," MacPhee says.

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Risk factors associated with stress, anxiety, and depression among university undergraduate students

Mohammad mofatteh.

1 Lincoln College, University of Oxford, Turl Street, Oxford OX1 3DR, United Kingdom

2 Merton College, University of Oxford, Merton Street, Oxford OX1 4DJ, United Kingdom

3 Sir William Dunn School of Pathology, University of Oxford, South Parks Road, Oxford OX1 3RE, United Kingdom

It is well-known that prevalence of stress, anxiety, and depression is high among university undergraduate students in developed and developing countries. Students entering university are from different socioeconomic background, which can bring a variety of mental health risk factors. The aim of this review was to investigate present literatures to identify risk factors associated with stress, anxiety, and depression among university undergraduate students in developed and developing countries. I identified and critically evaluated forty-one articles about risk factors associated with mental health of undergraduate university students in developed and developing countries from 2000 to 2020 according to the inclusion criteria. Selected papers were analyzed for risk factor themes. Six different themes of risk factors were identified: psychological, academic, biological, lifestyle, social and financial. Different risk factor groups can have different degree of impact on students' stress, anxiety, and depression. Each theme of risk factor was further divided into multiple subthemes. Risk factors associated with stress, depression and anxiety among university students should be identified early in university to provide them with additional mental health support and prevent exacerbation of risk factors.

1. Introduction

Mental health is one of the most significant determinants of life quality and satisfaction. Poor mental health is a complex and common psychological problem among university undergraduate students in developed and developing countries [1] . Different psychological and psychiatric studies conducted in multiple developed and developing countries across the past decades have shown that prevalence of stress, anxiety, and depression (SAD) is higher among university students compared with the general population [2] – [4] . It is well established that as a multi-factorial problem, SAD cause personal, health, societal, and occupational issues [5] which can directly influence and be influenced by the quality of life. The level of stress cited in self-reported examinations and surveys is inversely correlated with life quality and well-being [6] .

Untreated poor mental health can cause distress among students and, hence, negatively influence their quality of lives and academic performance, including, but not limited to, lower academic integrity, alcohol and substance abuse as well as a reduced empathetic behaviour, relationship instability, lack of self-confidence, and suicidal thoughts [7] – [9] .

A 21-item self-evaluating questionnaire, Beck Depression Inventory (BDI), is the most common tool used for diagnoses of depression [10] . A BDI-based survey in five developed countries in Europe (European Outcome of Depression International Network-ODIN in the United Kingdom, Netherlands, Greece, Norway, and Spain) concluded that overall 8.6% (95% CI, 7.95–10.37) of the resident population are dealing with depression [11] . Similar studies confirmed that about 8% of the population in developed and developing countries suffer from depression [12] . Data from systematic review studies revealed that this depression rate is much higher among university students and around one third of all students in the majority of the developed countries have some degree of SAD disorders; and depression prevalence has been increasing in academic environments over the past few decades [3] .

Despite all the efforts to increase awareness and tackle mental health problems among university students, there is still an increasing number of depression and suicide among students [13] , indicating a lack of effectiveness of the measures adopted. In addition to an increase in the prevalence of mental health issues, comparing students and non-college-attending peers demonstrated that the severity of psychological disorders that students receive treatment for has also increased [14] . For example, the rate of suicide among adolescents has increased significantly over the past few decades [15] . In fact, suicide as a result of untreated mental health is the second cause of death among American college students [16] , emphasizing the importance of identifying and treating risk factors associated with SAD.

SAD can be manifested in different forms; however, some common overt symptoms include loss of appetite, sleep disturbance, lack of concentration, apathy (lack of enthusiasm and concern), and poor hygiene. Studying SAD is particularly important among university students who are future representatives and leaders of a country. Furthermore, most undergraduate students enter university at an early age; and dealing with SAD early in life can have long-term negative consequences on the mental and social life of students [3] . For example, a longitudinal study in New Zealand over 25 years demonstrated that depression among people aged 16–21 could increase their unemployment and welfare-dependence in long-term [17] .

A better understanding of SAD among students in developed and developing countries not only helps governments, universities, families, and healthcare agencies to identify risk factors associated with mental health problems in order to minimise such risk factors, but also provides them with an opportunity to study how these factors have been changing in the academia.

This review aims to provide an updated understanding of risk factors associated with SAD among post-secondary undergraduate and college students in developed and developing countries by using existing literature resources available to answer the following question:

“Aetiology of depression and anxiety: What are risk factors associated with stress, anxiety and depression among university and college undergraduate students studying in developed and developing countries?”

It is worth mentioning that this review focuses on SAD risk factors of university students in developed and developed countries, and does not cover underdeveloped countries which can have their own niche problems (such as poverty). However, this review takes into account international students who migrate from underdeveloped countries to developed and developing countries to pursue their education.

2.1. Aims and objectives

The aims of this review were to identifying principal themes associated with depression and anxiety risk factors among university undergraduate students. The objectives of this review are to design a rigorous searching methodology approach by using appropriate inclusion and exclusion criteria, to conduct literature searches of publicly available databases using the designed methodology approach, to investigated collected literature resources to identify risk factors associated with the depression and anxiety which have not changed, and to identify principal themes associated with SAD risk factors among university undergraduate students.

2.2. Designed approach for literature review

A narrative review based on a comprehensive and replicable search strategy is used in this review. This approach is justified and preferred, over other approaches such as primary data gathering, because of the timescale of the research (2000 to 2020-temporal reasons), and extent of the research (developed and developing countries-spatial reasons).

2.3. Criteria for inclusion and exclusion of articles

Inclusion and exclusion criteria for articles and academic writings used in this review are as follows:

2.3.1. Date

2000 to 2020 are included Academic writings which are published between in this review. Initially, during a pilot search, search strategies covered 1990 to 2020. However, the majority of the search results (more than 80% of the search results and more than 88% of applicable search results) were from 2000 to 2020, which indicates the importance of mental health issue and increased awareness over the past two decades. Therefore, for the final search, papers from 2000 to 2020 were included.

2.3.2. Study design

Literatures included in this narrative review were primary research articles, review articles, systematic reviews, mini-reviews, opinion pieces, correspondence, clinical trials, and cases reports published in peer reviewed journals.

2.3.3. Country

The narrative review was limited to developed and developing countries definition by the United Nations Department of Economic and Social Affairs [18] . Abstract and method sections of search results were screened to check the country of research.

2.3.4. Language

Peer-reviewed articles published in English were only included in this narrative review.

2.3.5. The explanation for papers exclusion

The main reason for papers excluded from consideration after search results was that they focused on intervention and therapies associated with SAD. Other reasons for exclusion was that studies were conducted on a mixture of undergraduate and graduate students or focused solely only graduate students. Studies which focused on other types of mental disorders such as eating disorders but did not focus on SAD were excluded too. The conducted search did not exclude any gender or specific age category.

2.4. Strategies used for search and limitations

In this review, a robust and replicable search strategy was designed to identify appropriate articles by searching PubMed, MEDLINE via Ovid, and JSTOR electronic databases. These databases were selected because they encompass biopsychosocial papers published on SAD. The date chosen for this search was for articles published between 2000 to 2020 which covers the past two decades. Once key articles were identified, a search for citation of those papers was conducted, and the bibliography of those papers were further screened to identify potential articles which can be relevant.

2.5. Search terminologies used

To conduct searches in databases mentioned above, the following search terms were used: students stress, anxiety, depression risk factors, university stress, anxiety, depression risk factors, student mental health developed and developing countries, students stress, anxiety and depression developed and developing countries. The operation AND was used to connect stress, anxiety, depression, mental health, developed, developing, countries, students. The search for each term was conducted in all fields (title, abstract, full text, etc.).

2.6. Screening, selecting search results, and data extraction

The search results were exported into separate Excel and EndNote X8 files. Titles and abstracts from all articles were screened to determine their relevance to the topic of this review. Potentially relevant articles were fully read to establish their relevance. Each paper which was included according to the inclusion criteria described above was read fully. A word file was created to identify themes associated with SAD risk factors which is included in the Results. An initial search resulted in 1305 articles. The title and abstract of individual papers were read for relevance, resulting in 60 papers which were relevant for the research question asked in this review. All 60 papers were read completely, and from those, 19 were excluded based on the criteria mentioned before. Therefore, the total number of papers for consideration was 41. A flowchart explaining the procedure for identification, screening, eligibility, and inclusion of papers is shown in Figure 1 .

Figure 2 provides a quantitative summary of the papers included in this narrative review. In terms of the distribution of the countries where the research was conducted, included papers were mainly articles which carried out studies in the USA (n = 17), followed by China and Canada (each n = 5), UK (n = 4), Japan (n = 3), Germany and Australia (each n = 2), South Korea, Hungary, Switzerland (each n =1) ( Figure 2A ). As for article types included in this review, original research articles, including quantitative and qualitative studies, which relied on obtaining data including cross-sectional studies, interviews, case-control studies, surveys, and questionnaire, were the highest (n = 37) followed by meta-analysis, literature and systematic reviews ( Figure 2B ). Another interesting observation was that although the search was carried out from 2000–2020, most papers were concentrated in the period from 2016 to 2020 ( Figure 2C ). This can be due to the reason that mental health is becoming more important over the past few years. Alternatively, a higher number of papers included from 2016 onward can be due to unintended selection bias. The smallest study covered in this narrative review was conducted on 19 students and the largest one on 153,635 students, adding up to 236,104 students, who were included in articles covered in this narrative review in total. Most studies on mental health, anxiety, and depression use standardised approaches such as patient-filled general health questionnaires, Pearling coping questionnaire, internally regulated surveys, BDI, DSM-IV symptomology, and general anxiety and burnout scales such as Maslach Burnout Inventory.

3.1. Literature search results

Following the search protocol shown in Figure 3 , a list of included papers identified which can be found in the Table 1 .

3.2. Prevalence of mental health disorders in students

Literature showed that mental health problems are common phenomenon among students with a higher prevalence compared to the general public. For example, surveying more than 2800 students in five American large public universities demonstrated that more than half of them experienced anxiety and depression in their last year of studies [19] . Similarly, a survey of Coventry University undergraduate students in the UK showed that more than one-third of them had experienced mental health issues such as anxiety and depression over the past one year since they were surveyed [20] . In agreements with these results, Maser et al. [21] found that prevalence of mental health disorders including anxiety and depression was higher among medical students compared to the general non-student population of the same age. These studies demonstrated that the prevalence of SAD among students has remained higher than the average population over the past two decades.

SAD are not only prevalent among students, but also persistent. By conducting a follow-up survey study of students over two years, Zivin et al. [19] demonstrated that more than half of students retain their higher levels of anxiety and depression over time. This can be due to a lack of SAD treatment or persistence of existing risk factors over time.

3.3. Risk factors associated with stress, anxiety, and depression

SAD are multifactorial, complex psychological issues which can have underlying biopsychosocial reasons. Multiple risk factors which affect the formation of SAD among undergraduate university students in developed and developing countries were identified in this review. These factors can be categorized into multiple themes including psychological, academic, biological, lifestyle, social and financial. A summary of risk factors and their associated publications are shown in Table 2 .

3.3.1. Psychological factors

Self-esteem, self-confidence, personality types, and loneliness can be associated with SAD among university students. Students who have a lower level of self-esteem are more susceptible to develop anxiety and depression [22] . Also, students with high neuroticism and low extraversion in five-factor personality inventory [23] are more likely to develop SAD during university years [24] . Other psychological factors such as feeling of loneliness plays important roles in increasing SAD risk factors [24] . Moving away from family and beginning an independent life can pose challenges for fresher students such as loneliness until they adjust to university life and expand their social network. Indeed, Kawase et al. [24] showed that students who live in other cities than their hometown for studying purposes are more likely to develop anxiety and depression.

Some students enter the university with underlying mental conditions, which can become exacerbated as they transition into the independent life at university. While depression is higher among university and college students compared to the general public, students with a history of mental health problems, such as post-traumatic stress disorder (PTSD), are more prone to development of anxiety and depression during their university lives compared to students who did not have such experience before starting their degrees [25] . Furthermore, exposure to violence in childhood either at the household or the community correlates with SAD formation later in life and at University [26] . Therefore, low self-esteem and self-confidence, having an underlying mental health condition before beginning the university, personality type (high neuroticism and low extravasation), and loneliness can increase the probability of SAD formation in students.

3.3.2. Academic factors

Multiple university-related academic stressors can lead to SAD among students. One of these factors which was strongly present in many studies evaluated in this review was the subject of the degree. Medical, nursing, and health-related students have a higher prevalence of depression and anxiety compared to their non-medical peers [24] , [27] – [28] . Medical and nursing students who have both theoretical duties and patient-related work usually have the highest level of workload among university students, consequently deal more with anxiety and depression [27] , [29] . In addition, students who major in psychology and philosophy, similar to nursing and medical students, are more likely to develop depression during their studies compared to others [24] . These studies did not identify whether students who have underlying mental health conditions are more likely to choose certain subjects such as philosophy, psychology, or subjects which lead to caring roles such as nursing and medicine. Because of the nature of their work, medical and nursing students who deal with people's health can experience depression and anxiety as a result of fears of making mistakes which can result in harming patients [27] . Students with practical components in their degree are required to travel to unfamiliar places for fieldwork and work experience which can add to their stress and anxiety [27] .

Also, some prospective students, especially those who study nursing and medicine, usually do not have a clear understanding of the curriculum and workload associated with the subject before entering the university, therefore, they can face a state of disillusionment once they begin their studies at university [27] – [29] . It is worth mentioning that not all studies found a significant correlation between the subject of study and SAD development [30] . This can be explained by differences in sample type and size which results in variations existing in the amount of workload and curriculum in similar subjects taught in various universities in different countries.

Studying a higher degree can be a challenging task which requires mental effort. Mastery of the subject can negatively correlate with self-esteem, anxiety, and depression among university students with students who have a mastery of subject demonstrating a lower level of stress and anxiety [31] . Also, students who study in a non-native language report the highest level of anxiety and depression during their freshman years, and their stress levels decrease during the subsequent study years [32] . This can be explained by the fact that students who are studying in a foreign language usually are those who have migrated abroad, therefore, require some time to adjust to their new lives. Different studies showed that the level of anxiety and depression among both international and home students could correlate with the year of study with fresher students who enter the university and students at the final year of their studies experience the greatest amount of anxiety and depression with different risk factors [22] , [32] . While fresher students experience SAD because of challenges in adjustments to university life, past negative family experience, social isolation and not having many friends, final year students report uncertainty about their future, prospective employment, university debt repayment and adjusting to the life after university as major risk factors for their SAD [22] , [32] . Therefore, a shift in SAD risk factors themes are observed as students make a progress in their degrees.

Students spend a significant portion of their time at university being engaged with their academic activities, and unpleasant academic outcomes can influence their mental health. Receiving lower grades during the time of studies can negatively influence students' mental health, causing them to develop SAD [33] , [34] . Academic performance during undergraduate studies can determine the degree classification, which can, subsequently, influence students' opportunities such as employment success rate or access to postgraduate courses [27] . Conversely, both the number of students with mental health problem symptoms and the severity of students' SAD increase during exam time [35] , reflecting a direct relationship between academic pressure and students' mental health states. However, the causal relationship is not well-established; it is possible that depression and associated problems such as temporary memory loss and lack of concentration [36] are reasons for poor academic grades or inversely, students feel stressed leading to depression because of their poor performance in their exams. A mutual relationship can exist between grades and mental health, as having a poor mental health can reciprocally cause students to get lower grades [34] , leading to a vicious cycle of mental health and academic performance. Interestingly, students' sense of social belonging and coherence to the university community was reduced during exam periods [35] . This can be explained by the reduced participation rate of students in university social activities and clubs as well as an increased sense of competition with their peers. Furthermore, students interact directly and indirectly with teachers, lecturers, tutors, and other staff; therefore, the relationship between students and academic staff can influence students' mental health. A negative and abusive relationship with teachers and mentors can be another factor causing SAD among undergraduate students [27] .

On the other hand, being a part-time student is a protective factor for anxiety and depression, and part-time students have better mental health compared to students with full-time status [34] . This can be explained by financial securities which have a source of income can bring or because part-time students are usually older than full-time students [34] , and therefore, more emotionally stable. In conclusion, risk factors increasing SAD among university students include high workload pressure, fear of poor performance in exams and assessments, wrong expectations from the course and university, insufficient mastery in the subject, year of study, and a negative relationship with academic staff.

3.3.3. Biological factors

Mental health can be influenced by ones' physical health. Presence of an underlying health condition or a chronic disease before entering the university can be a predictor of having SAD during university years [31] , [33] . Students with physical and mental disabilities can be in a more disadvantaged position and do not fully participate in university life leading to SAD formation [33] .

An association between gender and depressive disorders have been observed in several studies [21] , [27] , [34] , [37] . Female students had a higher prevalence of SAD compared to male students. Interestingly, while female students demonstrated a higher level of SAD, the dropout rate of female students with a mental health problem from university was lower compared to their male counterparts [33] . On the other hand, while females are at a higher risk of developing depressive disorders, males with depressive disorders are less willing to seek professional help and ask for support due to the stigma attached to mental health [38] , causing exacerbation of their problem over time [20] .

Age can be another factor related to SAD. Younger students report a higher level of SAD compared to older students [34] , [37] . However, other meta-analysis studies did not find a significant correlation between students' age and their mental health which can be due to sampling differences [39] . Some studies showed that while older undergraduate students have a higher determination to do well in the university [40] , those who have family commitments are more prone to develop SAD during their degrees [27] . These discrepancies in findings can be explained by different sample sizes and types of studies which can be influenced by various confounding factors such as nationality, country of study, degree of studies, gender, and socioeconomic status. Similarly, a lack of correlation between depression prevalence and year of study is observed as some studies have reported a higher prevalence among earlier years of studies, while others have shown a higher prevalence among students as they move closer to the end of their studies [41] . These differences can be explained by different causes of depression in a different age; for example, while depression in younger adults can be due to changes in their environment and difficulties in adapting to a new life, older adults can have depression symptoms because of a lack of certainty for their future and employment. Nevertheless, differences exist between SAD risk factors associated with young and older students. Overall, biological risk factors affecting SAD include age of students, gender, and underlying physical conditions before entering the university.

3.3.4. Lifestyle factors

Moving away from families and beginning a new life requires flexibility and adaptation to adjust to a new lifestyle. As most undergraduate students leave their family environment and enter a new life with their peers, friends, and classmates, their behaviour and lifestyle change too. Multiple lifestyle factors such as alcohol consumption, tobacco smoking, dietary habits, exercise, and drug abuse can affect SAD. Alcohol consumption is high among students with SAD [28] ; a causal relationship was not been established in this study though.

Tobacco smoking is another risk factor associated with SAD which is common among students, especially students who study in Eastern developed and developing countries such as China, Japan and South Korea [24] , [42] . Most students, especially male students, smoke because of social bonding and the rate of social smoking is directly correlated with SAD [24] , [42] . Social smokers are less willing to quit smoking, and more likely to persist in their habit, resulting in long term negative physical and psychological health consequences [42] . Illegal substance abuse can be another factor important in SAD among young people [43] . Academic-related stress and social environment in university dormitories and student accommodations can encourage students to use illegal drugs, smoke tobacco and consume alcohol excessively as a coping mechanism, resulting in SAD [44] . Interestingly, students who perceived they had support from the university were feeling less stressed and were less at the risk of substance abuse [45] , indicating the important role of social support in preventing and alleviating depression symptoms. This is of particular importance as a new social habit and behaviour adapted early during life can last for a long time. Furthermore, students who do not have a healthy lifestyle can feel guilt, which can worsen their SAD condition [46] . Interestingly, Rosenthal et al. [47] showed that negative behaviours resulting from alcohol consumption such as missing the next day class, careless behaviour and self-harm, verbal argument or physical fight, being involved in unwanted sexual behaviour, and personal regret and shame could be the main reasons for depression associated with drinking alcohol, rather than the amount of alcohol consumed.

In contrast, a moderate to vigorous level of physical activity can be a protective factor against developing SAD during university life [37] , [48] . Students who have a perception of having inadequate time during their studies do not spend enough time for exercise and can develop SAD symptoms [27] .

Another lifestyle-related risk fact associated with SAD is sleep. Many young people do not receive sufficient sleep, and sleep deprivation is a serious risk factor for low mood and depression [28] , [47] . Self-reported high level of stress and sleep deprivation is common among American students [31] , [49] . Insufficient sleep can act as a vicious cycle- academic stress can cause sleep deprivation, and insufficient sleep can cause stress due to poor academic performance since both sleep quality and quantity is associated with academic performance [28] . Overall, poor sleeping habit is associated with a decreased learning ability, increase in anxiety and stress, leading to depression.

Different negative lifestyle behaviours such as tobacco smoking, excessive alcohol consumption, unhealthy diet, lack of adequate physical activity, and insufficient sleep can increase the risk of SAD formation among university students.

3.3.5. Social factors

Having a supportive social network can influence students' social and emotional wellbeing, and subsequently lower their probability of having anxiety and depression in university [27] , [37] , [50] . The quality of relationship with family and friends is important in developing SAD. Having a well-established and supportive relationship with family members can be a protective factor against SAD development, which, in turn, can affect the sense of students' fulfilment from their university life [27] . The frequency of family visits during university years negatively correlates with SAD development [33] . Family visits can be more challenging for international students who live far away from their families, therefore adding to existing problems of international students who live and study abroad.

In contrast, having a negative relationship with family members, especially parents, can cause SAD formation among students in university [51] . Similarly, having a strict family who posed restrictions on behaviours and activities during childhood can be a predictor of developing SAD during university years [51] .

Also, it is shown that being in a committed relationship has a beneficial protective factor against developing depressive symptoms in female, but not male, students [52] . Interestingly, both male and female students who were in committed relationships reported a lower alcohol consumption compared to their peers who were not in committed relationships [52] .

Involvement in social events such as participating in sporting events and engaging in club activities can be a protective factor for mental health [32] , [37] . Assessing preclinical medical students' social, mental, and psychological wellbeing showed that while first year students demonstrate a decrease in their mental wellbeing during the academic year, they have an increase in their social wellbeing and social integration [53] . This can be explained by the time period required for fresher students who enter the university to adjust to the social environment, make new friends, and integrate into the social life of the university.

Access to social support from university is another factor which is negatively correlated with developing anxiety and depression [31] . It is worth mentioning that different universities provide different degrees of social support for students which can reflect on different anxiety and depression observed among students of different universities.

Importantly, sexual victimization during university life can be a predictor of depression. By surveying female Canadian undergraduate students, McDougall et al. [54] found that students who were sexually victimized and had non-consensual sex were at a higher chance of developing depression following their experience, emphasizing the importance of safeguarding mechanism for students at university campuses.

While the internet and social media can be great tools for maintaining a social relationship with classmates, pre-university friends and family members, it can have negative mental health effects. Excessive usage of social media and the internet during freshman year can be a predictor of developing SAD during the following years [55] . Students who have a higher dependence on the social media report a higher feeling of loneliness, which can result in SAD [56] . Students with internet addiction and excessive usage of social media are usually in first year of their degrees [55] , [56] which can reflect a lack of adjustment to university life and forming a social network. Also, students who use social media more often have a lower level of self-esteem and prefer to recreate their sense of self [56] , indicating an intertwined relationship between biopsychosocial factors in developing SAD among students.

Demographic status, ethnic and sexual minority groups including international Asian students, black and bisexual students were at an elevated risk of depression and suicidal behaviour [16] , [50] . The frequency of mental health is usually more common among ethnic minorities. For example, Turner et al. [20] showed that ethnic minority students report a higher level of anxiety and depression compared to their white peers; however, they do not ask for help as much. Other studies supported these findings by showing that students from ethnic and religious minorities, regardless of their country of origin and country in which they study, have a higher prevalence of anxiety and depression compared to their peers [50] . Also, students' expectations from university can be different among ethnic minorities students, and most of them do not have a sufficient understanding of the services that university can provide for them [40] .

Therefore, lack of support from family and university, adverse relationships with family, lack of engagement in social activities, sexual victimization, excessive social media usage, belonging to ethnic and religious minority groups, and stigma associated with the mental health are among risk factors for SAD in university students.

3.3.6. Economic factors

Students' family economic status can influence their mental health. A low family income and experiencing poverty can be predictors of SAD development during university years [22] , [50] , [57] , [58] . A higher family income can even ameliorate negative psychological experiences during childhood, which can have long-term negative consequences on the mental health of students once they enter university [57] . Also, experiencing poverty during childhood can have negative long-term consequences on adults, leading to SAD development during university life [58] .

Some students take up part-time job to partially fund their studies. Vaughn et al. [59] showed that relationship of employed students with their colleagues in the workplace could affect students' mental health; and those students who had a poor relationship with their colleagues had worse mental health. However, it is worth mentioning that a causal relationship was not established. It can be possible that students who have poor mental health cannot get along with their co-workers, resulting in an adverse working relationship.

Because of paying higher tuition fees and less access to scholarships and bursaries available, international students can have more financial problems, causing a higher degree of anxiety and depression compared to home students [60] .

Lack of adequate financial support, low family income and poverty during childhood are risk factors of SAD in students of undergraduate courses in developed and developing countries.

3.4. Stigma associated with mental health

While efforts have been put to reduce the stigma associated with receiving help for mental health problems, this still remains a challenge. For example, more than half of students who had SAD did not receive any help or treatment for their condition because of the stigma associated with mental health [19] , [61] . This is not related to the awareness of the availability of mental health resources which was ruled out by authors, as most of the students who did not receive any help for their mental health problem were aware of available help and support to them [19] .

Furthermore, the social stigma associated with receiving help for mental health problems was significantly associated with suicidal behaviour, acting as a preventive barrier to seek help (planning and attempt) [16] . Among students, those with a history of mental health problem such as veterans with PTSD are less likely to seek for help compared to non-veteran students [25] , making them more susceptible to struggling with untreated mental health.

4. Discussion

This review tried to identify and summarise risk factors associated with SAD in undergraduate students studying in developed and developing countries. The prevalence of SAD is high among undergraduate university students who study in developed and developing countries. Untreated SAD can lead to eating disorders, self-harm, suicide, social problems [28] . Similar to a complex society, differences exist among students leading to complicated risk factors causing SAD. Because different themes influencing SAD has been investigated as a distinct body of research by different literature, a concept map is created to demonstrate the relationship between various risk factors contributing to the development of SAD in undergraduate students in developed and developing countries. Figure 3 bridges risk factors concepts between different literature. For most students, entering university is a new step in their lives which is associated with certain challenges such as moving into independent accommodation, social identity, financial management, making decisions, and forming a social network. Different students have different needs depending on the stage of their degree, which needs to be fulfilled. For example, coping with a new university life style can be a challenging task for students who enter the university. This becomes more significant for students moving abroad for their studying who need to adapt to a new lifestyle, speak in a different language, and live away from their families. In agreement with this, different levels of anxiety and depression with different risk factors are observed among students as they progress in their degrees. On the other hand, students who are finishing their degrees can have SAD because of uncertainties about their future.

Students learn different modules in different degrees and have different abilities. Mastery of the subject can be a factor affecting students' sense of self-esteem, influencing their anxiety level and developing depressive symptoms. This partially can explain changes in risk factors observed as students' progress in their degrees. Final year students who adjust to the university environment and develop mastery in their subject can deal with academic pressure better compared to freshers who transform from secondary school life to university lifestyle.

Students can come with a varied and challenging background such as those who experienced household and domestic violence, sexual abuse, and child poverty which can make them susceptible to developing anxiety and depression once academic pressure is mounted. As universities are diverse environment which enrol students from different socioeconomic background and different cultures, universities need to identify risk factors for different students and have robust plans to tackle them to provide a fostering environment for future leaders of the society. Therefore, early mental health screening can help to identify those students who are at risk to provide them with special and additional mental health support. Students not only should be screened for their mental health state as they enter university, but also regular follow up check-ups should be conducted to monitor their conditions as they progress in their degrees to detect early signs of SAD.

University and academic staff can play a significant role in either exaggerating or ameliorating risk factors associated with anxiety and depression. While teachers and mentors can support students to cope with SAD, they can be a source of problem too by discriminating, bullying, and hampering students' progress.

Managing finance and expenses can be a challenging task for students who are stepping into an independent lifestyle and need to pay for their tuitions in addition to their maintenance fees. While some students have access to private funding, bursaries, and scholarships, other students receive loans which they need to pay back or have part-time jobs to meet their expenses. Students who work need to have a work-life balance and the time spent in their jobs can affect the quality of their education.

Fresher students try to establish their social network and might feel isolated, which can push them to excessive usage of social media to fill their social gap. While internet addiction and excessive usage of social media can have a negative impact on students' mental health, technology, such as mobile phone applications can be used in universities campuses to promote a healthier lifestyle and reducing risk factors among students. For example, many students refuse to receive face-to-face mental health counselling support during their anxiety and depression due to stigma associated with disclosure of mental health issues. Providing students with anonymized counselling services through mobile phone applications can be one way of delivering help to students at universities.

With the advent of social media platforms such as Facebook, Twitter, Instagram, TikTok, etc., more and more students rely on such networks for socialisation. While the internet and online platforms can have beneficial consequences for students, such as rapid access to a variety of online learning resources and keeping in contact with friends and families, excessive usage of social media and internet can have negative consequences on students' academic performance. A poor mental health state at the beginning of university life is a predictor of internet addiction later during the degree. Heavy reliance on the internet can be a coping mechanism for students with anxiety and depression to overcome their mental health problems.

As governments and educational bodies in developed and developing countries are emphasising recruitment of ethnic minority students to university to increase the range of equality and diversity among students, it is important to consider the mental health of those students in the university as well. Students in minority groups such as black, international Chinese and bisexual student report a higher level of anxiety and depression compared to other non-minority group students. This can be due to either pre-existing conditions which student experience before entering the university, and can be exacerbated during the university, or can be because of problems which can develop during university life.

Also, more mental health support is available in universities as the number of university students is increasing, and there is a better understanding of the importance of mental health in academia; however, the stigma associated with mental health has not changed proportionately.

While research and understanding of mental health have changed significantly over the past two decades and many more articles are present, risk factors associated with SAD remain unchanged.

One caveat with studies of mental health among student is that most studies have been conducted among medical and nursing students and neglected non-medical students. One potential explanation for the tendency to conduct depression surveys among medical students is the higher response rate as medical students are more willing to fill out the questionnaires and surveys. It is understandable that students studying medical subjects, who directly interact with the public and treating them once they enter the healthcare profession should have a reasonably sound mental health to be able to conduct their duties, but it does not justify neglecting the mental health of other students. Therefore, more research on mental health and risk factors associated with SAD of non-medical students is required in the future.

Another caveat with most mental health studies is that they are based on self-reports and surveys. Different people can have different perception and understanding of mental health and anxiety, and many confounding factors can influence the response of participants in the time of participation. Furthermore, students with severe mental health conditions are less likely to participate in any activity including surveys and questionnaires, leading to a non-response bias.

Another area which requires improvement in future studies of mental health is the categorisation of different types of depression and their severity. Depression and anxiety are a spectrum which can comprise of minor and major symptoms; however, most studies did not specify the scale of depression in their findings. Furthermore, while various risk factors were identified, a causal relationship between mental health and behaviours were not established.

While counselling services provided by universities in Western countries such as the UK and USA have increased over the past few years [62] , it is still not clear how effective such services are; therefore, more research is required to assess the effectiveness of counselling services at universities.

Therefore, a better understanding of the aetiology, associated factors is required for an effective intervention to reduce the disease incidence and prevalence among students in the population and providing them with a fostering environment to achieve their potential.

University undergraduate students are at a higher risk of developing SAD in developed and developing countries. Promoting the mental health of students is an important issue which should be addressed in the education and healthcare systems of developed and developing countries. Since students entering university are from different socioeconomic background, screening should be carried out early as students.

A personalized approach is required to assess mental health of different students. In addition, a majority of mental health risk factors can be related to the academic environment. A personalised, student-centred approach to include needs and requirements of different students from different background can help students to foster their talent to reach their full potential. Furthermore, more training should be provided for teaching and university staff to help students identify risk factors, and provide appropriate treatment.

5. Conclusion

Despite all the efforts over the past two decades to destigmatise mental health, the stigma associated with mental health is still a significant barrier for students, especially male students and students from ethnic and religious minorities to seek help for SAD treatment. Universities need to continue to destigmatise mental health in university campuses to enable students to receive more in campus support by providing designated time for positive metal health activities such as group exercise, physical activities, and counselling services. There is no shortage of athletic and group activities in form of clubs and social classes in most universities in developed and developing countries; however, more incentives such as athletic bursaries and prizes should be provided to students to encourage their participation in such activities which can act as protective factors against SAD development. Therefore, universities need to allocate more resources for sporting and social activities which can impact the mental health of students. Furthermore, an increase in mental health problems in universities has created a huge burden on university counselling services to meet the demands of students. More novel approaches, such as online counselling services can help universities to meet those increased demands.

Students in different years of studies deal with different risk factors from the time that they enter the university until they graduate, therefore, different coping strategies are required for students at different levels. Universities should be aware of these risk factors and implement measures to minimise those factors while providing mental health treatments to students.

Future studies are required to investigate long-term effects of experiencing SAD on students. A longitudinal study with a large randomly recruited sample size (different age, sex, degree of study, – socioeconomic status, etc.) is required to address how students' mental health change from entering the university until they graduate. Also, more extended follow up studies can be included to address the effect of depression and poor mental health on people's lives after they graduate from the university.

Abbreviations

Conflict of interest: All authors declare no conflicts of interest in this paper.

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Understanding Academic Stress in College

How can you tell if your college stress is unhealthy, signs you may need professional support, get more academic stress tips.

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If you’re like most college students, you experience school-related stress. Stress isn’t always a bad thing. At manageable levels, it’s necessary and healthy because it keeps you motivated and pushes you to stay on track with studying and classwork. 

But when stress, worry, and anxiety start to overwhelm you, it makes it harder to focus and get things done. National studies of college students have repeatedly found that the biggest stumbling blocks to academic success are emotional health challenges including:

• Not getting enough sleep
• Depression 

Many things can create stress in college. Maybe you’re on a scholarship and you need to maintain certain grades to stay eligible. Maybe you’re worried about the financial burden of college on your family. You may even be the first person in your family to attend college, and it can be a lot of pressure to carry the weight of those expectations.

Stress seems like it should be typical, so it’s easy to dismiss it. You may even get down on yourself because you feel like you should handle it better. But research shows that feeling overwhelming school-related stress actually reduces your motivation to do the work, impacts your overall academic achievement, and increases your odds of dropping out.

Stress can also cause health problems such as depression, poor sleep, substance abuse, and anxiety.

For all those reasons—and just because you deserve as much balance in your life as possible—it’s important to figure out if your stress is making things harder than they need to be, affecting your health, or getting in the way of your life.

Then you can get help and learn ways to reduce the impact of stress on your life. 

First identify what’s causing your stress.

• Is it a particular class or type of work?
• Is it an issue of time management and prioritization?
• Do you have too much on your plate?
• Is it due to family expectations or financial obligations?

Next think about how college stress affects you overall.

• Does it prevent you from sleeping?
• Does it make it take longer to do your work or paralyze you from even starting?
• Does it cause you to feel anxious, unwell, or depressed?

If any of that feels familiar, it’s time to find support to ease your stress and help you feel better. Check out these tips to figure out the best support and approach for you. 

It’s important to be able to recognize when stress starts to become all-encompassing, affecting your overall mental health and well-being. Here are some signs you might need to get help:

• Insomnia or chronic trouble sleeping
• Inability to motivate
• Anxiety that results in physical symptoms such as hair loss, nail biting, or losing weight
• Depression, which may manifest as not wanting to spend time with friends, making excuses, or sleeping excessively
• Mood swings, such as bursting into tears or bouts of anger

Learn how to find professional mental health support at your school or elsewhere. 

If you need help right now, text HOME to 741-741 for a free, confidential conversation with a trained counselor any time of day, or text or call 988 or use the chat function at 988lifeline.org .

If this is a medical emergency or there is immediate danger of harm, call 911 and explain that you need support for a mental health crisis.

Tips for Managing Academic Stress in College

How to Reduce Stress by Prioritizing and Getting Organized

5 Ways to Stay Calm When You’re Stressed About School

6 Ways to Take Care of Yourself During Exam Time

Related resources

3 steps to make it easier to ask for mental health support, how to identify and talk about your feelings, election stress: tips to manage anxious feelings about politics, search resource center.

If you or someone you know needs to talk to someone right now, text, call, or chat  988 for a free confidential conversation with a trained counselor 24/7. 

You can also contact the Crisis Text Line by texting HOME to 741-741.

If this is a medical emergency or if there is immediate danger of harm, call 911 and explain that you need support for a mental health crisis.

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Stress in College Students: How To Cope

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A college student's guide to stress.

College is an exciting time, full of new challenges that continually drive you to expand your horizons. While some of these experiences can be thrilling, others may simply leave you feeling stressed. In fact, many college students feel stress while going to school. Only 1.6 percent of undergraduates reported that they felt no stress in the last 12 months, according to the National College Health Assessment (NCHA).

Being able to manage stress is crucial for your academic success and personal well-being in college. Luckily, this guide from Western Governors University will provide you with information about how to recognize different kinds of stress, various sources of stress for college students, as well as tips for coping in a healthy way. If you are able to identify and understand stress, you will be able to ensure your time as a student is rewarding and enjoyable.

What is stress?

Stress is a normal and necessary part of life. It is your fight-or-flight response to challenges you see in the world. This natural reaction has certain physical effects on the body to allow you to better handle these challenges, such as increased heart rate and blood circulation. While it can manifest differently for each individual, the National Institute of Mental Health notes that everyone feels stress at some point in their lives, regardless of age, gender, or circumstance.

Though it is a universal human experience, the American Institute of Stress (AIS) notes that defining and measuring stress is difficult because “there has been no definition of stress that everyone accepts” and “people have very different ideas with respect to their definition of stress.” They also state that a definition of stress is incomplete without mention of good stress (called eustress), its physical effects, or the body’s instinctive fight-or-flight response.

Researcher Andrew Baum , however, created a succinct, unique definition. He determines that stress is any “emotional experience accompanied by predictable biochemical, physiological and behavioral changes.” For the purposes of this guide, we will use Baum’s definition of stress.

Acute stress.

According to the American Psychological Association (APA), acute stress is the most common type of stress that every person will experience during the course of their life. It arises quickly in response to unexpected or alarming events to help you better handle the situation at hand. Typically, it fades quickly, either on its own or once the stressful event is over.

Acute stress doesn’t often lead to serious health problems. In certain situations, it can actually be a positive experience; for example, riding a roller coaster can cause acute stress, but in a thrilling way.

This type of stress occurs frequently and is easy to identify. Some signs of acute stress include:

Stomach pain, such as heartburn, diarrhea, or acid stomach.

Heightened blood pressure and heartbeat.

Shortness of breath or chest pain.

Headaches, back pain, jaw pain.

Because it is so common and lasts for a short amount of time, acute stress is usually simple to manage and treat.

Episodic stress.

When acute stress occurs frequently, it is classified as episodic or episodic acute stress. People who suffer from episodic stress are almost always in “crisis mode,” are often irritable and anxious, and may be prone to constant worrying. Essentially, people with episodic stress are often overwhelmed by it and have difficulty managing it.

Symptoms of episodic stress are the same as acute stress, but they can be more extreme or occur constantly. Some signs of long-term episodic stress according to the APA are:

Constant headaches or migraines.

Hypertension.

Heart disease.

People who suffer from episodic stress typically accept this kind of stress as a normal part of life and may not be aware of how detrimental its effects can be. The APA notes that it may be difficult for sufferers of episodic stress to get treatment because they are so used to feeling its effects and accept them as normal.

Chronic stress.

Chronic stress is a form of stress that occurs over a long period of time and that can have serious effects on your physical and mental health . Unlike acute stress, which can be exciting, chronic stress is dull, constant, and seemingly never-ending. It often arises in response to situations that feel hopeless and beyond your control, such as a troubled marriage, a toxic job, or poverty.

Chronic stress is, perhaps, the most dangerous type. This is the kind of stress that can lead to complicated, permanent health problems, such as heart attack, stroke, and suicide. Unfortunately, recognizing that you are experiencing this kind of stress is difficult because most sufferers are used to feeling this way. You may have grown comfortable living this way. Treating chronic stress can be challenging, and almost always necessitates the help of a professional to make long-term progress in recovery.

Signs and symptoms of stress.

Stress isn’t just a physical reaction; it can also affect your emotions, behavior, and cognition. Just as everyone is stressed by different things, everyone experiences its effects in different ways.

Certain signs of stress can be confused with other ailments. Be sure to understand how it affects you so you can correctly identify when you are experiencing stress. Some of the most common signs and symptoms include:

Keep in mind that these are just a few of the many signs of stress; the AIS identifies fifty of them, and notes that there may even be more effects that we haven’t been able to recognize yet.

Understanding stress.

Whether you attend college online or in-person, you will most likely face new stressors during your time at school. As you begin to notice how you and your body react to it, you may come to recognize symptoms that only appear in certain situations. Understanding the type of stress you are experiencing when you encounter these challenges can help you overcome them without feeling drained.

Dr. Karl Albrecht, a social scientist and management consultant, outlined four main varieties of stress: time, anticipatory, situational, and encounter. While these different types can be experienced in many different situations, from the workplace to the home, they are especially relevant to the life of a student.

Time stress.

Time stress occurs when you feel worried about time, and more specifically, when you don’t have enough time to accomplish all necessary tasks. People often experience this when they fear they can’t meet their deadlines, or will be late to a meeting or appointment.

As a student, you may feel time stress in several different ways. You may worry about being late to your classes as you learn the geography of your campus or if you have to get home and log onto your computer for a lecture after running errands. You may also panic about the heft of your workload or the quality of your work for class, which can be a difficult adjustment, whether you’re attending college for the first time or returning after a break .

Anticipatory stress.

Anticipatory stress occurs when you feel anxious about the future. When some people experience anticipatory stress, they may be nervous about a particular upcoming event; for others, it may simply be a general sense of uncertainty about what’s to come.

You may feel this kind of stress in both a vague and concrete way during your studies. If you feel anxious about a forthcoming test, assignment, or presentation, you are experiencing a more concrete form of anticipatory stress. If you have a sense of dread or fear of uncertainty about your future in general, that is a more vague manifestation. Students may feel this kind of stress more frequently as they get nearer to graduation and are making decisions about their life after college.

Situational stress.

You experience situational stress when you are in an upsetting or alarming situation that you cannot control. Unlike time-related and anticipatory stress, this kind of stress happens suddenly and with little — if any — warning. In fact, you may not have anticipated the situation at all.

For students, this type of stress can arise in a number of different circumstances. It may come from something as minor as forgetting your words during a presentation, or as major as a phone call about a family emergency. This kind of stress can occur during a number of situations, from receiving a poor grade on an assignment, to arguing with a friend, to nearly hitting a car in front of you on the road.

Encounter stress.

Encounter stress results when you feel anxious about seeing certain people, either alone or in a group. You may not enjoy spending time with them or have difficulties communicating with them. Whatever the reason, there is something about this person or group that makes you anxious. Encounter stress can also occur if you have spent too much time with others and feel burnt out, even if you like being around them.

Students may feel encounter stress in situations ranging from intimidating professors to unfamiliar classmates. Further, you might only experience this feeling with a person for a limited amount of time. For example, you might dread seeing your roommate for the first time after an argument, but the stress may disappear after you resolve the issue.

Causes of stress in college.

Though everyone experiences it differently and has their own distinct stressors, researchers have found that many college students share several common sources of stress. Whether you major in business or education , you likely share at least one common stressor with your peers. From worries about your health to concerns about your life after graduation, here are some of the most common causes of stress in college students:

In a survey conducted by the APA, 63 percent of adults cite “health-related concerns” as their number one source of stress. For college students, in particular, worries about or issues with health might be a major stressor because of how it can impact academic performance. The NCHA reported that the academic performance of nearly 30 percent of students was impacted by a physical ailment, ranging from allergies to bronchitis.

Regardless if the cause is a simple cold, mental health condition , or chronic illness, one thing remains the same: when you’re sick, it can be difficult to keep up with your studies. If you are contagious, you should avoid attending class (unless you are a distance learner or can sit in on the lecture at home), which means missing out on important information from your professor. Even if you aren’t contagious but are simply feeling under the weather, you may not have the energy to focus on the lectures and assignments.

If a particular illness is going around your campus or community, try your best to avoid contact with anyone who is contagious and wash your hands frequently. Everyone gets sick on occasion; accept that, despite your best efforts, you might too. If you do catch something, take care of yourself and rest as much as possible before resuming your normal activities.

Balancing work, school, and family life.

In college, you have to figure out the right balance between work, family, and school. The academic load in college is often larger and involves more complicated work than in high school. Attempting to keep up with that, on top of your job and family responsibilities, can add additional stress to your daily life — especially if your family and work obligations are so demanding that you fall behind with your schoolwork.

For non-traditional students , in particular, achieving that balance can be difficult. While traditional students may be worried about missing another call from their parents, if you are a non-traditional student, you may have children of your own to take care of. You may have to focus your energy on financially supporting your family or caring for your sick children, instead of school.

These strategies can help you establish boundaries between the different areas of your life, in order to give each one the attention it needs. Keep in mind that it’s also important to be able to adapt to new concerns and demands. You may feel stressed to a greater extent if you feel like you can’t make necessary adjustments to your plans.

Class scheduling and credit load.

Scheduling your college classes may stress you out. Trying to sign up for the courses at times that work well for you, and making sure you’re taking all your necessary prerequisite classes, are just a couple of the many factors that you need to consider.

For some students, this may be the first time they have to create their own schedules. You may not know how many credits you should be taking, or what class times are best for your academic performance. You might get frustrated with yourself after a few weeks of classes if your schedule is not what you hoped it would be.

If your schedule is overwhelming, remember that it isn’t permanent. Your current classes will end, and you will have to build an entirely new schedule in a few short weeks or months. Use that  opportunity to make a schedule  that’s better suited to fit your needs.

Costs of colleges/finances.

Over the past few decades, the cost of college tuition at traditional schools has risen notably. Combined with other expenses — like the cost of housing, food, and books — students may feel stress over their finances while they’re in school. Even if you qualify for aid, receive help from your family members, or work during the school year, you may still feel anxiety about money.

Students may feel further stress because of loans they have to pay off after graduation. The debt you acquire can be a burden before you complete school, because it can affect your finances for years after, as well as during, college.

Always keep in mind why you chose to pursue a degree in the first place, and remind yourself that it can lead to better job opportunities after you graduate. Experts still believe that, in the long-term,  college is worth the investment .

Grades and exams.

Academic performance is another stressor that you may encounter as a college student. You may feel pressure to get certain grades in your classes due to a number of factors, such as meeting the expectations of others, or your desire to go on to a master’s program. You may study frequently, but get so anxious about taking an exam , that you find yourself unable to do well (or in some cases, to even take the test).

Further, balancing your classes, family responsibilities, work schedule, and social life can be hard due to the increased workload and greater difficulty of college courses. In some classes, tests or projects also make up a large percentage of students’ grades.

Conquering school-related anxiety can be tricky, as you are constantly surrounded by your stressors and equally stressed classmates. However, you are at school to learn and grow, not to get straight A’s on your report card. Focus on getting your education instead of on getting certain grades.

Preparing for post-graduation life.

For many students — traditional ones in particular — being in school is comfortable. The prospect of life after college can be daunting simply because it is unknown and unfamiliar. For even the most well-prepared student, the unpredictability of life outside of school can be anxiety-inducing.

Your stress may be amplified if it seems like all of your friends and peers already have a post-graduation plan that they seem confident about. You might feel anxious if you don’t have any idea what you want to do; on the other hand, you may question decisions you’ve already made about your future.

The uncertainty of the future can be difficult to handle, but you aren’t alone. Don’t hesitate to reach out to your friends, family, professors, or advisors for help and advice as you start to think about what you want to do after graduation.

Relationships.

Your relationships with friends, family members, and significant other can change after you start college. School may be a bigger priority than ever before, and as you navigate the challenges associated with that, you may have less energy to give to your loved ones. Feeling like you aren’t as close to your support system, in addition to dealing with the pressures of school, can create tension in your life.

Make an effort to only befriend people whose company you enjoy. Your time at college is too short to spend interacting with people who you don’t get along with. Whether you are working in a group project online, or engaging in a class discussion via chat, you have the opportunity to be selective about who you give extra energy to. You can make lifelong friends in college, so try your best to only invest your time and attention into the relationships that matter to you.

Managing stress as a student.

There are many ways you can manage your stress as a college student. Just as everyone experiences stress in their own way, we all have our preferred methods of coping with it. However, not all stress management strategies are healthy, and some may leave you feeling even worse than you did before.

To overcome stress while going to school, it’s crucial to learn how to cope with it productively. After all, you can’t control the stressors in your life, but you can choose how to respond to them.

Unhealthy ways to manage stress.

Healthy ways to manage stress..

In college, stress is inevitable, but it doesn’t have to dominate your life. Do your best to understand what kind of stress you’re feeling, what’s causing it, and how you can respond to it productively. By addressing your stress in a healthy way, you are doing all that you can to make the most of your college education.

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How to Cope with Stress Essay

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Introduction

How do stress and stressors help a person in identifying ways to cope, problem solving approach in coping stress, the identification of the stressor.

According to Aamodt (2009) stress is the psychological and physical reaction to certain life events or situations. Fear, resistance, resentment, change, relations with others, organizational politics, and unfavorable physical environment are the main causes of stress (Aamodt, 2009). Even though stress affects different personalities differently, it could result to grave consequences if not well managed.

Many people often think there is little that can be done about their level of stress. However, the fact is contrary. Individuals should identify their stressors and develop coping strategies aimed at neutralizing and finally eliminating the effects of the stressors. I have in the past adopted various strategies in coping with stress.

There are many stress coping methods. However, individuals often find themselves employing unhealthy and unproductive methods, which end compounding the problem. Such methods include withdrawal from friends and families, use of pills, drinking, smoking, overeating, and taking out of stress on other people. Even though these methods can work, their results are temporary as individuals soon face the reality of the stressor.

Healthier and effective ways of controlling stress require either situation change, or reaction change. Every individual exhibits unique response to stress, which makes it impossible to have a common method of coping. The simplest approaches to coping with stress, which I have used in the past, include problem identification and solving, acceptance, alteration, self-nurturing, and anticipatory approach also suggested by Aldwin (2007).

Problem solving approach is a strategy that its applicability is dependent on the determination of the main cause of stress. Once the stressor is identified, it becomes easy to solve the stress as an individual directs his or her energy towards subduing the stressor. For example, if lack of finances is the main cause of stress, then an individual may seek for new employment to provide for the much-needed cash.

The identification of the stressor also opens a window for an individual to explore other adaptation methods, which can be of help in the future such as avoidance. In anticipatory approach, an individual prepares for possible causes of stress and consequently prepares for them before their actual occurrence. Past trends and acquired knowledge can help an individual in such preparations.

For example, a student subjected to last minute revision pressures and stress for failing to revise in time may expect the same, hence prepare early in the following semesters to avoid going through the same. This method is very effective as an individual can review and continually revise the best method to use every time the stressor reoccurs. Sometimes stressful situations are not only complex, but also impossible to avoid.

It is only prudent for individuals affected to alter and adapt to such situations. This involves finding possible ways of changing an individual’s operation to avoid the stress from reoccurring. For example, stress caused by coworkers could be avoided by expressing ones’ feelings to the specific workers instead of bottling them up. If the desired change is not achieved, then one can go a step further by changing his or her own behaviors.

Stressors such as the death of people we love, fatal accidents, and illness are unavoidable and impossible to ignore. However, letting such stressors take tall of an individual’s life is also unacceptable. In such cases, the best coping strategy is acceptance. Though hard to take, acceptance is the only way out for individuals facing unchangeable life-threatening situations.

There are other effective coping strategies, which even though I have not used, I would consider applying. Self-nurturing is such “effective way of coping with stress” (Aldwin, 2007).

Creating time for fun and relaxing, enhance our ability to copy with life’s unending stressors. It is therefore prudent for an individual to engage frequently in healthy ways of relaxing such as, going for a walk, playing with a pet, going adventures, watching comedies, and lighting scented candles.

Aamodt, M. G. (2009). Industrial/Organizational Psychology: An Applied Approach (6th ed.). Belmont, CA: Cengage Learning.

Aldwin, C. M. (2007). Stress, coping, and development: an integrative perspective (2nd ed.). New York, NY: Guilford Press.

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Coping with Stress at University

Introduction, stress among university students, inadequate resources, lack of proper guidelines, provision of inadequate knowledge and training, poor learning environments, coping strategies.

Stress is one of the major challenges that students face in universities. Studies have found out that many institutions of higher education do not help students cope with stress thus increasing the prevalence f stress-related problems such as anxiety, eating disorders, and depression. The main reasons why universities do not connect with students in regard to coping with stress include inadequate resources, lack of proper guidelines on how to deal with stress among students, inadequate training, and poor learning environments that are not conducive for healthy lifestyles. In order to mitigate the problem, universities need to develop training programs to teach students about the various techniques they can use to manage stress. In addition, the need to end stigma against mental health issues, create environments that encourage students to talk about their problems to peers and counselors, and create a student-monitoring students to track the progress of students especially those with mental health issues.

Numerous research studies have found out that a certain amount of stress is inevitable when students make a transition from high school to university. Students experience stress overload as they juggle their academic work with part-time jobs, financial constraints, high expectations from guardians, and great uncertainty in the labor market (Bataineh, 2013). There are many forms of stress experienced by students in universities. There is a certain amount of inevitable stress that helps students to work harder, stay focused, and persevere in the attainment of their academic goals (Thawabieh, 2012). On the other hand, there is a form of stress that is debilitating and that cripples students thus making them lose focus, become hopeless and helpless, develop depression, and engage in destructive behavior such as alcohol and drug use (Bayram & Bilgel, 2008). Many universities have numerous resources that include wellness centers, counseling centers, and support groups to help students cope with stress (Papadopoulos & Ali, 2013). However, incidences of stress-related complications are on the rise. Universities fail to help students cope with stress because of inadequate resources, lack of proper guidelines to identify students in most need of help, poor learning environments, and inadequate knowledge and training.

After joining university, many students become stressed because of their inability to develop the skills necessary to balance academic and social responsibilities, deal with the numerous academic demands, and make transition from dependence to independence (Race to Nowhere, 2010). Higher education is very demanding because of its high expectations and standards that subject students to heightened levels of stress that in many cases affect their academic performance negatively (Bataineh, 2013). Symptoms and signs of high stress levels in students include tension, anxiety, frequent headaches, absenteeism, difficulty concentrating, increased agitation, irregular sleeping habits, and increased worrying (Bayram & Bilgel, 2008). Universities create resources such as wellness centers and counseling programs to help students cope with stress. However, they fail to connect with learners who continue to suffer the detrimental effects of stress.

Research has revealed that many universities have scarce resources with regard to handling the high numbers of students who need help with regard to coping with stress. Counselors in universities are overwhelmed because of the high number of students that seek help (Coughlan, 2015). In that regard, counselors are usually exhausted and as a result fail to offer quality services. On the other hand, many students who are in most need of help fail to receive attention and continue to suffer silently. The most common outcomes of excessive stress in universities are depression and related disorders such as anxiety that affect the performance of students (Bataineh, 2013). Moreover, many students fail to seek help because of the fear of discrimination and ridicule from fellow students.

In many universities, seeking help for mental health-related issues is seen as a form of weakness and lack of emotional toughness. In that regard, many stressed students shy away from seeking help. Studies have shown that demand for counseling services has been on the rise as university life becomes more complex and demanding (Coughlan, 2015). This rapid increase in demand for professional help has overwhelmed universities and rendered their resources inadequate. This problem has emanated from lack of transparency and honesty by universities regarding the scope of the problem. The problem of stress among students is more severe that many universities would want to admit because of the fear that they will be accused of being negligent and abdicating their responsibilities of improving students’ welfare and wellbeing (Coughlan, 2015). In the United Kingdom, this problem has been on the rise. For example, a report released by the Higher Education Funding Council of England revealed that certain institutions are experiencing a 50% increased in demand for counseling services every year. Many universities are unable to keep up with this rapid rise in demand.

Students become depressed because of many reasons such as relationships, homesickness, competition, environment, social stressors, lifestyle changes, and academic demands (Hamaideh, 2011). There is a certain level of stress that is inevitable in university. Many students are unable to differentiate between necessary and unnecessary stress. Studies have established that students want help with more serious problems such as anxiety, depression, worry, and learning challenges (Howard, 2014). Many universities have not established guidelines to enable counselors identify students who are in most need of help (Hamaideh, 2011). As a result, students who experience serious problems continue to suffer while those with minor problems get all the attention. This phenomenon has led to a rapid increase in the number of individuals in need of help. Higher education has become more expensive while the prospects of getting a job after graduating have decreased significantly (Papadopoulos & Ali, 2013).

Students are not sure whether spending a lot of money for higher education is worth the struggle and as a result deal with such frustrations and confusions on their own. On the other hand, there is a very pervasive myth that university students should have lots of fun and enjoy themselves. Many students waste their time partying and engaging in unnecessary extracurricular activities that eat away time that they could spend studying (Race to Nowhere, 2010). They perform poorly in exams and develop stress that affects their physical, emotional, and psychological wellbeing (Hamaideh, 2011). In addition, this myth compels them to turn their social lives into platforms for showoff rather than platforms for relaxation, interaction, and learning. Universities have also failed to offer guidelines to instructors, counselors, and other staff members on the proper avenues of supporting students with mental health problems (Howard, 2014).

Students find it difficult to make a transition from high school life to university life. University life comes with higher academic, financial, emotional and academic expectations that many students cannot cope with (Howard, 2014). On the other hand, universities do not give freshmen adequate training that is necessary for effective transition into the new life. Many students start higher education life with little knowledge and few skills on how to cope with stress and live a healthy lifestyle that supports optimal performance and productivity (Hamaideh, 2011). Studies have shown that activities such as relaxation, physical exercise, meditation, and yoga play an important role in stress alleviation (Landow, 2006).

However, many universities do not dedicate time and resources to teach students some techniques that can help them to cope with stress effectively. Joining university is a critical moment in life because it is a period of transition from childhood to adulthood. The stresses associated with the transition can overwhelm many students who lack the necessary knowledge and skills to deal with them. Another contributing factor is the role played by parents. Many parents are over protective and do not give their children an opportunity to handle stress (Richards-Gustafson, 2015). Shielding adolescents from stress and failure denies them the opportunity to learn and gain skills that are needed I adult life (Landow, 2006). S

tudents join university terrified and anxious because of the lack of skills on how to cope with stress. This situation is worsened by lack of adequate training from the administration teams of universities. Another cause of high stress levels among university students is competition for high grades (Howard, 2014). Many students leave high school to join university with high grades. However, competition among students who got high grades in high schools is stiff and a major cause of stress. Majority of new students expect to get high grades in order to feel confident and significant. However, they fail to realize that university education is very different from high school education because it requires a lot of time, patience, hard work, perseverance, and determination. These critical aspects of academic success require students to have certain qualities and skills that can be learned. The most important strategy for dealing with stress is learning how to manage it. Inability to manage stress compels students to try alternative lifestyles that are aimed at eliminating it altogether such as alcohol and drug use (Landow, 2006).

These techniques fail because instead of eliminating stress, they increase it. Another main cause of stress among university students is financial pressure. Over the last decade, the cost of education has increased and students find it difficult to handle the pressure of dealing with high student loans to finance their education (Richards-Gustafson, 2015). It is important for universities to teach students basics of finance management in order to instill in them personal finance skills that could aid in managing stress that emanates from financial pressure (Landow, 2006). Students need to realize that focusing on things that are out of their control is a source of unnecessary stress that can be easily managed by focusing only on things that are within their circles of influence.

The learning environments found in many universities are not conducive for learning and healthy lifestyles. In addition, they do not encourage students with difficulties to share them or seek help. Many universities find it difficult to offer assistance because troubled students are reluctant to disclose their problems and therefore suffer in silence (Landow, 2006). Students are expected to tackle numerous responsibilities daily without the knowledge of how to go about it. The learning environments in many institutions do not support a growth mindset that is important for academic prosperity. This growth mindset can be developed by creating programs and initiatives that teach students how to handle failure by learning from their mistakes and doing better the next time (Palmer & Puri, 2006).

On the other hand, many institutions do not have well developed support groups and networks to help students cope (Palmer & Puri, 2006). Another factor that characterizes university environments is stigmatization. There is a lot of stigma surrounding mental health issues in universities and administrations have not done enough to create learning environments that eradicate it (Thawabieh, 2012). Discourses regarding conditions such as anxiety disorders and depression are very few. Many students do not feel comfortable seeking professional help for fear of ridicule from their peers (Palmer & Puri, 2006). As a result, universities are unable to help students who are in need. The rapid increase in incidences of problems such as depression, eating disorders, and anxiety is proof enough that universities are not doing enough to help students to cope with stress. Many institutions of higher education have not yet fully taken responsibility for the wellbeing of their students who are left to struggle and suffer on their own with little or no help.

There are several measures that universities can take or implement to help students cope with stress and anxiety. First, they should create training programs and workshops that teach students how to cope with stress, anxiety, and related problems. A coping program could teach students aspects of stress management such as meditation, social support, relaxation, physical exercise, and the importance of sleep and good nutrition (Palmer & Puri, 2006). Many students enrolled into universities lack the knowledge and skills that are necessary for effective stress management. Second, they can create environments that encourage students to talk about their problems and seek professional help. This can be achieved by conducting workshops and implementing awareness programs that teach about the importance of ending stigma against mental health problems as well as the importance of student wellbeing on academic performance (Palmer & Puri, 2006).

Students can only be healthy mentally, emotionally, and physically only if they know how to address their various needs. Third, universities can create more wellness and counseling centers to help students deal with anxiety issues. Students can visit these centers for professional guidance on how to deal with anxiety and other related conditions. Some students undergo pain and suffering because they do not know who to contact or where to seek help from. Fourth, universities should develop policies and anti-mental health stigma campaigns to encourage students to openly share their problems with their peers and counselors (Palmer & Puri, 2006). On the other hand, they should regularly monitor students especially those who are admitted with mental health issues. The complexities of university life require the development of certain qualities and skills that many students lack during admission.

One of the many challenges of joining university is the stress associated with making the transition from high school to an institution of higher learning. The demands of academic work, relationships, assimilation, and new lifestyles subject students to stress that in many cases leads to conditions such as anxiety and depression if not managed properly. Universities have failed to connect with students in regard to proper management of stress because of inadequate resources, lack of adequate knowledge and training, unclear guidelines regarding stress management, and poor learning environments. In addition, stigma against mental health discourages many students from talking about their challenges and seeking help. Studies have shown that in the past decade, stress-related problems have been on the rise in universities. Causes of stress include exams, high expectations from parents, uncertain job opportunities, social pressures, and financial constraints. The learning environments in universities are not conducive for healthy living hence the rising numbers of stress-related problems among students.

On the other hand, many universities are overwhelmed by the high numbers of students who seek help from the wellness and counseling centers. Due to scarce resources, available counselors and health professionals are unable to attend to the students. Poor stress management skills and knowledge due to lack of adequate training is another reason why universities have failed to help students cope with stress. Many students join universities without the necessary skills and knowledge need for effective stress management. The training they receive after admission is inadequate to help them cope and lead productive lives. In order to help mitigate this problem and deal with anxiety, universities should create wellness programs and awareness workshops to teach students how to manage stress. They should also implement policies that eradicate stigma against mental health issues.

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PTSD Has Surged Among College Students

The prevalence of post-traumatic stress disorder among college students rose to 7.5 percent in 2022, more than double the rate five years earlier, researchers found.

By Ellen Barry

Post-traumatic stress disorder diagnoses among college students more than doubled between 2017 and 2022, climbing most sharply as the coronavirus pandemic shut down campuses and upended young adults’ lives, according to new research published on Thursday.

The prevalence of PTSD rose to 7.5 percent from 3.4 percent during that period, according to the findings . Researchers analyzed responses from more than 390,000 participants in the Healthy Minds Study, an annual web-based survey.

“The magnitude of this rise is indeed shocking,” said Yusen Zhai, the paper’s lead author, who heads the community counseling clinic at the University of Alabama at Birmingham. His clinic had seen more young people struggling in the aftermath of traumatic events. So he expected an increase, but not such a large one.

Dr. Zhai, an assistant professor in the Department of Human Studies, attributed the rise to “broader societal stressors” on college students, such as campus shootings, social unrest and the sudden loss of loved ones from the coronavirus.

PTSD is a mental health disorder characterized by intrusive thoughts, flashbacks and heightened sensitivity to reminders of an event, continuing more than a month after it occurs.

It is a relatively common disorder , with an estimated 5 percent of adults in the United States experiencing it in any given year, according to the most recent epidemiological survey conducted by the Department of Health and Human Services. Lifetime prevalence is 8 percent in women and 4 percent in men, the survey found.

The new research also found a sharp rise in the prevalence of a similar condition, acute stress disorder, which is diagnosed less than a month after a trauma. Diagnoses rose to 0.7 percent among college students in 2022, up from 0.2 percent five years earlier.

Use of mental health care increased nationally during the pandemic, as teletherapy made it far easier to see clinicians. Treatment for anxiety disorders increased most steeply, followed by PTSD, bipolar disorder and depression, according to economists who analyzed more than 1.5 million insurance claims for clinician visits between 2020 and 2022.

PTSD was introduced as an official diagnosis in 1980, as it became clear that combat experiences had imprinted on many Vietnam veterans, making it difficult for them to work or participate in family life. Over the decades that followed, the definition was revised to encompass a larger range of injury, violence and abuse, as well as indirect exposure to traumatic events.

However, the diagnosis still requires exposure to a Criterion A trauma, defined in the Diagnostic and Statistical Manual of Mental Disorders as “death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence.”

It is not uncommon for young adults to experience traumatic events. A 1996 study of Detroit residents found that exposure to traumatic events — such as violent assaults, injuries or unexpected death — peaked sharply between the ages of 16 and 20. It then declined precipitously after age 20.

Research suggests that less than one-third of people exposed to traumatic events go on to develop PTSD.

Shannon E. Cusack, an academic researcher who has studied PTSD in college students, said there was division within the field about whether the profound disruptions that young adults experienced during the pandemic — abrupt loss of housing and income, social isolation and fear about infections — amount to triggering events.

“They’re causing symptoms that are consistent with the PTSD diagnosis,” said Dr. Cusack, a clinical psychologist and an assistant professor of psychiatry at Virginia Commonwealth University. “Am I not going to treat them because their stressor doesn’t count as a trauma?”

The prevalence data, she said, points to a pressing need for PTSD treatment on college campuses. Short-term treatments developed for veterans, such as prolonged exposure therapy and cognitive processing therapy, have proved effective in managing PTSD symptoms.

Stephen P. Hinshaw, a professor of psychology at the University of California, Berkeley, said that the disruptions of the pandemic might have left college students emotionally depleted and less resilient when faced with traumatic events.

“Midway through this study, there may have been legitimately more trauma and death,” he said, adding that the lockdowns may have caused more general despair among young people. “With the general mental health deterioration, is it harder to cope with traumatic stressors if you do get exposed to them?”

Some changes to the diagnostic manual may have blurred the line between PTSD and disorders like depression or anxiety, Dr. Hinshaw said. In 2013, the committee overseeing revisions to the manual expanded the list of potential PTSD symptoms to include dysphoria, or a deep sense of unease, and a negative worldview, which could also be caused by depression, he said. But the changes, he added, do not account for the sharp increase in diagnoses.

Ellen Barry is a reporter covering mental health for The Times. More about Ellen Barry

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Timed Tests and Their Effect on Student Performance

By Andrew J. Browning

Published: June 06, 2024

Timed tests are a major source of stress for students and can often cause many students to underperform. While the stress and pressure from time limits can improve students’ focus and productivity, for many students, severe time limits don’t allow them to fully demonstrate their knowledge. In education, speed has long been equated with intelligence and seen as a sign of subject mastery, so teachers have designed their tests around this idea. But are the fastest students necessarily the smartest students, and are timed tests the most effective means to measure student knowledge and intelligence? Every student is unique, and there are different types of test takers, just as there are different types of learners. From study to study, none have found direct correlations between test-taking pace and accuracy. Instead, other factors like disability, gender, age, and language proficiency all affect students’ test-taking pace but not necessarily their performance. Placing time limits on tests disproportionately affects students’ performance and thus is an ineffective means to assess students’ academic knowledge and intelligence. Therefore, schools should take steps to allot more time during tests for all students to better assess their true knowledge and grow their potential.

Inefficacy of Time Limits

It is a common misconception in education that students with mastery of a topic will solve problems faster. However, placing severe time constraints on tests does not effectively assess a student’s fluency in a subject. Students with higher intelligence scores solve easy problems faster but are consistently slower when solving difficult problems (Schirner, et al., 2023). A study on the relationship between brain network structure and intelligence determined intelligence scores by a series of tests that measured factors such as fluid intelligence (the ability to solve new problems independent of previous experience) and reaction time (the individual’s processing speed) to calculate an overall, or general, intelligence. In an untimed test where questions were ordered by increasing difficulty, participants with higher general and fluid intelligences were found to have higher processing speeds, but this didn’t correspond to a faster testing pace. In fact, “a meta-analysis over 172 studies and 53,542 participants reported strong negative correlations between general intelligence and diverse measures of RT [reaction time],” but for more difficult questions, the data showed a positive correlation (see Appendix A) (Schirner, et al., 2023). These high-scoring individuals were quicker to answer the first set of simple questions but were slower to answer questions as the difficulty increased. The study found that slower response times correlated with higher accuracy on test questions, showing that students will perform better when taking more time to answer questions (Schirner, et al., 2023). For tests that aim to assess students’ intelligence by their ability to solve difficult problems rather than their speed at solving simple ones, time limits should therefore be ample or abolished completely.

Timed exams reward quick thinking, a skill not necessarily correlated with the types of students who have the most knowledge or highest intelligence. Instead of assessing student knowledge, timed tests evaluate how well a student can reason under stress and guess answers quickly, making timed tests an ineffective measure of actual student performance (Gladwell 2019). To use Gladwell’s metaphor, timed tests reward the hare over the tortoise, or the quick thinker over the slow, methodical one. A timed test aimed at forcing students to rush instead “favors those capable of processing without understanding,” i.e., hares, not tortoises (Gladwell 2019). This test format evaluates how well students can solve difficult problems quickly, not how well they can solve difficult problems. The issue with this is that in most careers, success is not determined by whether a person is a tortoise or a hare, but rather how hard and passionately they work. This means that important standardized tests like the ACT and LSAT shouldn’t distinguish one group of students as the better tester because the world needs both, so tests should reflect that and assess both.

By not assessing both methods of thinking, severe time limits, those which cause most students to not finish a test, arbitrarily and unfairly increase the performance gap between high and low-scoring test-takers, particularly between fast and slow readers. Looking at a multiple-choice reading comprehension test with fixed time limits, a study from the Journal of Psychoeducational Assessment analyzed the impact that non-attempted questions had on student performance. The data showed a steep drop-off in the percentage of correct responses toward the end of the test, most notably for the bottom third of scorers during the final third of the test (see Appendix B). This decrease in accuracy was steeper and began earlier in the test for lower-scoring test-takers, a trend caused by two factors: the increase of both question difficulty and percentage of unanswered questions throughout the test (Clemens et al., 2014). By looking at the correct response percentage for only the attempted test questions (see Figure B2), the performance decline throughout the test was less pronounced, particularly for the lower-third of scorers. This shows that non-attempted questions had a more significant effect on the performance of lower-scoring test-takers than the increasing difficulty of the problems. The high rates of non-attempted questions can be attributed primarily to the time limits placed on test-takers, but also to other problems caused by long, continuous reading assessments, which have high rates of students losing focus or giving up entirely (Clemens, et al., 2014). When there are such high rates of incompletion, the tests do not accurately assess the students’ reading comprehension skills or their ability to answer accurately but rather how quickly they can read and how many questions they can answer in a short time. Such tests only show how well the students can take tests and not their knowledge of the material or intelligence.

Overall, this study shows that more consideration must be made over the effectiveness of timed tests. Examiners need to consider multiple factors when there are low test completion percentages. One such consideration would be for students whose first language differs from the language of the test. These students are typically not as fluent or quick of readers. This means non-native speakers will perform disproportionately poorly on tests of reading comprehension (Gernsbacher, et al., 2020). Thus, when time restrictions on tests are imposed, performance gaps increase to the detriment of slow thinkers and slow readers, regardless of their overall intelligence.

Disproportionate Demographic Effects

When increased time is given on tests, the gaps and disparities seen in test performance between demographics close, leveling the playing field to make tests more equitable for all. For example, increasing time limits decreases the gender disparities seen in subjects such as mathematics and reading comprehension (Grant 2023). Statistically, boys outperform girls in areas of mental rotation and spatial ability, which refers to the ability to mentally transform and rotate 3D objects. This skill helps in STEM fields, specifically problem solving in mathematics and design and graphical skills in engineering. For measuring this mental rotation ability, the Purdue Spatial Visualization Tests: Visualization of Rotations (PSVT:R) is the leading test in STEM education research. Under severe time constraints for this test (less than 30 seconds per multiple-choice question), males scored significantly better than females. But, when given more time on the PSVT:R (around 40-60 seconds per question), both males and females’ scores increased, while the gap between their scores decreased (Maeda and Yoon Yoon, 2013). More generous time limits for STEM-related tests, then, equalize the scores between males and females, which could encourage more high-achieving women who are disadvantaged by these inadequate time limits to pursue education and careers in STEM.

Males also perform better than females under intense time pressure, but this advantage also decreases as more time is given on tests and the pressure on the student is lessened. A study from the Journal of Economic Behavior & Organization analyzes the effects that continuous assessment, a class grading method that bases grades on midterm exams in addition to the final, has on student performance. The study found that for high-pressure, multiple-choice exams (the final exam in this case), females tend to omit answers to more questions and subsequently underperform relative to their male peers (Montolio and Taberner, 2021). The researchers attribute these results to differing test-taking approaches, as females may experience more test anxiety, resulting in decreased levels of confidence, and may be less prone to take risks by guesswork, a tendency which only increases for higher pressure tests. As a result, “male students are found to outperform female students when sitting high-stake exams (0.132 s.d. [standard deviations]). However, as the stakes at hand decreases, the gender gap in favour of male students is narrowed until it is mitigated and ultimately, in the lowest stake scenario, reversed in favour of female students (0.08 s.d.)” (Montolio and Taberner, 2021). This standard deviation data, which quantifies the relative difference between average scores, shows that the gender performance gaps shrunk for lower-pressure exams. This result demonstrates that females perform better under less pressure, as opposed to males performing worse, because both males and females scored better on average for lower-pressure exams, but females’ scores improved significantly more than males’ (0.153 s.d. compared to 0.018 s.d.) (Montolio and Taberner, 2021). With more time given for exams, there is less pressure put on the students. This means that males and females both are more likely to perform to their maximum potential, closing gender gaps in academic performance.

Giving more time for exams helps all students perform to their maximum potential, especially for persons with learning disabilities, who perform proportionally better compared to non-disabled persons when more time is allocated. The idea behind maximum potential is that the more time allowed on a test, the more equitable the test becomes because it enables all students to perform to their best ability. This makes the test a better assessment overall (Gernsbacher, et al., 2020). Furthermore, by the Differential-Boost Hypothesis, while all students are aided by extra time on exams, students with disabilities benefit more (Gernsbacher, et al., 2020). Not all persons with disabilities can get access to testing accommodations and alternative learning plans due to factors such as the cost of documentation and the stigma surrounding less visible disabilities. This means that increasing time limits for all students is the best way to remedy this disadvantage. This increased time helps equalize testing performance for everyone with slower thinking disadvantages, which holds true for people of older age.

With more time allowances, older adults perform just as well as younger adults when assessing divergent thinking for individuals with similar experience and education levels. Divergent thinking refers to the ability to come up with multiple possible and correct solutions to a single problem. This type of thinking correlates to creativity and overall cognitive ability. Older age is often attributed to cognitive decline, but the results of a study from Educational Gerontology showed that although middle and older-aged adults performed worse during timed divergent thinking tests, they performed slightly better during untimed power tests (power tests referring to tests with sufficient time to answer all questions) (see Appendix C). These results can be attributed to processing speeds slowing with age, while overall cognitive ability remains similar (Foos and Boone, 2008). Thus, time restrictions on tests disadvantage older-aged persons pursuing education and don’t assess a person’s cognitive ability as effectively as untimed tests.

It is important to note, however, that giving students more time on tests does not automatically produce better test scores. Rather, taking tests free of time pressure, i.e., power tests, is what significantly improves student performance (Gernsbacher, et al., 2020). In some cases, speed may be the best indicator of mastery in a subject. In these cases, tests should be designed with speed in mind and impose time restrictions accordingly. In most subjects, though, mastery is best indicated by the methodical acquisition of conceptual knowledge rather than the speed of memorization (Gernsbacher, et al., 2020). Examinations that are designed to test for speed should still consider how to make the tests as equitable as possible and should only administer severe time restrictions when necessary for knowledge assessment or preparation for certain careers. A common reason for these severe time limits is because instructors want to test students on the most material to best assess their students’ knowledge. So, they write longer tests with more questions rather than design better, multifaceted questions. The problem here is that these longer tests are still limited by finite testing times, which is the primary issue with administering untimed power tests: that practical considerations must be made to account for the finite time periods in which tests are given.

Making these practical considerations, instructors should allow just enough time for all students to complete their tests thoroughly, not an infinite amount of time. Untimed power tests offer the most effective assessment of student intelligence and allow students to demonstrate their maximum potential, unrestricted by time limits and other external pressures. While tests must have some time limit, allowing ample time for all students to complete the test achieves the same effect as untimed power tests while being practical for real-world testing scenarios (Clemens, et al., 2014). Shorter tests and tests divided into sections separated by breaks or tested over multiple days benefit student performance by improving student engagement, reducing test fatigue, and decreasing pressure. In cases such as subjects based on quick recall or rote memorization like math multiplication tables, tests may be designed to test for speed. However, for most applications in areas of higher learning, i.e., the high school and university level, which focus testing on complex critical thinking and problem-solving skills, power tests offer the most effective assessment of student intelligence. These power tests allow students to demonstrate their maximum potential unrestricted by time limits and other external pressures.

The only conclusion then is that severe time restraints on exams do not effectively assess student knowledge or intelligence. Instead, they increase the disparities seen between advantaged and disadvantaged groups. Likewise, time limits increase the pressure and stress on students. This causes many groups to underperform, tests for different skills than those that determine real-world success, and affects certain demographics differently. This makes timed tests an unfair and ineffective means of evaluating student performance. Professors should therefore take steps to design shorter tests to fit within a longer time frame so that all students may have the best opportunity to succeed.

Appendix A. Correlation between general intelligence ( g -factor) and reaction time (RT) for the easiest and hardest questions on the PMAT test.

Note : Figure reprinted from Schirner M., Deco, G., & Ritter, P. (2023). Learning how network structure shapes decision-making for bio-inspired computing. Nature Communications . https://doi.org/10.1038/s41467-023-38626-y .

Figure B1. Percentage of correct responses for each scoring group.

Figure B2. Percentage of correct responses for each scoring group with unanswered responses removed.

Figure B3. Percentage of students from each scoring group that answered a given question.

Note : Figures reprinted from Clemens, N.H., Davis, J. L., Simmons, L. E., Oslund, E. L., & Simmons, D. C. (2014). Interpreting Secondary Students’ Performance on a Timed, Multiple-Choice Reading Comprehension Assessment: The Prevalence and Impact of Non-Attempted Items. Journal of Psychoeducational Assessment , 33 (2). https://doi-org.proxy.library.nd.edu/10.1177/0734282914547493 .

Appendix C. Mean (standard deviation) scores of old vs. young adults for five different divergent thinking tests.

Note : Table reprinted from Foos P. W., & Boone, D. (2008). Adult Age Differences in Divergent Thinking: It's Just a Matter of Time. Educational Gerontology , 34 (7), 587-594. https://doi.org/10.1080/03601270801949393 .

Works Cited

Clemens, N.H., Davis, J. L., Simmons, L. E., Oslund, E. L., & Simmons, D. C. (2014). Interpreting Secondary Students’ Performance on a Timed, Multiple-Choice Reading Comprehension Assessment: The Prevalence and Impact of Non-Attempted Items. Journal of Psychoeducational Assessment , 33 (2). https://doi-org.proxy.library.nd.edu/10.1177/0734282914547493 .

Foos P. W., & Boone, D. (2008). Adult Age Differences in Divergent Thinking: It's Just a Matter of Time. Educational Gerontology , 34 (7), 587-594. https://doi.org/10.1080/03601270801949393 .

Gernsbacher M. A., Soicher R. N., & Becker-Blease, K. A. (2020). Four Empirically Based Reasons Not to Administer Time-Limited Tests. Translational Issues in Psychological Science , 6 (2): 175–190. https://doi.org/10.1037/tps0000232 .

Gladwell, M. (Host). (2019, June 27). The tortoise and the hare [Audio podcast episode]. In Revisionist History . Pushkin. https://www.pushkin.fm/podcasts/revisionist-history/the-tortoise-and-the-hare .

Grant, A. (2023, Sept. 20). The SATs will be different next year, and that could be a game-changer. The New York Times . https://www.nytimes.com/2023/09/20/opinion/culture/timed-tests-biased-kids.html .

Meada, Y., & Yoon Yoon, S. (2013). A Meta-Analysis on Gender Differences in Mental Rotation Ability Measured by the Purdue Spatial Visualization Tests: Visualization of Rotations (PSVT:R). Educational Psychology Review , 25 , 69-94. https://doi.org/10.1007/s10648-012-9215-x .

Montolio, D., & Taberner, P. A. (2021). Gender differences under test pressure and their impact on academic performance: A quasi-experimental design. Journal of Economic Behavior & Organization, 191 , 1065-1090. https://doi.org/10.1016/j.jebo.2021.09.021 .

Schirner M., Deco, G., & Ritter, P. (2023). Learning how network structure shapes decision-making for bio-inspired computing. Nature Communications . https://doi.org/10.1038/s41467-023-38626-y .

Andrew J. Browning

Andrew Browning is a mechanical engineering student and member of the Class of 2027. Born in Chicago, Drew grew up in Kentucky in the greater Cincinnati area but now calls Carroll Hall his home. Inspired by his own experiences taking standardized tests, “Timed Tests and Their Effect on Student Performance” researches the consequences of time restrictions on students and highlights the disparities they cause. Drew thanks his Writing and Rhetoric professor, Miranda Macfarlane, for her invaluable feedback and encouragement during the writing process. Driven by a love for racing, engineering design, and community sports, Drew is a member of the FSAE Fighting Irish Racing team and athletic commissioner for Carroll Hall. Drew plans to continue living out his research mission by pursuing research in biomechanics and automotive engineering during his academic career.

Essay on Stress Management

500 words essay on stress management.

Stress is a very complex phenomenon that we can define in several ways. However, if you put them together, it is basically the wear and tear of daily life. Stress management refers to a wide spectrum of techniques and psychotherapies for controlling a person’s stress level, especially chronic stress . If there is effective stress management, we can help one another break the hold of stress on our lives. The essay on stress management will throw light on the very same thing.

Identifying the Source of Stress

The first step of stress management is identifying the source of stress in your life. It is not as easy as that but it is essential. The true source of stress may not always be evident as we tend to overlook our own stress-inducing thoughts and feelings.

For instance, you might constantly worry about meeting your deadline. But, in reality, maybe your procrastination is what leads to this stress than the actual deadline. In order to identify the source of stress, we must look closely within ourselves.

If you explain away stress as temporary, then it may be a problem. Like if you yourself don’t take a breather from time to time, what is the point? On the other hand, is stress an integral part of your work and you acknowledging it like that?

If you make it a part of your personality, like you label things as crazy or nervous energy, you need to look further. Most importantly, do you blame the stress on people around you or the events surrounding you?

It is essential to take responsibility for the role one plays in creating or maintaining stress. Your stress will remain outside your control if you do not do it.

Strategies for Stress Management

It is obvious that we cannot avoid all kinds of stress but there are many stressors in your life which you can definitely eliminate. It is important to learn how to say no and stick to them.  Try to avoid people who stress you out.

Further, if you cannot avoid a stressful situation, try altering it. Express your feelings don’t bottle them up and manage your time better. Moreover, you can also adapt to the stressor if you can’t change it.

Reframe problems and look at the big picture. Similarly, adjust your standards and focus on the positive side. Never try to control the uncontrollable. Most importantly, make time for having fun and relaxing.

Spend some time with nature, go for a walk or call a friend, whatever pleases you.  You can also try working out, listening to music and more. As long as it makes you happy, never give up.

Get the huge list of more than 500 Essay Topics and Ideas

Conclusion of the Essay on Stress Management

All in all, we can control our stress levels with relaxation techniques that evoke the relaxation response of our body. It is the state of restfulness that is the opposite of the stress response. Thus, when you practice these techniques regularly, you can build your resilience and heal yourself.

FAQ of Essay on Stress Management

Question 1: What is the importance of stress management?

Answer 1: Stress management is very efficient as it helps in breaking the hold which stress has on our lives. Moreover, you can also become happy, healthy and more productive because of it. The ultimate goal should be to live a balanced life and have the resilience to hold up under pressure.

Question 2: Give some stress management techniques.

Answer 2: There are many stress management techniques through which one can reduce stress in their lives. One can change their situation or their reaction to it. We can try by altering the situation. If not, we can change our attitudes towards it. Remember, accept things that you cannot change.

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Applying to college can be quite a stressful process for many. Between the essay prompts, documents, and deadlines, it’s hard not to feel overwhelmed by it all. At SEU, we want to make the application process as stress-free as possible! Here are our top tips on how to manage college application stress.

Plan Ahead 

It’s always a good idea to plan ahead and get an early start. This gives you time to truly think about your goals, motivations, and what you’re looking for in your college experience. Start by asking yourself things like what your academic and professional goals are, what are some non-negotiables for your college experience, how far away from home are you willing to go, and what is an ideal price range for tuition? When you start considering these things early on, you can make the process that much easier. 

Schedule a Visit

Scheduling a visit to campus is also a great way to feel connected to the process, and can help solidify any decisions you will make. A brochure or website can only show you so much. By touring a campus, you can get an inside look into what it is like to be a student at that college, and even get answers to questions through a one-on-one experience with admission counselors, faculty, staff, and current students that you would not have been able to get without visiting the campus.  You can schedule a visit to SEU here !

Stay Organized 

College applications, and all their components, often come with a lot of information to keep track of. It is important that you are on top of deadlines and the requirements for each application, but if you try to file all of this information in your head, it can get confusing and lead to stress. A great way to stay organized is by creating a folder that will hold things like college brochures, important information (like what you’ll need for filling out the FAFSA ), a list of contacts, account logins you’ll need to refer to often, etc. It’s also a good idea to set reminders in your Google or Apple calendar so that you don’t miss an important deadline.

Ask for Help 

Don’t be afraid to ask for help. It’s important to have people who can support you during this process. This can look like confiding in a trusted adult who has been in your shoes and knows what the college application process is like, or even a close friend who is going through this process as well. Your school guidance counselor or college/career counselor can also be a great source of information. Don’t forget, our team of enrollment counselors here at SEU are always available to help! Having a good support system can greatly minimize stress, and you’ll be glad you asked for help.

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When applying to college, you’ll want to make sure that the college you’re checking out offers programs you are passionate about. At SEU, we offer more than 100 degree programs at the associate, bachelor’s, master’s, and doctoral levels. You might already know what career field you want to pursue, or you might need a little more time to figure it out. If you are unsure about what you want to study, don’t worry! Our completely revised Foundational Core Experience and Divine Design credits give you the space to explore your interests and discover your calling without losing time or being penalized for deciding on a different path. SEU also has plenty of additional student support resources like our Career Services office and academic advising .

Know Your Limits and Be True to Yourself

If at any time during the application process you start to feel overwhelmed, it is completely okay to just take a step back and breathe. It is important to know your limitations and when something is becoming more than you can handle at a certain point in time. Clearing your mind, whether that be by going for a walk or doing something that brings you joy, will help you come back to that application with a fresh perspective.  It is also important to know your goals and motivations, and pursue the things that you are passionate about. Not everyone’s application process will look the same, and everyone moves at a different pace. So if you start to feel overwhelmed and anxious, remember that your application journey is your own, and we’re here to provide you with all the resources you’ll need!

Pray About It

New chapters in your life can be simultaneously exciting and overwhelming, but no matter what, remember to give it all to God. Praying throughout the process will not only help you through, it will help you discern where God is calling you. 

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Honors student produces prize-winning research on loneliness

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In her honors thesis, recent graduate Amber Duffy describes how loneliness influences a person’s ability to respond to stress

Amber Duffy, who graduated last semester magna cum laude , didn’t always plan to write an honor’s thesis.

She came to the University of Colorado Boulder on a pre-med track, studying neuroscience, but an introductory psychology class knocked her off that path and inspired her to change her major.  

“I really liked the behavioral aspect of psychology,” she says.

She liked psychology so much, in fact, that she wasn’t content simply to study it. She wanted to contribute to it. “If I’m not going to do medical school anymore,” she remembers thinking, “I should delve into research.”

Recent psychology and neuroscience graduate Amber Duffy won the the Outstanding Poster Presentation Talk award at the Society for Personality and Social Psychology’s Annual Convention in San Diego, recognizing her research on loneliness.

She contacted Erik Knight , a CU Boulder assistant professor of psychology and neuroscience, with whom she’d taken a class her sophomore year, and he invited her to join his lab . She ended up working there for two years, during which time she decided to write an honor’s thesis.

The topic? Loneliness and its effect on young adults’ stress responses.

Why loneliness?  

Duffy’s interest in loneliness isn’t purely academic. Many of her friends and family have struggled with it for years, even before the pandemic, she says. And she herself, the daughter of a Taiwanese mother and a Pennsylvanian father, has often felt its sting.  

“Growing up in a multicultural family in my predominantly white town”—Castle Rock, Colorado—“it was hard for me to connect with people sometimes,” she says. “I would learn about my mom’s culture at home and then go to school or talk with friends, and they just didn’t understand how I lived.”

Her concerns over loneliness only increased when she learned of Surgeon General Dr. Vivek H. Murthy’s warning that the United States is suffering from a loneliness epidemic.

“The mortality impact of being socially disconnected is similar to that caused by smoking up to 15 cigarettes a day,” Murthy states.  

Hearing this spurred Duffy to action. She wanted to contribute to the fight against loneliness and its potentially negative consequences.

“If we expand our knowledge of loneliness,” she says, “maybe there’s a way we can come up with a more substantial treatment.”

More gas, less brakes

For her honors experiment, Duffy gathered 51 CU Boulder undergraduates between the ages of 18 and 34 and divided them randomly into a control condition and an experimental condition. Those in the former provided a low-stress comparison to those in the latter, who were put through the wringer.

First, the subjects in the experimental condition had to interview for a high-stakes job Duffy and Knight had concocted specifically for the study.

“We told them, in the moment, ‘You have five minutes to prepare a five-minute speech on why you’re the perfect applicant,’” says Duffy.

Immediately following that, subjects had to solve subtraction problems for five minutes, out loud, perfectly, starting at 6,233 and going down from there in increments of 13. “If they made a mistake,” says Duffy, “they had to start over.”

While the subjects ran these gauntlets, Duffy monitored their heart-rate variability (HRV), or the change in interval between heartbeats, and their pre-ejection period (PEP), or the time it takes for a heart to prepare to push blood to the rest of the body. Both serve as indicators of how a person’s stress-response system is functioning, Duffy explains. 

Finally, when the stress tests were done, the subjects completed the UCLA Loneliness Scale Version 3 questionnaire, which research has found to be a reliable means of measuring loneliness.

Duffy had hypothesized that lonelier subjects would have more pronounced stress responses than less lonely subjects, and indeed that’s what her data revealed.

Lonelier subjects had higher heartrates, stronger responses from their sympathetic nervous systems (SNS) and weaker responses from their parasympathetic nervous systems (PNS). Duffy likens the SNS, which controls the fight-or-flight response, to a car’s gas pedal and the PNS, which counterbalances the SNS, to a car’s brakes.

When met with stressful situations, then, lonelier individuals had more gas and less brakes, which Duffy says could have long-term health implications.

Yet she is also quick to point out that more research needs to be done, preferably with more subjects.

If we expand our knowledge of loneliness, maybe there’s a way we can come up with a more substantial treatment.”

“We only had 51 people. An increase in sample size would help with more reliable data,” she says. “It’s also important to look at more clinical and diverse populations because there are other factors that could affect loneliness levels.” 

Posters, prizes and professorships

Duffy submitted an abstract of her research to The Society for Personality and Social Psychology’s Annual Convention in San Diego, where she hoped to present a poster, thinking this would be a nice, low-key way of getting some conference experience under her belt.

Her abstract was accepted. But then a conference organizer asked her if, in addition to presenting a poster, she could also give a fifteen-minute talk. She would be the only undergraduate at the conference to do so.

Duffy balked. The thought of speaking to a roomful of PhDs intimidated her. “Most of my life I’ve heard how cutthroat academia is,” she says. But she ultimately agreed, and she was glad she did.

Her talk and poster presentation went so well that not only did she receive interest and encouragement from several doctoral programs, but she also won an award that she didn’t even know existed: the Outstanding Poster Presentation Talk award.

“In the middle of my poster presentation, a woman came up to me—I didn’t know who she was—and said, ‘I have a check here for you for $500.’ I didn’t know that was supposed to happen, but it was great!”

Now graduated, Duffy isn’t 100% sure what her next steps will be, but she’s leaning toward one day pursuing a PhD. 

“When you get a PhD, you get to do research and also work with students,” she says. “I think it would be fun to be a professor and give back in that way.”

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PTSD, anxiety is rising among college students

by Ernie Mundell

America's college students seem to be more stressed than ever, with a new report finding a sharp rise in cases of post-traumatic stress disorder (PTSD) and acute stress disorder (ASD) on campuses across the country.

In a "national sample of U.S. college students , we found a notable increase in the prevalence of PTSD and ASD," concluded a team led by Yusan Zhai, of the University of Alabama at Birmingham.

Rates of PTSD rose by 4.1 percentage points between 2017 and 2022, and stress disorder diagnoses rose by 0.5 percentage points, the data showed.

Their findings were published in the journal JAMA Network Open .

As Zhai's group explained, any number of events—campus shootings, sexual assault , physical violence and natural disasters , for example—can trigger either PTSD or ASD. PTSD can lead to more persistent symptoms, while ASD's impact may be more transient—anywhere from a few days to a month.

In their study, the Birmingham researchers focused on 2017 through 2022, "a period marked by escalated societal stressors and global health crises," including, of course, the pandemic.

They looked at data from the ongoing Healthy Minds study, which tracks the mental health of over 392,000 people attending 332 different colleges and universities across the United States. About 58% of the students were female.

The data showed that during the study period, 19,349 (4.9%) of the college students had been diagnosed with PTSD, while 1,814 (0.5%) had been given a diagnosis of ASD.

"We observed upward trends in the prevalence of PTSD and ASD from 2017 to 2022," Zhai and colleagues wrote.

PTSD rates rose from 3.4% of participants in 2017-2018 to 7.5% by 2021-2022, and acute stress disorders rose from 0.2% to 0.7% over the same period.

The study wasn't designed to detect the main drivers of these trends. However, they "highlight the escalating mental health challenges among college students, which is consistent with recent research reporting a surge in psychiatric diagnoses," the researchers said.

Still, they speculated that pandemic-related losses (for example, the deaths of loved ones), campus shootings and racial trauma on and off campus might be contributing factors.

Whatever the reasons, the findings "suggest the need for targeted, trauma-informed prevention and intervention strategies by mental health professionals and policy makers to support the affected student population," Zhai and colleagues wrote.

Yusen Zhai et al, Trends in Diagnosed Posttraumatic Stress Disorder and Acute Stress Disorder in US College Students, 2017-2022, JAMA Network Open (2024). DOI: 10.1001/jamanetworkopen.2024.13874

2024 HealthDay. All rights reserved.

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• Open access
• Published: 05 June 2024

Stress management: how does the academic staff cope with it? a cross-sectional study at the university of Udine

• Olivia Giulia Bianca Vacchi   ORCID: orcid.org/0009-0007-6429-9434 1 ,
• Diana Menis   ORCID: orcid.org/0000-0002-9175-8831 1 ,
• Enrico Scarpis   ORCID: orcid.org/0000-0002-1471-486X 1 ,
• Annarita Tullio   ORCID: orcid.org/0000-0003-3332-7459 2 ,
• Benedetta Piciocchi   ORCID: orcid.org/0000-0003-4918-697X 1 ,
• Silvia Gazzetta   ORCID: orcid.org/0009-0001-2445-9217 1 ,
• Massimo Del Pin   ORCID: orcid.org/0000-0003-2666-8853 1 ,
• Edoardo Ruscio   ORCID: orcid.org/0000-0002-1688-1637 1 ,
• Silvio Brusaferro   ORCID: orcid.org/0000-0003-1018-7094 1 &
• Laura Brunelli   ORCID: orcid.org/0000-0002-5475-0021 1 , 3  

BMC Public Health volume  24 , Article number:  1509 ( 2024 ) Cite this article

Metrics details

Increasing work-related stress in academia can have an impact on physical and mental health. The aim of this study was to analyse the coping strategies of staff employed at the University of Udine and to verify whether sociodemographic data, professional position, and the presence of anxiety or depression symptoms are related to the use of different coping strategies.

We conducted a cross-sectional study between June and December 2020 using the Brief COPE questionnaire. We correlated coping strategies with professional position, sociodemographic data, and the presence of anxiety or depressive symptoms measured with the Patient Health Questionnaire–9 and the General Anxiety Disorder–7.

A total of 366 people participated in the study, including 109 junior academics, 146 senior academics, and 111 administrative staff (response rate 23.6%). The three most frequently used coping strategies in terms of approach coping style were planning (6.77 ± 1.41), active coping (6.58 ± 1.45) and acceptance (6.23 ± 1.44). Women were more likely than men to report using approach and avoidant coping strategies ( p  < 0.001). Positive reframing and religion were most commonly used by administrative staff ( p  < 0.05), in contrast to junior academics, who were more likely to use substances and self-blame ( p  < 0.05). Anxiety was found to correlate with self-blame (OR 1.94) as a coping strategy, while depression was associated with venting (OR 2.83), self-blame (OR 3.27), and humor (OR 3.02).

Identifying profiles of coping strategies can help higher education institutions to implement support strategies for the academic community, ultimately promoting healthier lives and more effective teaching and research. Our study has shown that women and junior academics among staff at the Udine University would benefit from a tailored health promotion intervention that encourages the use of approach coping styles to reduce their risk of developing anxiety and depressive symptoms.

Peer Review reports

Introduction

Stress is commonly described as the perception of an imbalance between the demands and the individual’s ability to respond to a situation with their resources [ 1 ]. However, stress can be divided into two different types and, according to Seyle’s definition (cited in Bienternova-Vascu et al., 2020), there is a “distress”, i.e. when the stress response is triggered by negative stressors, and a “eustress”, when the stress response is triggered by stimulating factors. In addition, the author emphasizes that stress is not what happens to someone, but how that person reacts to it [ 2 ].

When chronic stress is inadequately managed, it leads to burnout, which in turn is a risk factor for anxiety and depression [ 3 ].

The consequences of stress affect people’s health, their personal lives, and cause direct and indirect costs to the economy [ 4 , 5 ], estimated by the American Psychological Association at 500 billion dollars and 550 million workdays per year in the United States [ 6 ].

Traditionally, the academic category has been characterized by low levels of stress [ 7 ], which may be related in part to the notion that autonomous/self-managed work, such as that of an academic, is less stressful because one has direct control over one’s activities, which act as a buffer against work stress [ 8 ]. However, in the last decade, academics in Italy have been given a variety of tasks related to bureaucratic and social issues as part of a national reform. The former is related to the increasing popularity of temporary contracts, management tasks [ 9 ], and financial pressures as academics are expected to attract external funding [ 10 , 11 ]. Social issues include the competitive climate [ 5 ], loss of collegiality and support among colleagues [ 9 ], and lack of recognition [ 12 ].

In studies conducted at New Zealand and Australian universities, academics reported stress in up to 40% of respondents, more than general university staff [ 10 , 12 ]. Some authors believe that there is a link between stress and seniority in academics [ 13 ], while others found that stress is more common in younger academics [ 5 , 7 , 14 ], a category that typically has job instability [ 15 ]. Considering that temporary employment is one of the main causes of stress among academics [ 5 , 9 ], this issue is of great importance as PhD students, who are typically the youngest category of academics, are an important source of scientific progress [ 16 ]. The causes of stress in younger academics can also be seen in other aspects, such as lack of skills or experience in performing their own tasks and in leadership and management roles [ 9 ]. In addition, academics report the pursuit of publications [ 11 ], too much paperwork [ 5 ], inadequate salary [ 11 ], lack of promotion [ 5 , 9 ], and the competing demands of career and family life [ 11 ].

Stress management interventions can be categorized as primary (i.e., to prevent stress), secondary (i.e., to reduce the severity and duration of stress), or tertiary (i.e., to rehabilitate people already suffering from a mental illness) [ 17 ]. This classification can be made at both the individual and organizational level. Some authors also refer to a third intermediate category, the individual-organizational level, which aims to change the relationship between the individual and the organization [ 17 ].

At the organizational level, interventions should focus on job redesign, which aims to change the characteristics of the workplace to improve employee well-being (e.g., workplace discretion, workload, ergonomic design) [ 17 ], or to reduce role ambiguity by creating laws and regulations that define the expectations of a particular job [ 18 ].

On an individual level, some examples are cognitive-behavioural techniques [ 3 , 17 ], mindfulness [ 17 ], relaxation techniques (e.g., yoga, massage) [ 3 , 9 , 17 ], leisure activities [ 3 ], biofeedback [ 19 , 20 ], talking to colleagues [ 9 ], and flexible working conditions (e.g., part-time work and working from home one day a week) [ 9 , 20 ]. These various techniques for coping with stress at an individual level are referred to as coping strategies.

Individual ability to cope with stress also depends on personality [ 21 ], but there is a lack of systematic and comprehensive assessment of these aspects [ 22 ].

Coping strategies are indeed broad and refer to a variety of efforts to minimize the stress associated with negative life experiences (adaptive vs. maladaptive, active vs. passive, positive vs. negative, problem-oriented vs. emotion-oriented), and each of these strategies can be examined using specific questionnaires. Only a few studies have investigated coping strategies within the university [ 22 ], but most of them investigated coping strategies in a qualitative way using interviews [ 8 , 14 , 23 , 24 , 25 ], without applying an instrument with specific psychometric properties. This also makes it difficult to compare coping strategies between different studies.

As a result, there is still a lack of knowledge about the current use of coping strategies in the academic community. No data is available for the University of Udine. As this category of staff is crucial in terms of educating the new generations and for the creation of new knowledge, we can say that in universities progress and our future are being pursued and therefore studying and tracking the well-being of university staff is a priority.

Given the lack of specific quantitative data on coping with stress in the academic context, the present study therefore aimed primarily to analyse the coping strategies used by professionals in academia to deal with the main stressors they are exposed.

An accurate assessment of the coping strategies used by academic staff could be useful to implement targeted interventions to increase the resilience of the most vulnerable categories among academic staff (e.g., those who use maladaptive coping strategies).

Based on the hypothesis that age, type of employment contract, and different types of responsibilities may influence the use of specific coping strategies, we also wanted to investigate whether there was a relationship between coping style and occupational role (junior academics, senior academics and administrative staff). Referring to the literature, we wanted to confirm that age, sex, marital status, education, academic department, years of work experience, and symptoms of anxiety and depression could influence the use of different coping strategies.

This study wanted to obtain data for targeting interventions to provide prevention and support strategies for university members to increase their resilience to stress, to prevent burnout and improve psychosocial wellbeing. These data could also be useful for pursuing psychosocial well-being of academic staff in order to target interventions situated at a more organizational level.

Study design and setting

This was a cross-sectional study conducted at the University of Udine to investigate the coping styles of academics. The study was conducted between June and December 2020. The data on coping strategies were collected as part of a cross-sectional study (UN-SAD: Symptoms of Anxiety and Depression within the UNiversity community) conducted at the University of Udine, with the aim of investigating the mental health of academics [ 26 ]. This university is attended by approximately 15,000 students annually. The university was founded in 1978 and currently (in 2023) has 692 professors and researchers, 477 technical and administrative staff. The university is located in Northeastern Italy in a region called Friuli Venezia Giulia which has about 1.000.000 inhabitants. The region borders with Austria and Slovenia and the Italian region of Veneto. The main location of the university is set in the city of Udine which counts about 98.000 inhabitants, but there are branches in Pordenone, Gemona del Friuli and Gorizia.

Participants

All academic and administrative staff, assistants, fellows and short-term employees in all academic departments (Business and Economics, Life Sciences and Medicine, Basic Sciences and Engineering, Humanities, Political Sciences) with a total of about 1,500 eligible participants, were included in the study; only visiting professors were excluded.

Recruitment

We sent invitations through internal academic mailing list to all institutional email addresses to participate in the survey and reminders shortly before the deadline.

Data collection

Data collection took place between June and December 2020 via an anonymous online survey with a total of 69 items. The survey was conducted as a part of a broader study (the original UN-SAD study) [ 26 ], which aimed to identify the prevalence of depressive and anxiety symptoms among academic professionals, considering three groups: junior academics (i.e., on fixed-term contracts: researchers, post-doctoral researchers, PhD students), senior academics (i.e., on tenured contracts: full professors, associate professors, and researchers with tenured contracts), and administrative staff. It included a sociodemographic data section (age, sex, occupation, education, academic department, marital status, years of work experience and commuting distance) and two validated psychological assessment tests: Patient Health Questionnaire–9 (PHQ-9) [ 27 ] for depressive symptoms and General Anxiety Disorder–7 (GAD-7) [ 28 ] for anxiety symptoms. A special part of the survey examined coping styles using the Brief COPE (Coping Orientation to Problems Experienced) questionnaire [ 29 ]. The survey was conducted in Italian.

Research instruments

Questionnaire on coping orientation to problems experienced (brief cope).

The Brief COPE is a widely used instrument for investigating effective and ineffective coping styles in response to stressful life events. This questionnaire has been used in different countries [ 24 , 25 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 ], including Italy [ 38 ], on different population groups, which is why we chose this questionnaire to ensure cross-cultural applicability and comparison with previous literature. The scale also has good psychometric properties for the Italian sample [ 39 ]. This instrument consists of 28 items divided into 14 scales. The questionnaire divides the coping strategies into denial, substance use, venting, behavioural disengagement, self-distraction, self-blame, active coping, positive reframing, planning, acceptance, seeking emotional support, seeking information support, religion, and humor. Each scale is represented by a score, which is the sum of the two items measured on a 4-point Likert scale. The scales range from two to eight: the higher the score, the more the specific coping strategy examined on the scale is used. The instrument does not offer the possibility of calculating an overall score.

The coping strategies can be divided into two large groups: the first six coping styles can be classified as avoidant coping and the second six as approach coping. Humor and religion are neither approach nor avoidant coping styles [ 40 ]. The first group includes coping styles in which the person approaches a stressor to seek information or social support, plan ahead, and try to solve the problems. The second group describes a passive strategy of moving away from a stressor, or an active strategy of moving away from or trying to escape from the stressor [ 40 ]. Specifically, six scales of the Brief COPE questionnaire address approach coping strategies (active coping, positive reframing, planning, acceptance, seeking emotional support, and seeking information support), while the other six scales examine avoidant coping strategies (denial, substance use, venting, behavioural disengagement, self-distraction, and self-blame); the two additional scales address the use of religion and humour, which are neither approach nor avoidant styles.

Patient Health Questionnaire–9 (PHQ-9)

This test was selected for psychological assessment because it has good sensitivity and specificity for the presence of depressive symptoms [ 27 ]. The scale has also good psychometric properties for the Italian sample [ 41 ]. The PHQ-9 is the 9-item depression module of the full PHQ. If five or more of the nine criteria for depressive symptoms were present on at least “more than half of the days” in the last two weeks and one of the symptoms is depressed mood or anhedonia, major depression can be diagnosed. If two, three, or four depressive symptoms have been present on at least “more than half of the days” in the past two weeks and one of the symptoms is depressed mood or anhedonia, other types of depression can be diagnosed. If the symptom “thoughts that you would be better off dead or thoughts about hurting yourself in some way” is present, it counts regardless of duration. Responses to the questionnaire are reported on a 3-point Likert scale, so the PHQ-9 score can range from 0 to 27, as each item can be scored from 0 (not at all) to 3 (almost every day) [ 27 ].

General anxiety Disorder–7 (GAD-7)

The GAD-7 is a validated test for the psychological assessment of anxiety symptoms [ 28 ]. This test was selected for psychological assessment because it has good sensitivity and specificity for the presence of anxiety symptoms. The scale has also good psychometric properties for the Italian sample [ 41 ].

The questionnaire consists of seven items asking about anxiety related problems in the last two weeks. The answers are given on a 4-point Likert scale, so that the questionnaire can range from 0 to 21 points. It serves as a screening tool for anxiety symptoms, so scores of five, 10, and 15 are considered to be the cut-off points for mild, moderate and severe anxiety, respectively. If the score is 10 or higher, further testing is recommended [ 28 ].

Sample size

The sample size was calculated for the original UN-SAD study with a 95% confidence level and based on the hypothesis of a different prevalence of minor psychiatric disorders in the three groups (junior academics, senior academics and administrative staff) [ 26 ]. The same individuals were interviewed using the Brief COPE questionnaire, which was also included in the original UN-SAD questionnaire.

We could find no previous data on the coping strategies used by academics at the University of Udine, so we hypotized that avoidant and approach coping styles might be evenly distributed in this population. Assuming that the prevalence of approach and avoidant coping styles was 50% in each group, and using the same 95% confidence level, we calculated an accuracy of 9% with the collected UN-SAD questionnaires. The study was approved by the Institutional Review Broad of the University of Udine, Italy.

Data analysis

Descriptive analyses were carried out for all variables. Data were presented as frequencies and percentages for categorical variables and as means ± standard deviations or median ± interquartile range (IQR) and minimum and maximum values for continuous variables. Results were presented as both categorical (values from two to eight) and dichotomous variables (avoidant or approach coping style). Chi-square tests and Fisher’s Exact tests were used where appropriate to assess the possible association between categorised variables. Student’s t-test, Wilcoxon–Mann–Whitney test, or Kruskal-Wallis test were used to compare continuous variables based on the Kolmogorov–Smirnov normality test. Binary univariate and multivariate logistic regression analyses were used to assess the association with dichotomous outcomes. Regression results were expressed as raw and adjusted ORs with 95% CI and p -values. The significance level was set at 0.05. All statistical analyses were performed using R. software, version 3.4.2 (R Foundation for Statistical Computing, Vienna, Austria) [R: The R Project for Statistical Computing. Available at: https://www.r-project.org/ . [Last accessed 2022 Aug 13]].

A total of 366 academic professionals responded to our survey, which corresponds to a response rate of 23.6% (366/1,550). The professional groups were evenly distributed between senior academics (N. 145; 39.9%), administrative staff (N. 111; 30.3%), and junior academics (N. 109; 29.8%). The majority of respondents in the groups of junior academics and administrative staff were women, namely 53.2% (N. 58) and 77.5% (N. 86), respectively, while the senior academics were predominantly men (N. 86; 58.9%). The mean age of the participants was 47.9 ± 12.0 years, with the junior academics being younger than the others (33.2 ± 6.4 years). The majority of respondents among senior academics and administrative staff were married/cohabiting (79.5% and 78.0%, respectively), while most junior academics (61.5%) were single. Thirty-three (9%) of respondents were divorced/separated or widowed. The most common position among senior academics was associate professor (N. 70; 47.9%), while junior academics were mostly fellows (N. 55; 50.5%). The sociodemographic characteristics of the respondents are presented in Table 1 . The full description of the characteristics of the respondents is included in the original article by Scarpis et al. [ 26 ].

As shown in Table  2 , the three most frequently used coping strategies in terms of approach coping style were planning (mean ± SD, 6.77 ± 1.41), active coping (6.58 ± 1.45), and acceptance (6.23 ± 1.44). The least used strategies related to avoidant coping styles included behavioural disengagement (2.90 ± 1.19), denial (2.49 ± 0.93), and substance use (2.20 ± 0.78). Overall, all other coping styles belonging to the approach and avoidant groups were used about equally often. Humour and religion were also in the middle range, although they were among the three least common. Women were more likely than men to use approach coping strategies based on external support - informational support (5.31 ± 1.54) and emotional support (5.09 ± 1.57), positive reframing (5.51 ± 1.63), and planning (6.88 ± 1.40), and avoidant coping styles such as self-distraction (5.28 ± 1.57), venting (5.10 ± 1.53), and self-blame (5.88 ± 1.38). Women were also more inclined to use religion than men (3.64 ± 1.91). In terms of occupational groups, positive reframing (5.59 ± 1.73) and religion (4.05 ± 2.03) were most frequently used by administrative staff compared to junior and senior academics. In contrast, junior academics were less likely than others to use acceptance (5.89 ± 1.43) and planning (6.48 ± 1.44), while they were more likely to use substances (2.46 ± 1.24) and self-blame (5.92 ± 1.58). Finally, senior academics were found to be less likely to use the denial strategy (2.35 ± 0.78) than younger colleagues and administrative staff.

Multivariate analysis revealed, in a statistically significant manner, that men were less likely than women to use positive reframing (OR 0.47), information support (OR 0.34), emotional support (OR 0.3), self-distraction (OR 0.53) and self-blame (OR 0.33). The presence of anxiety, as measured by the GAD-7, was statistically significantly negatively correlated with the use of positive reframing (OR 0.45) and positively correlated with self-blame (OR 1.94) as a coping strategy. The presence of depression assessed with the PHQ-9 was statistically significantly negatively associated with the use of active coping (OR 0.32) and planning (OR 0.46), whereas there was a positive correlation with the use of venting (OR 2.83), self-blame (OR 3.27), and humor (OR 3.02). The results of the multivariate analysis are shown in Table  3 . No significant association was found for age, occupation, education, academic department, years of work experience, and commuting distance. The only significant association was found with marital status: married individuals used humor less often than unmarried individuals, separated/divorced individuals used acceptance less often than unmarried individuals, and married and separated/divorced individuals used positive reframing less often than unmarried individuals.

The aim of our study was to investigate the use of different coping strategies to deal with stress in academia and to examine whether there is an association with professional position, sociodemographic data, and the presence of anxiety/depressive symptoms, as reported in the original paper [ 26 ].

The distribution of the study participants’ characteristics was close to the available data on Italian administrative staff, junior and senior academics [ 42 ].

Our results showed that the three most frequently used coping strategies in terms of approach coping style included planning, active coping and acceptance. The least used strategies related to avoidant coping styles included behavioural disengagement, denial, and substance use. Overall, all other coping styles belonging to the approach and avoidant groups were about equally used.

Humour and religion were also in the middle range. Similarly, adaptive coping strategies (acceptance, active coping, positive reframing) were most frequently used in the Lee et al.’s study involving students and university employees (i.e., academics and administrative) [ 8 ]. This study differs from our study in that it included both staff and students as participants. However, in a subgroup analysis, the only two coping strategies that were used more frequently among academic staff than students were positive reframing and religion. On the other hand, the study has similarities in that it was conducted during the COVID-19 pandemic. This is an important factor when considering that the use of a particular coping style is influenced by both the predisposition of the individual and the context in which it is used (e.g., social context, duration, and exposure to the stressor).

However, in a study conducted among academics at universities in Malaysia, maladaptive coping strategies were more prevalent than adaptive ones [ 43 ]. The author’s interpretation was that the stress load was so high that the assumption of an adaptive coping pattern did not work. In another recent study, the two most prevalent coping strategies among academic staff at a Northern Irish university were substance use and behavioural disengagement (both of which are avoidant strategies) [ 34 ].

However, it should be noted that these data [ 8 , 34 , 43 ] should be interpreted with caution as the Brief COPE questionnaire was used in different ways: some authors calculated the total score for each participant [ 8 ], others used a shortened version [ 34 ], and still others used a modified Likert scale [ 43 ].

Differences in the coping strategy used can affect people’s ability to manage problems in an effective way, leading to different individual and collective outcomes. For example, people who use active coping strategies have been found to have higher self-esteem and attempt to purposefully cope with problems by seeking social support, whereas those with passive coping strategies have lower self-esteem and seek self-imposed social isolation [ 37 , 44 ]. In addition, the problem-oriented coper with active coping and planning aims to eliminate the stressor, whereas the emotion-oriented coper with venting, positive reappraisal, rumination, and self-blame aims to change their emotional response to the stressor [ 45 ].

Gender and coping styles

Overall, we found in this study that women reported coping strategies more frequently than men. This was particularly true for some approach coping styles (i.e. positive reframing, use of informational support, emotional support, and planning), as well as for avoidant coping styles (i.e. self-distraction, venting, and self-blame). Women were also more likely to use religion to cope with stress.

In our study, we found that women were more likely than men to use external support-based approach coping strategies (i.e., informational support, and emotional support, positive reframing, and planning), and avoidant coping styles (i.e., self-distraction, venting, and self-blame), and that, they generally tended to use more coping styles than men.

Conversely, Darabi et al. found no statistically significant differences in coping strategies between men and women in British academics [ 30 ].

Likewise to our findings, Kataoka et al.’s study of gender differences found that women employed at a Japanese university were significantly more likely to use self-distraction, emotional support, informational support, behavioural disengagement, venting, and self-blame [ 25 ].

Similarly, we reported that women were generally more likely to use coping strategies than men, not only those they mentioned, but also positive reframing and planning. In contrast, we found no gender differences in behavioural disengagement.

The cluster analysis conducted by Doron et al. revealed that individuals typically fall into four subgroups [ 36 ]. The first group includes individuals who frequently seek external support and distraction (high-copers); the second group consists of participants characterized by high use of problem solving and moderate cognitive restructuring (adaptive copers); the third group is represented by individuals with high avoidance (avoidant copers); and the fourth group includes individuals with high cognitive restructuring (low-copers). Their results seem to confirm the existing difference between men and women in coping styles, as women were overrepresented in the high copers and avoidant copers groups, while men were mainly represented in the low copers group [ 36 ].

Zehra et al. investigated the coping strategies of residents in an emergency department in Pakistan [ 31 ]. Similar to our results, they found that all coping strategies, except for substance use, were predominantly chosen by women.

Our observation that women are more likely than men to use coping strategies related to emotional support confirms what Marinaki et al. found at Greek universities [ 46 ]. The study by Marinaki et al. included academic staff at Greek public universities and found that female academics were more likely to seek social support than their male counterparts. However, they did not use the same instrument to assess coping styles, which makes it difficult to compare their results with ours.

The greater use of some coping strategies by women may be related to the greater burden of mental health problems [ 47 ] and stress [ 37 ] reported to affect them.

Another reason for stress in female academics could be job role: a recent study showed that female employees at a university in gender-incongruent roles reported higher levels of stress than men in a gender-incongruent role [ 23 ].

As mentioned earlier, these differences between men and women could be due to differences in exposure to stress triggers, but also to differences in perception or reporting. Although it could be argued that women’s stress levels may be higher, the observed tendency to rely more on emotions could mean that they are more sensitive to external or internal stressors that have been reported to affect academics, such as excessive workload, job insecurity, and lack of support [ 22 ]. In addition, the fact that they seek external support to a high degree could be the reason for the increased reporting of this phenomenon. Our study did not focus on issues of equality, diversity and inclusion (EDI issues), we did not investigate whether participants felt part of a marginalized group. Unfortunately, data collected by the Equal Opportunities Committee of the University of Udine, published in their annual report [ 48 ], still confirms an important gender gap in the roles of professors and researchers (e.g., only 25% of full professors are women, and there is also a glass ceiling, as women are mainly represented at the base of the pyramid as students, and become fewer and fewer towards the top as full professors and the management levels). Consequently, it is possible that some of the stress faced by female academic staff is related to the gender gap, but since we did not investigate feelings of the marginalization, we could not relate coping style to EDI issues.

Occupational role and coping styles

In terms of occupational groups, positive reframing and religion were most frequently used by administrative staff compared to junior and senior academics, while junior academics resorted to substances and self-blame more frequently than others. Finally, senior academics were found to use the denial strategy less frequently than junior colleagues and administrative staff.

In contrast to the reports of Marinaki et al. [ 46 ], we found different patterns of coping styles among administrative staff, junior and senior academics. To some extent, the differences between junior and senior academics may also be considered as differences in experience, as senior academic positions are often given to more experienced professionals. Some studies suggest that coping strategies may change over the course of a career, shifting from a problem-oriented coping strategy to an emotion-oriented coping strategy [ 49 , 50 ]. This could be due to different problems that a person faces at different stages of their career, e.g., decisions in the early career years that may be crucial for the development of the young academic, while activities in the late career years are more routine. Some authors argue that this difference is related to age, as younger people experience life-changing events (e.g., marriage, birth of children), whereas older people mostly experience routine or loss events (e.g., loss of health or loved ones) [ 49 ]. Another study conducted in an academic setting that indirectly examined the differences between the coping strategies of different age groups is that of Lee et al. In their case, the older group of administrative and academic staff used positive reframing and religion more frequently than the younger group of students [ 8 ]. Similarly, we showed that positive reframing and religion were most frequently used by administrative staff compared to junior and senior academics.

In addition, our study showed that junior academics were less likely than others to use acceptance and planning, whereas they were more likely to use substances and self-blame. A higher prevalence of stress [ 5 ] and depression [ 26 ] has already been reported in younger academics. In addition, a worrying overlap has been found between burnout, depression, and substance abuse [ 51 ] and between feelings of inadequacy, hopelessness, and self-blame associated with depressed mood [ 52 ].

To cite the Lee et al. article again, we must consider that the context of the COVID-19 pandemic may have influenced the results of the study. Positions associated with a stable job that provided income during lockdown may have led to less frequent use of avoidant coping strategies such as substance use and self-blame compared to more unstable positions, such as those held by junior academics [ 8 ].

Mental health and coping styles

Our findings suggest that there is some association between mental health status (anxious or depressed) and the coping strategies that individuals typically use, as was also the case in the study by Kataoka et al. [ 24 ]. In both studies, an association was found between mental health problems and the use of avoidant coping styles, although not in relation to the same strategies, with the exception of self-blame. As in our study, Kataoka et al. also found a significant correlation between anxiety and self-blame [ 24 ]. Although coping styles were measured with the same instrument, the limitation of this comparison is that anxiety symptoms were assessed with different questionnaires.

On the other hand, our results differ from those previously reported in the study by Batsikoura et al. [ 35 ]. In their case, the use of denial, behavioural disengagement, and substances were positively correlated with anxiety scores, whereas humor, acceptance, and planning were negatively associated with anxiety. In the Greek general population over the age of 18, the use of self-blame was positively correlated with anxiety, similar to our results, and the risk of anxiety when using positive reframing was lower in the same group. However, as the questionnaire used to assess anxiety in the study by Batzikoura et al. differs from the questionnaire used in our study, a true comparison is not possible [ 35 ].

Other studies in Italian and Australian populations, confirmed that approach coping styles were associated with lower levels of anxiety and depressive symptoms, and added that avoidant coping strategies were significantly associated with higher levels of anxiety and depression [ 38 , 53 ].

Also, in the study by Agha et al. in which the 28 items of the Brief COPE were categorized into four subscales (i.e., active avoidance, problem-focused, positive coping, religious/denial), there is a significant association between anxiety and depression and the subscales with avoidant coping strategies: active avoidance and religious/denial [ 54 ].

It is important to consider the social and cultural context as it may lead to relevant differences in the results. For example, in Muslim cultures, the two most commonly used coping styles were religion and acceptance, both in the general population [ 55 ] and among university students [ 56 ] and in a population with anxiety and depressive symptoms [ 33 ].

Limitations and strengths of the study

Although the use of a validated instrument is a methodological strength, it made it difficult to compare our results with other studies conducted in academia using other instruments. In addition, we found some heterogeneity in the use of terms and classifications to describe the different coping styles (e.g., approach/avoidant, active/passive, positive/negative, adaptive/maladaptive, problem/emotion-oriented), which made such comparisons difficult. The design of our study, which was cross-sectional and involved only one academic centre, certainly represents a limitation, as the representativeness of our results may have been influenced by this choice. Furthermore, as participation in the study was voluntary, it may have been influenced by some selection bias. Nonetheless, the sample size was adequate and the results were representative of our academic community, including senior and junior academics as well as administrative staff.

Another critical aspect is that our survey did not investigate whether participants felt they belonged to a marginalized group, so we cannot assess whether academic staff belonging marginalized groups (i.e. women, ethnic minorities, disabled people, etc.) have different coping styles from the rest of the academic staff. In addition, when interpreting the results, we must bear in mind that the data was collected during the second wave of the COVID-19 pandemic. Given the reported increase in anxiety and depression during the pandemic, both nationally [ 57 ] and internationally [ 58 ], this may have influenced our results. Finally, contextual considerations regarding differences in cultural coping with stress across countries need to be made before our findings can be generalized.

Conclusions

Coping styles remain largely unexplored in academia, but further studies such as the present one would facilitate the identification of links with risk or protective factors so that higher education institutions could be informed about what can be done to support their community. Such support is necessary to improve both the personal and professional lives of academic staff, ultimately leading to healthier lives and more effective teaching and research. Our study showed that the use of the coping style self-blame was positively related to anxiety symptoms and the use of venting and self-blame was positively related to depression symptoms. In our population, women used self-distraction, venting, and self-blame more frequently than men, whereas junior academics used substance use and self-blame more frequently than senior academics and administrative staff. This suggests that women and junior academics would benefit from a tailored health promotion and prevention intervention to encourage these populations to use more approach coping styles such as active coping and planning. Examining the complexity of coping can help identify individuals at increased risk for stress and unhealthy behaviours and develop health promotion and prevention interventions that enable people to use the most effective coping methods. Such interventions should be implemented at the organizational level with laws and regulations to improve working conditions, at the organizational-individual level with strategies such as peer support groups, and at the individual level with cognitive behavioural techniques.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

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The author would thank all professional that participate in the survey.

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LB, ES, MDP, ER designed the research; ES, ER collected data; ES, MPD, OV, DM, BP, SG, ER, AT, LB discussed the investigation methodology and contributed to result interpretation; AT performed data analysis; LB, SB supervised the study conduction; OV, DM wrote the original draft; LB, ES revised contents. All authors revised the paper and agreed with the final version of the manuscript.

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Vacchi, O.B., Menis, D., Scarpis, E. et al. Stress management: how does the academic staff cope with it? a cross-sectional study at the university of Udine. BMC Public Health 24 , 1509 (2024). https://doi.org/10.1186/s12889-024-18935-7

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• Open access
• Published: 27 May 2024

Associations between medical students’ stress, academic burnout and moral courage efficacy

• Galit Neufeld-Kroszynski   ORCID: orcid.org/0000-0001-9093-1308 1   na1 ,
• Keren Michael   ORCID: orcid.org/0000-0003-2662-6362 2   na1 &
• Orit Karnieli-Miller   ORCID: orcid.org/0000-0002-5790-0697 1  

BMC Psychology volume  12 , Article number:  296 ( 2024 ) Cite this article

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Metrics details

Medical students, especially during the clinical years, are often exposed to breaches of safety and professionalism. These contradict personal and professional values exposing them to moral distress and to the dilemma of whether and how to act. Acting requires moral courage, i.e., overcoming fear to maintain one’s core values and professional obligations. It includes speaking up and “doing the right thing” despite stressors and risks (e.g., humiliation). Acting morally courageously is difficult, and ways to enhance it are needed. Though moral courage efficacy, i.e., individuals’ belief in their capability to act morally, might play a significant role, there is little empirical research on the factors contributing to students’ moral courage efficacy. Therefore, this study examined the associations between perceived stress, academic burnout, and moral courage efficacy.

A cross-sectional study among 239 medical students who completed self-reported questionnaires measuring perceived stress, academic burnout (‘exhaustion,’ ‘cynicism,’ ‘reduced professional efficacy’), and moral courage efficacy (toward others’ actions and toward self-actions). Data analysis via Pearson’s correlations, regression-based PROCESS macro, and independent t -tests for group differences.

The burnout dimension of ‘reduced professional efficacy’ mediated the association between perceived stress and moral courage efficacy toward others’ actions. The burnout dimensions ‘exhaustion’ and ‘reduced professional efficacy’ mediated the association between perceived stress and moral courage efficacy toward self-actions.

Conclusions

The results emphasize the importance of promoting medical students’ well-being—in terms of stress and burnout—to enhance their moral courage efficacy. Medical education interventions should focus on improving medical students’ professional efficacy since it affects both their moral courage efficacy toward others and their self-actions. This can help create a safer and more appropriate medical culture.

Peer Review reports

Introduction

In medical school, and especially during clinical years, medical students (MS) are often exposed to physicians’ inappropriate behaviors and various breaches of professionalism or safety [ 1 , 2 , 3 ]. These can include lack of respect or sensitivity toward patients and other healthcare staff, deliberate lies and deceptions, breaching confidentiality, inadequate hand hygiene, or breach of a sterile field [ 4 , 5 ]. Furthermore, MS find themselves performing and/or participating in these inappropriate behaviors. For example, a study found that 80% of 3 rd– 4th year MS reported having done something they believed was unethical or having misled a patient [ 6 ]. Another study showed that 47.1–61.3% of females and 48.8–56.6% of male MS reported violating a patient’s dignity, participating in safety breaches, or examining/performing a procedure on a patient without valid consent, following a clinical teacher’s request, as a learning exercise [ 5 ]. These behaviors contradict professional values and MS’ own personal and moral values, exposing them to a dilemma in which they must choose if and how to act.

Taking action requires moral courage, i.e., taking an active stand or acting in the face of wrongdoing or moral injustice jeopardizing mental well-being [ 7 , 8 , 9 , 10 ]. Moral courage includes speaking up and “doing the right thing” despite risks, such as shame, retaliation, threat to reputation, or even loss of employment [ 8 ]. Moral courage is expressed in two main situations: when addressing others’ wrongdoing (e.g., identifying and disclosing a past/present medical error by colleagues/physicians); or when admitting one’s own wrongdoing (e.g., disclosing an error or lack of knowledge) [ 11 ].

Due to its “calling out” nature, acting on moral courage is difficult. A hierarchy and unsafe learning environment inhibits the ability for assertive expression of concern [ 12 , 13 , 14 ]. This leads to concerning findings indicating that only 38% of MS reported that they would approach someone performing an unsafe behavior [ 12 ], and about half claimed that they would report an error they had observed [ 15 ].

Various reasons were suggested to explain why MS, interns, residents, or nurses, hesitate to act in a morally courageous way, including difficulty questioning the decisions or actions of those with more authority [ 12 ], and fear of negative social consequences, such as being disgraced, excluded, attacked, punished, or poorly evaluated [ 13 ]. Other reasons were the wish to fit into the team [ 6 ] and being a young professional experiencing “lack of knowledge” or “unfamiliarity” with clinical subtleties [ 16 ].

Nevertheless, failing to act on moral courage might lead to negative consequences, including moral distress [ 17 ]. Moral distress is a psychological disequilibrium that occurs when knowing the ethically right course of action but not acting upon it [ 18 ]. Moral distress is a known phenomenon among MS [ 19 ], e.g., 90% of MS at a New York City medical school reported moral distress when carrying for older patients [ 20 ]. MS’ moral distress was associated with thoughts of dropping out of medical school, choosing a nonclinical specialty, and increased burnout [ 20 ].

These consequences of moral distress and challenges to acting in a morally courageous way require further exploration of MS’ moral courage in general and their moral courage efficacy specifically. Bandura coined the term self-efficacy, focused on one’s perception of how well s/he can execute the action required to deal successfully with future situations and to achieve desired outcomes [ 21 ]. Self-efficacy plays a significant role in human behavior since individuals are more likely to engage in activities they believe they can handle [ 21 ]. Therefore, self-efficacy regarding a particular skill is a major motivating factor in the acquisition, development, and application of that skill [ 22 ]. For example, individuals’ perception regarding their ability to deal positively with ethical issues [ 23 ], their beliefs that they can handle effectively what is required to achieve moral performance [ 24 ], and to practically act as moral agents [ 25 ], can become a key psychological determinant of moral motivation and action [ 26 ]. Due to self-efficacy’s importance there is a need to learn about moral courage efficacy, i.e., individuals’ belief in their ability to exhibit moral courage through sharing their concerns regarding others and their own wrongdoing. Moral courage efficacy was suggested as important to moral courage in the field of business [ 27 ], but not empirically explored in medicine. Thus, there is no known prevalence of moral courage efficacy toward others and toward one’s own wrongdoing in medicine in general and for MS in particular. Furthermore, the potential contributing factors to moral courage efficacy, such as stress and burnout, require further exploration.

The associations between stress, burnout, and moral courage efficacy

Stress occurs when people view environmental demands as exceeding their ability to cope with them [ 28 ]. MS experience high levels of stress during their studies [ 29 ], due to excessive workload, time management difficulties, work–life balance conflicts, health concerns, and financial worries [ 30 ]. Studies show that high levels of stress were associated with decreased empathy [ 31 ], increased academic burnout, academic dishonesty, poor academic performance [ 32 ], and thoughts about dropping out of medical school [ 33 ]. As stress may impact one’s perceived efficacy [ 34 ], this study examined whether stress can inhibit individuals’ moral courage efficacy to address others’ and their own wrongdoing.

An aspect related to a poor mental state that may mediate the association between stress and MS’ moral courage efficacy is burnout. Burnout includes emotional exhaustion, cynicism toward one’s occupation value, and doubting performance ability [ 35 ]. Burnout is usually work-related and is common in the helping professions [ 60 ]. For students, this concept relates to academic burnout [ 36 ], which includes exhaustion due to study demands, a cynical and detached attitude to studying, and low/reduced professional efficacy, i.e. feeling incompetent as learners [ 37 ].

Burnout has various negative implications for MS’ well-being and professional development. Burnout is associated with psychiatric disorders and thoughts of dropping out of medical school [ 33 ]. Furthermore, MS’ burnout is associated with increased involvement in unprofessional behavior, eroding professional development, diminishing qualities such as honesty, integrity, altruism, and self-regulation [ 38 ], reducing empathy [ 31 , 39 ] and unwillingness to provide care for the medically underserved [ 40 ]. Thus, burnout may also impact MS’ views on their responsibility and perceived ability to promote high-quality care and advocate for patients [ 41 ], possibly leading them to feel reluctant and incapable to act with moral courage [ 42 ]. Earlier studies exploring stress and its various outcomes, found that burnout, and specifically exhaustion, can become a crucial mediator for various harmful outcomes [ 43 ]. Although stress is impactful to creating discomfort, the decision and ability to intervene requires one’s own drive and power. When one is feeling stress, leading to burnout their depleted energy reserves and diminished sense of professional worth likely undermine their perceived power (due to exhaustion) or will (due to cynicism) to uphold professional ethical standards and intervene to advocate for patient care in challenging circumstances, such as the need to speak up in front of authority members. Furthermore, burnout may facilitate a cognitive distancing from professional values and responsibilities, allowing for moral disengagement and reducing the likelihood of morally courageous actions. This mediation role requires further exploration.

This study examined associations between perceived stress, academic burnout, and moral courage efficacy. In addition to the mere associations among the variables, it will be examined whether there is a mediation effect (perceived stress → academic burnout → moral courage efficacy) to gain more insight into possible mechanisms of the development of moral courage efficacy and of protective factors. Understanding these mechanisms has educational benefit for guiding interventions to enhance MS’ moral courage efficacy.

H1: Perceived stress and academic burnout dimensions will be negatively associated with moral courage efficacy dimensions.

H2: Perceived stress will be positively associated with academic burnout dimensions.

H3: Academic burnout dimensions will mediate the association between perceived stress and moral courage efficacy dimensions.

Materials and methods

Sample and procedure.

A quantitative cross-sectional study among 239 MS. Most participants were female (60%), aged 29 or less (90%), and unmarried (75%). About two thirds (64.3%) were at the pre-clinical stage of medical school and about a third (35.7%) at the clinical stage. In December 2019, the research team approached MS through email and social media to participate in the study and complete an online questionnaire. This was a part of a national study focused on MS’ burnout [ 44 ]. The 239 participants were recruited by a convenience sampling. Data were collected online through Qualtrics platform, via anonymous self-reported questionnaires. The University Ethics Committee approved the study, and all participants signed an informed consent form.

Moral courage efficacy —This 8-item instrument, developed for this study, is based on the literature on moral courage, professionalism, and speaking-up, including qualitative and quantitative studies [ 7 , 13 , 45 , 46 , 47 ], and discussions with MS and medical educators. The main developing team included a Ph.D. medical educator expert in communication in healthcare and professionalism; an M.D. psychiatrist expert in decision making, professionalism, and philosophy; a Ph.D. graduate who analyzed MS’ narratives focused on moral dilemmas and moral courage during professionalism breaches; and a Ph.D. candidate focused on assertiveness in medicine [ 14 ]. This allowed the identification of different types of situations MS face that may require moral courage.

As guided by instructions for measuring self-efficacy, which encourage using specific statements that relate to the specific situation and skill required [ 48 ], the instrument measures MS’ perception of their own ability, i.e., self-efficacy, to act based on their moral beliefs when exposed to safety and professionalism breaches or challenges. Due to our qualitative findings indicating that students change their interpretation of the problematic event based on their decision to act in a morally courageous way and that some are exposed to specific professionalism violations while others are not when designing the questionnaire, we decided to make the cases not explicit to specific types of professionalism breaches – e.g., not focused on talking above a patient’s head [ 1 ], but rather general the type of behavior e.g., “behaves immorally”. This decreases the personal interpretation if one behavior is acceptable by this individual; and also decreases the possibility of not answering the question if the individual student has never seen that specific behavior. Furthermore, to avoid “gray areas” in moral issues, we wrote the statements in a manner where there is no doubt whether there is a moral problem (“problematic situation”) [ 47 ], and thus the focus was only on one’s feeling of being capable of speaking up about their concern, i.e., act in a moral courage efficacy (see Table  1 ).

The instrument’s initial development consisted of 14 items addressing various populations, including senior MDs. The 14-item tool included questions regarding the willingness to recommend a second opinion or to convey one’s medical mistake to patients and their families. These actions are less relevant to MS. Thus, we extracted the questionnaire to a parsimonious instrument of 8 items.

The 8 items were divided into two dimensions: others and the self. This division is supported by the literature on moral courage that distinguishes between courage regarding others- vs. self-behavior. Hence, the questionnaire was designed to assess one’s perceived ability to act/speak up in these two dimensions: (a) situations of moral courage efficacy relating to others’ behavior (e.g., “ capable of telling a senior physician if I have detected a mistake s/he might have made ”); (b) situations of moral courage efficacy relating to self (e.g., “ capable of disclosing my mistakes to a senior physician ”). This two-dimension division is important and was absent in former measurements of moral courage. It was also replicated in another study we conducted among MS [ 49 ]. Furthermore, factor analysis with Oblimin rotation supported this two-factor structure (Table  1 ). All items had a high factor loading on the relevant factor (it should be mentioned that item 4 was loaded 0.59 on the relevant factor and 0.32 on the non-relevant factor).

All items are rated on a 5-point Likert scale (0 = to a small extent; 4 = to a very great extent) and are calculated by averaging the answers on the dimension, with higher scores representing higher moral courage efficacy. Internal reliability was α = 0.80 for the “others” dimension and α = 0.84 for the “self” dimension.

Perceived stress —This single-item questionnaire (“How would you rate the level of stress you’ve been experiencing in the last few days?” ) evaluates MS’ perceived stress currently in their life on an 11-point Likert scale (0 = no stress; 10 = extreme stress), with higher scores representing higher perceived stress. It is based on a similar question evaluating MS’ perceived emotional stress [ 29 ]. Even though a multi-item measure might be more stable, previous studies indicated that using a single item is a practical, reliable alternative, with high construct validity in the context of felt/perceived stress, self-esteem, health status, etc [ 43 , 50 , 51 ].

Academic burnout —This 15-item instrument is a translated version [ 44 ] of the MBI-SS (MBI–Student Survey) [ 37 ], a common instrument used to measure burnout in the academic context, e.g. MS [ 52 , 53 ]. It measures students’ feelings of burnout regarding their studies on three dimensions: (a) ‘exhaustion’ (5 items; e.g., “ Studying or attending a class is a real strain for me ”), (b) ‘cynicism’ (4 items; e.g., “ I doubt the significance of my studies ”), (c) lack of personal academic efficacy (‘reduced professional efficacy’) (6 items; “ I feel [un]stimulated when I achieve my study goals ”). Each item is rated on a 7-point Likert scale (0 = never; 6 = always) and is calculated by summing the answers on the dimension (after re-coding all professional efficacy items), with higher scores representing more frequent feelings of burnout. Internal reliability was α = 0.80 for ‘exhaustion’, α = 0.80 for ‘cynicism’, and α = 0.84 for ‘reduced professional efficacy’.

Statistical analyses

IBM-SPSS (version 25) was used to analyze the data. Pearson’s correlations examined all possible bivariate associations between the study variables. PROCESS macro examined the mediation effects (via model#4). The significance of the mediation effects was examined by calculating 5,000 samples to estimate the 95% percentile bootstrap confidence intervals (CIs) of indirect effects of the predictor on the outcome through the mediator [ 54 ]. T -tests for independent samples examined differences between the study variables in the pre-clinic and clinic stages. The defined significance level was set generally to 5% ( p  < 0.05).

This study focused on understanding moral courage efficacy, i.e., MS’ perceived ability to speak up and act while exposed to others’ and their own wrongdoing. The sample’s frequencies demonstrate that only 10% of the MS reported that their moral courage efficacy toward the others was “very high to high,” and 54% reported this toward the self. Mean scores demonstrate that regarding the others, MS showed relatively low/moderate levels of moral courage and higher levels regarding the self. As for the variables tested to be associated with moral courage efficacy, MS showed relatively high perceived stress and low-to-moderate academic burnout (see Table  2 for the variables’ psychometric characteristics).

Table  2 also shows the correlations among the study variables. According to Cohen’s (1988) [ 55 ] interpretation of the strength in bivariate associations (Pearson correlation), the effect size is low when r value varies around 0.1, medium when it is around 0.3, and large when it is more than 0.5. Hence, regarding the associations between the two dimensions of moral courage efficacy: we found a moderate positive correlation between the efficacy toward others and the efficacy toward the self. Regarding the associations among the three academic burnout dimensions: we found a strong positive correlation between ‘exhaustion’ and ‘cynicism,’ a weak positive correlation between ‘exhaustion’ and ‘reduced professional efficacy,’ and a moderate positive correlation between ‘cynicism,’ and ‘reduced professional efficacy.’

As for the associations concerning H1, Table  2 indicates that one academic burnout dimension, i.e., ‘reduced professional efficacy,’ had a weak negative correlation with moral courage efficacy toward the others, thus high burnout was associated with lower perceived moral courage efficacy toward others. Additionally, perceived stress and all three burnout dimensions had weak negative correlations with moral courage efficacy toward the self—partially supporting H1.

As for the associations concerning H2, Table  2 indicates that perceived stress had a strong positive correlation with ‘exhaustion,’ a moderate positive correlation with ‘cynicism,’ and a weak positive correlation with ‘reduced professional efficacy’—supporting H2.

Based on these correlations, we conducted regression-based models to examine the unique and complex relationships among the study variable, including their various dimensions, while focusing on the examination of whether academic burnout mediates the association between perceived stress and moral courage efficacy (see Tables  3 and 4 ; and Figs.  1 and 2 ).

A model presenting the association between perceived stress and moral courage efficacy toward others, mediated by academic burnout. Note full arrows contain significant β coefficient values (fractured arrows mean nonsignificance

Focusing on moral courage efficacy toward others

Table  3  and Fig.  1 indicate that perceived stress was positively associated with all three academic burnout dimensions: ‘exhaustion’ (path a 1 ), ‘cynicism’ (path a 2 ), and ‘reduced professional efficacy’ (path a 3 ). These paths support H2. In turn, ‘reduced professional efficacy’ was negatively associated with moral courage efficacy toward the others (path b 3 ), supporting H1. The CIs of the indirect effect (paths a 3 b 3 ) did not contain zero; therefore, perceived stress had a significant indirect effect on moral courage efficacy toward the others, through the burnout dimension ‘reduced professional efficacy.’ This path supports H3.

A model presenting the association between perceived stress and moral courage efficacy towards self, mediated by academic burnout. Note full arrows contain significant β coefficient values (fractured arrows mean non-significance

Focusing on moral courage efficacy toward the self

Table  4  and Fig.  2 also indicate that perceived stress was positively associated with all three academic burnout dimensions: ‘exhaustion’ (path a 4 ), ‘cynicism’ (path a 5 ), and ‘reduced professional efficacy’ (path a 6 ). These paths support H2. In turn, ‘exhaustion’ and ‘reduced professional efficacy’ were negatively associated with moral courage efficacy toward the self (paths b 4 , b 6 respectively). These paths support H1 The CIs of the indirect effects (paths a 4 b 4 , a 6 b 6 ) did not contain zero; therefore, perceived stress had a significant indirect effect on moral courage efficacy toward the self, through the burnout dimensions ‘exhaustion’ and ‘reduced professional efficacy.’ These paths support H3. It should be noted that in this analysis, the initially significant association between perceived stress and moral courage efficacy toward the self (path c 2, representing H1) became insignificant in the existence of academic burnout dimensions (path c’ 2 ). These results demonstrate complete mediation and also support H3.

In addition to examining the complex relationships between stress, academic burnout, and moral courage efficacy among MS, we tested the differences between MS in the pre-clinical and clinical school stages in all study variables. The results indicate non-significant differences in moral courage efficacy. However, medical-school-stage differences were found in stress [t(197.4)=-4.36, p  < 0.001] and in one academic burnout dimension [t(233)=-2.40, p  < 0.01]. In that way, MS at the clinical stage reported higher levels of perceived stress ( M  = 7.32; SD  = 2.17) and exhaustion ( M  = 19.67; SD  = 6.58) than MS in the pre-clinical stage ( M  = 5.94; SD  = 2.59 and M  = 17.48; SD  = 6.78, respectively).

This study examined the associations between perceived stress, academic burnout, and moral courage efficacy to understand MS’ perceived ability to speak up and act while exposed to others’ and their own wrongdoing. The findings show that one dimension of burnout, that of ‘reduced professional efficacy,’ mediated the associations between perceived stress and moral courage efficacy toward both others and self. ‘Exhaustion’ mediated the association between perceived stress and moral courage efficacy only toward the self.

Before discussing the meanings of the associations, this study was an opportunity to explore moral courage efficacy occurrence. The findings indicated fairly low/moderate mean scores of perceived ability to speak up and act while confronted with others’ wrongdoing and moderate/high scores of perceived ability while confronted with one’s own wrongdoing. This implies that students do not feel capable enough to share their concerns regarding others’ possible errors and feel more able, but still not enough, to share their own flaws and needs for guidance. These findings require attention, from both patient safety and learning perspectives.

Regarding patient safety, feeling unable to act while confronted with others or self- wrongdoing means that some errors may occur and not be addressed. This is in line with former findings that showed that less than 50% of MS would actually approach someone performing an unsafe behavior [ 12 ], or report an error they had observed [ 15 ]. These numbers are likely to improve in postgraduates as studies showed that between 64 and 79% of interns and residents reported they would likely speak up to an attending when exposed to a safety threat [ 56 , 57 ].

Regarding learning, our MS’ scores must improve for various reasons. First, moderate scores may indicate a psychologically unsafe learning environment, which prevents or discourages sharing uncertainties, especially about others’ behavior, and creates difficulty for students to share their own concerns, limitations, mistakes, and hesitations when feeling incapable or unqualified for a task [ 58 ]. Second, limited sharing of errors may be problematic because by not disclosing their error, students miss the chance to learn from it; [ 59 ] they lose the opportunity for reflective guidance to explore what worked well, what did not, and how to improve [ 59 , 60 ]. Third, if they do not discuss others’ errors or their own, they may deny themselves the necessary support to learn the all-important skills of how to deal with the emotional turmoil and challenges of errors, and how to share the error with a patient or family member [ 61 ]. Furthermore, if MS feel incapable of sharing their concern about a senior’s possible mistake, they miss other learning opportunities—e.g., the senior’s reasoning and clinical judgment may show that a mistake was not made. In this case, the student would miss being shown why they were wrong and what they did do well. Thus, identifying what can enhance moral courage efficacy and practice is needed. The fact that there are no significant differences between pre-clinical and clinical years students in their perceived ability to apply moral courage, may indicate that there is a cultural barrier in perceiving the idea of sharing weakness or of revealing others’ mistakes as unacceptable. Thus, the socialization, in the medical school environment, both in pre-clinical and clinical years, perhaps lacks the encouragement to speak up and provision of safe space.

This study examined the associations between perceived stress, academic burnout, and moral courage efficacy among MS. The findings indicate that, like earlier studies, stress is not directly connected to speaking up [ 62 ] or moral courage. It rather contributes to it indirectly, through the impact of burnout. Beyond the well-established role of stress in explaining burnout [ 63 , 64 ], we identified a negative consequence of burnout—hindering moral courage efficacy. This may help explain the path in which previous studies found burnout to impair MS’ quality of life, how it leads to dropout, and to more medical errors [ 65 ]. When individuals experience the burnout dimension of ‘reduced professional efficacy,’ they may feel less confident and fit, leading them to feel more disempowered to take the risk (required in courage) and share their concerns and hesitations about others’ mistakes and their own challenges. This fits earlier studies indicating that being a young professional experiencing “lack of knowledge” or “unfamiliarity” with clinical subtleties is a barrier to moral courage [ 11 ]. This may have various negative implications, of limited moral courage efficacy, as seen here, as well as paying less attention and not fully addressing their learning needs, leading to a vicious cycle of “feeding” the misfit feeling, potentially increasing their moral distress. Furthermore, those who feel they know less and, therefore, need more support to fill the gap in knowledge and skills, are less inclined to ask for help.

Beside the negative associations between ‘reduced professional efficacy’ and both dimensions of moral courage efficacy (toward others and the self), another dimension of academic burnout—‘exhaustion’—was negatively associated with moral courage efficacy toward the self. This is worrying because when learners are exhausted, their attention is reduced and they are at greater risk of error, as proven in an earlier study [ 65 ]. The current study adds to this information another worry, showing that MS are less willing to share their hesitations about themselves or the mistakes they already made, thus perhaps not preventing the error or fixing it. MS might create an unspoken contract with senior physicians about not exposing each other’s mistakes, with various possible negative implications. Some MS’ tendency to defend physicians’ mistakes was identified elsewhere [ 66 ].

The findings concerning medical-school-stage differences demonstrated that MS in the clinical stage had higher perceived stress and exhaustion levels than MS in the pre-clinical stage. These results support previous studies indicating stress, academic burnout, and more challenging characteristics among more senior students, including a decline in ideals, altruistic attitudes, and empathy during medical school studies; or more exhaustion, cynicism, and higher levels of detached emotions and depression through the years of medical school [ 67 , 68 , 69 ]. These higher levels of stress and exhaustion, can be explained by the senior students’ exposure to the rounds in the hospitals, which requires ongoing learning, more pressure, and a sense of overload in their academic life.

Limitations and future studies

Despite the importance of the findings, the study has several limitations. First, the participants were from one university, and recruited via convenience sampling, including only MS who voluntarily completed the questionnaires, undermining generalizability. To address this limitation, future research should aim to include a more diverse and representative sample of medical students from multiple universities and geographical regions. This would enhance the external validity and applicability of the findings across different educational and cultural contexts. Second, future studies are recommended to follow up on medical students’ stress, academic burnout, and moral courage efficacy over time. Exploring the development of professional efficacy and the barriers to exposing one’s and others’ weaknesses and flaws within the medical environment can help improve the medical culture into a safer space. Third, an intriguing avenue for future research is the exploration of the construct of ‘moral courage efficacy’ within different cohorts of healthcare students throughout their undergraduate and postgraduate years to learn about their moral courage efficacy development as well as and to verify the association between the findings from this newly developed scale and actual moral courage behavior. Additionally, experimental designs, such as interventions to reduce stress and burnout among medical students, could be employed to observe the impact on moral courage efficacy.

Conclusions and implications

This study is a first step in understanding moral courage efficacy and what contributes to it. The study emphasizes the importance of promoting MS’ well-being—in terms of stress and burnout—to enhance their moral courage efficacy. The findings show that the ‘reduced professional efficacy’ mediated the association between perceived stress and moral courage efficacy, toward both the others and self. This has potential implications for safety, learning, and well-being. To encourage MS to develop moral courage efficacy that will potentially increase their morally courageous behavior, we must find ways to reduce their stress and burnout levels. As the learning and work environments are a major cause of burnout [ 38 ], it would be helpful to focus on creating safe spaces where they can share others- and self-related concerns [ 70 ]. The first step is a learning environment promoting students’ overall health and well-being [ 71 ]. Useful additions are processes that support MS while dealing with education- and training-related stresses, improving their academic-professional efficacy, and constructively helping them handle challenging situations through empathic feedback [ 70 ]. This can lead them to a stronger belief in their ability to share safety and professionalism issues, thus enhancing their learning and patient care.

Data availability

No datasets were generated or analysed during the current study.

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Acknowledgements

The authors wish to thank Dr. Lior Rozental in helping in recruiting students to the study. This study was done as part of Orit Karnieli-Miller’s Endowed chair of the Dr. Sol Amsterdam, Dr. David P. Schumann in Medical Education, Tel Aviv University. This study is written in the blessed memory of Oshrit Bar-El, devoted to enhancing Moral Courage.

The manuscript was partially supported by a grant by the by the Israel Science Foundation (grant no. 1599/21).

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Galit Neufeld-Kroszynski and Keren Michael contributed equally to this work.

Authors and Affiliations

Department of Medical Education, Faculty of Medical & Health Sciences, Tel Aviv University, Tel Aviv, 69778, Israel

Galit Neufeld-Kroszynski & Orit Karnieli-Miller

Department of Human Services, Max Stern Yezreel Valley College, Yezreel Valley, Israel

Keren Michael

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Contributions

GNK: conception and design, interpretation of data, drafting and revision of the manuscript, and final approval of the version to be published; KM: analysis and interpretation of data, drafting and revision of the manuscript, and final approval of the version to be published; OKM: conception and design, interpretation of data, drafting and revision of the manuscript, and final approval of the version to be published.

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Correspondence to Orit Karnieli-Miller .

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This study was conducted in accordance with the principles outlined in the Declaration of Helsinki and received ethical approval by the Ethics Committee of Tel-Aviv University on 31/10/2019. Informed written consent was obtained from all participants before their participation in this study.

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Not applicable.

Previous presentations

Study findings were presented at the Academy for Professionalism in Healthcare Conference, June 2nd, 2022, virtual; and the 7th International Conference on Public Health, August 8th, 2021, virtual.

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The authors declare no competing interests.

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Neufeld-Kroszynski, G., Michael, K. & Karnieli-Miller, O. Associations between medical students’ stress, academic burnout and moral courage efficacy. BMC Psychol 12 , 296 (2024). https://doi.org/10.1186/s40359-024-01787-6

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Received : 03 December 2023

Accepted : 13 May 2024

Published : 27 May 2024

DOI : https://doi.org/10.1186/s40359-024-01787-6

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