Coping strategies and chiropractic student perceived stress

Study Participants

Prior to implementation, the study protocol was reviewed and approved by the Palmer College of Chiropractic, Institutional Review Board (assurance # X2014-1-8-Z). Four hundred sixty-one students in our quarter-based system, 4 quarters/academic year, all 1st-quarter students across 8 consecutive classes were invited to participate during the 2014 and 2015 academic years. Invited student participants were provided with a verbal explanation of the investigation, including the aims and objectives, and were informed that they could withdraw from the study at any time without punitive consequences. Data from fully completed surveys were entered into an Excel (Microsoft Corp, Redmond, WA) spreadsheet using a double-data-entry method.

Perceived Stress Assessment

As reported previously,⁶ perceived stress in the chiropractic training program was assessed via a modification of Vitaliano Perceived Medical School Stress (PMSS) survey.^35,36 The PMSS is the most widely used, validated assessor of perceived stress in medical educational programs.^37–39 It consists of 11 items focusing on 4 areas³⁶: (1) Medical school curriculum and environment, 5 items; (2) Personal competence/endurance, 4 items; (3) Social/recreational life, 1 item; and (4) Finances, 1 item. All items are rated on 5-point Likert scales (0 = strongly disagree, 1 = disagree, 2 = neutral, 3 = agree, and 4 = strongly agree) with total instrument scores ranging from 0 to 44. The mean instrument score (0 to 4) is calculated by summing all items and then dividing by 11. Higher scores indicate higher level of stress. We modified the PMSS by replacing the word “medical” in all survey items with the word “chiropractic” to produce a PCCS survey. All 1st and 3rd quarter chiropractic students received this modified stress assessment via unmarked envelopes that were distributed during the 1st week of their respective quarters in the 2014 and 2015 academic years. Students completed the surveys and returned them to the course instructor during subsequent class meetings. Observed PCCS levels for students in this study have been reported previously.⁶

Coping Strategy Assessment

In the 1st week of the 1st quarter of 2014 and 2015, the Brief COPE survey (B-COPE) was distributed to the same students in unmarked envelopes and returned as above.²² The B-COPE is a validated inventory that is widely used to identify the behavioral strategy individuals use to cope with stress. Individuals indicate their typical response for each of 28 behaviors in a questionnaire via a 4-point scale: 1 = “I haven't been doing this at all,” 2 = “I've been doing this a little bit,” 3 = “I've been doing this a medium amount,” and 4 = “I've been doing this a lot.” These 28 B-COPE items are collapsed into 14 coping behavior subscales (2 items per behavior) and are then grouped into 2 broad coping categories (problem-focused coping and emotion-focused coping). Emotion-focused coping is further subdivided into active-emotion, and avoidant-emotion substrategies. Problem-focused coping is expressed by 4 behaviors: active coping, planning, instrumental support, and religion. Emotion-focused coping is expressed by 10 behaviors: 5 active-emotion behaviors: acceptance, emotional support, positive reframing, venting, and humor; and 5 avoidant-emotion behaviors: self-distraction, denial, behavioral disengagement, self-blame, and substance use.²² The problem-focused and emotion-focused substrategies are generally used in combination.

Usage ranking across the 14 coping behavior subscales was determined by ordering them according to the mean reported usage points across all participants (8 points maximum per subscale). The highest use rank (rank 1) was given to the highest usage score for the given coping behavior. The mean reported usage score was obtained by summing the reported points for each of the 14 behavior subscales across all participants and dividing each of these sums by n = 407.^19,40

Data Analysis

Data were plotted to reveal underlying distribution patterns and identify outliers. We then summarized and analyzed our data using the statistical computing environment R (version 3.4.1, Vienna, Austria). Both zero-order correlation and linear regression analyses were performed. Statistical test assumptions were evaluated, standardized effect sizes and 95% confidence levels were calculated. Study hypotheses were evaluated at a .05 family-wise α level.

Demographic Information

Out of 461 students, 407 completed and returned the questionnaire, giving an overall response rate of 88.3%. The demographic distributions of participating and nonparticipating students were similar (Table 1). For participating students: Males (n = 248, 61%) were more prevalent than females. Sex, academic degree, age, and ethnicity substantially favored the bachelor's degree, the age group “less than 30 years of age” (87%), and Caucasians (75%).

Table 1- Study Demographics, n = 461 (sum of participating + nonparticipating)

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Perceived Stress and Coping Assessments

Stress and coping category assessments are summarized in Table 2. Student-PCCS was greater in males than females at the beginning of the academic term and 6 months into the training program (PCCS1 and PCCS2, respectively). This sex difference was statistically significant for PCCS1 (p = .023), but not for PCCS2 (p = .408). As reported previously,⁶ perceived stress increased over the term (PCCS 2 – PCCS 1, p < .001), with a greater increase in female students, but the sex difference was not statistically significant (p = .230).

Table 2- Stress and Coping Assessments Summary (n = 407)^a

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Similarly, usage of problem-focused and active-emotion behaviors were slightly higher in female students, but these differences also were not statistically significant (p = .364 and p = .117, respectively). The avoidant-emotional coping category was essentially equivalent across both sexes (p = .891).

Ranked Usage of Coping Behaviors

The 14 coping behaviors assessed by the B-COPE survey instrument were ranked by mean usage scores (Table 3). The 2nd column (Rt) ranks the coping behavior subscales for all study participants by usage, whereas the 4th and 6th columns report rank by males and females, (Rm and Rf, respectively). For total behaviors (Rt), “active coping,” “acceptance,” “planning,” and “positive reframing” were the 4 most-used behaviors. The “venting,” “denial,” “behavioral engagement,” and “substance use” behaviors were the 4 least-used. Mean usage scores and their standard deviations are reported in columns 3, 5, and 7. Both males and females (Rm and Rf, respectively) reported similar coping usage, but differed with “Planning” and “Positive reframing,” and with “Using emotional support” and “Self-distraction,” in which the ranks were reversed (bold-italicized ranks). The 8th column in the table reports the uncorrected p-value for male/female comparisons with the null hypothesis, “no difference between male and female usage scores for a given coping behavior.” After the Holm-Bonferroni Sequential Correction for Multiple Comparisons was applied (last column)⁴¹ to maintain the family wise error rate at .05, only the greater usage by females of “Using emotional support” was statistically significant (p = .004).

Table 3- B-COPE Subscale – Usage Rank (Most Used = 1, Least Used = 14)

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Perceived Stress and Coping Correlations

Both unstandardized and standardized regression coefficients are reported for each of the 3 study hypotheses in Table 4 and then explained below.

Table 4- Hypotheses Regression

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Hypothesis 1: Coping strategies (problem-focused, active-emotion, and avoidant-emotion) identified at the beginning of the chiropractic training program will correlate with student PCCS assessed at the beginning of the chiropractic training program (PCCS1), with possible sex interaction.

A regression model with 2 of the 3 coping categories (problem-focused and avoidant-emotion) and sex explained 21% of the PCCS1 variance. Active-emotion coping was removed from the model because it did not make a statistically significant contribution. A single-unit increase in avoidant-emotion coping was associated with a 0.06-unit increase in PCCS1, whereas being male was associated with a 0.12-unit increase in perceived stress. Standardized effect sizes (β in Table 4) demonstrate that, in this model, the avoidant-emotion strategy influence on perceived stress was more than 3-times that of problem-focused. Although sex was a predictor of perceived stress at the beginning of the training program, neither the problem-focused nor the avoidant-emotion influences were moderated by sex. Sex interactions with problem-focused and avoidant-emotion were p = .579 and p = .764, respectively.

Hypothesis 2: Coping strategies (problem-focused, active-emotion, and avoidant-emotion) identified at the beginning of the chiropractic training program will predict student PCCS after 6 months in the program (PCCS2).

Only the avoidant-emotion coping strategy predicted PCCS2, explaining 10% of PCCS2 variance. A single-unit increase in the avoidant-emotion coping strategy was associated with a 0.06-unit increase in PCCS2. Sex was not a statistically significant PCCS2 predictor (p = .411).

Hypothesis 3: Coping strategies (problem-focused, active-emotion, and avoidant-emotion) identified at the beginning of the chiropractic training program will predict student PCCS change after 6 months in the program (PCCS2 – PCCS1).

Perceived stress in both males and females increased over the 6-month study period (PCCS Change, Table 2). This increase was statistically significant within each sex (males: t₂₄₇ = 4.2, p < .001 and females: t₁₅₈ = 4.8, p < .001), but the magnitude of change was not significantly different across sexes (p = .191). In addition, none of the 3 coping strategies were statistically significant predictors of PCCS change (PCCS2 – PCCS1: Table 4).

Student-Perceived Stress

Conflicting observations have been reported by researchers concerning sex-related levels of stress in academic environments. Chen et al⁴² found that male students reported higher levels of stress. However, Ng and Jeffery,⁴³ Shaw et al,⁴⁴ and Kneavel⁴⁵ reported that females were more likely to be stressed than males. Most recently, we reported that student-perceived stress levels increased substantially (18%) after 6 months in our institution's chiropractic training program compared with the 1st week of the program (t₄₀₆ = 6.32, p < .001, d = .33). Although this increase was greater for women than for men, the sex effect was not statistically significant (d_men = 0.28, d_women = 0.43, p = .233).

Our previous paper reported PCCS but did not closely examine sex differences.⁶ We also reported the top 4 stressors identified by students in our chiropractic training program. In this paper, we explored students' self-reported coping behaviors when responding to those stressors and how associated PCCS and behavioral strategies might differ between sexes.

We report that PCCS amongst 1st term students (PCCS1) was greater in males than females and this observation was also observed at a 2nd assessment, 6 months into the training program (Table 2, PCCS2). Although this sex-related difference was statistically significant for PCCS1, it was not statistically significant for PCCS2. In addition, student-perceived stress increased as students progressed 6 months into the chiropractic training program (PCCS 2 – PCCS 1), with a greater increase in female students. Although this increase was statistically significant within each sex, the cross-sex increased-stress difference was very small and not statistically significant. We conclude that the conflicting sex-related differences in perceived stress reported in the literature may reflect a small and labile correlation between sex and perceived stress.

Student Coping Strategies

It is important for educators to appreciate both the stress sources and the coping strategies used by students as they help students navigate challenging training programs. In the present study, students reported using more healthy than unhealthy coping strategies (Table 3, B-COPE Subscale Usage Rank). Among all study participants, “active coping” was the most common and “substance use” was the least common self-reported coping strategy. Males and females reported substantially similar ranking of the 14 coping strategies, with just 2 reversals of adjacent ranks. Females ranked “positive reframing” ahead of “planning” whereas males ranked “self-distraction” ahead of “using emotional support.” This difference in rank can be explained, in part, by the statistically significant, greater usage by females of “using emotional support.” Both males and females gave “venting” a rank of “11,” with females reporting greater, but not statistically significant, use of venting. In a related study, Garcia et al⁴⁰ ranked coping strategies use by 1847 adults recruited from the Chilean general population. They reported the same 4 most-used coping behaviors, although they ranked them as follows: (1) acceptance, (2) active coping, (3) planning, and (4) positive reframing. Out of the 14 coping strategies, the 4 least-used in their study were as follows: (11) humor, (12) denial, (13) behavioral engagement, and (14) substance use. This usage was similar to our findings, although venting, not humor, occupied position 11 in our study. Interestingly, the mean coping scores reported in the Chilean population study for the top 4 coping behaviors that we reported were 24% to 35% less than our scores. This may be due to higher stress typically experienced by chiropractic students compared with the general population⁶ or it may reflect cultural differences in coping usage between the US and Chilean populations. The possibility that the difference in reported coping scores might reflect higher stress experienced by chiropractic students is supported by a recent study of coping strategies and stress in 407 Nepal undergraduate medical students.¹⁹ The authors of that study reported student coping scores that were substantially closer to our reported values (7%–17% greater, for our top 4 coping behaviors). Although those authors did not rank order the reported coping score usage, their tabulated usage scores could be readily placed in rank order. When we rank ordered their tabulated data, we found that their top 4 coping behaviors were the same behaviors we observed, although the order within that “top 4” group differed from the within-group order that we observed. The bottom 4 behaviors were the same ordered coping strategies that were reported in the Chilean study, which were similar to our findings, as discussed above. Additional studies are needed to clarify cultural/ethnic versus academic rigor as explanatory factors for the magnitude differences in perceived stress noted above.

Stress and Coping Strategy Correlations

Our data demonstrated correlation at the beginning of the chiropractic-training program between 1st-term student perceived stress (PCCS1) and 2 coping strategies, problem-focused and avoidant-emotion (Hypothesis 1). Problem-focused strategies (active coping, planning, and instrumental support) and avoidant-emotion strategies (self-blame, denial, substance use, and behavioral disengagement) correlated moderately with PCCS1, sharing 21% of the PCCS1 variation, whereas active-emotion did not contribute. PCCS1 was slightly greater for males, but regression analysis revealed that sex did not modify the 2 coping strategy effects on student stress. Not surprisingly, avoidant strategies were positively correlated with perceived stress 6 months into the program (PCCS 2, Hypothesis 2). Sex did not predict perceived stress levels 6 months into the program and was not a statistically significant modifier of avoidant-emotion influence. Positive correlation between avoidant coping and student-perceived stress is consistent with a study by Fitzsimmons and Bardone-Cone.⁴⁶ Although use of avoidant strategies was a positive predictor of perceived stress at both the 1st term (PCCS1) and 6 months into the program (PCCS2), it was not a statistically significant predictor of the increased perceived stress observed in our study (Table 4, Hypothesis 3).

Of the 2 broad coping dimensions identified by Lazarus and Folkman,²⁰ the problem-focused dimension is generally viewed as an adaptive mode of coping involving active planning or engagement in a specific behavior to overcome the problem causing distress.^28,47,48 Previous studies reported that adopting a problem-focused style was generally associated with successful adapting to stressful situations with improved psychological functioning,⁴⁹ perceived effectiveness,⁵⁰ and improved health outcomes.⁵¹

The emotion-focused coping dimension involves attempts to self-regulate emotions and takes either active or avoidant forms, which are often considered adaptive and maladaptive, respectively. The active form includes behaviors such as venting emotional distress or cognitively reframing a stressor's impact, typically viewed as an adaptive emotion-regulating form of emotion-focused coping. By contrast, the avoidant form of emotion-focused coping uses denial or self-distraction to avoid the source of distress without engaging in problem-focused behavior and is frequently maladaptive.^28,52 Reliance on avoidance coping has been linked to increased depressive symptoms among general community adults and college students.^53–55 In summary, the same coping strategy may be adaptive or maladaptive. Context and time determine the relative effect. For example, problem-focused strategies are adaptive when dealing with poor grades or inadequate academic training, but they are generally maladaptive when dealing with loss of a parent or a failed final exam. Although no “magic bullet” strategy exists for coping with stress,⁵⁶ we believe this study will inform college services that can reduce student-perceived stress, enhance students' sense of wellbeing, and facilitate learning.

Institutions seeking to reduce PCCS should encourage adaptive problem-focused and active emotion coping behaviors commonly used by both sexes (eg, active coping, acceptance, planning, and positive reframing) and help students change maladaptive avoidant-emotion behaviors such as self-blame, venting, denial, and substance abuse that are associated with increased PCCS. This has been accomplished at other institutions by offering classes and workshops that teach stress management and self-care skills.^57–59

Study Limitations

This study has many limitations. It is only a starting point for exploring the relationship between perceived stress and coping behaviors in a chiropractic training institution. The study assumes no substantial change in students' coping strategies from the single time they were assessed at the beginning of the 1st term of the chiropractic training program and 6 months into the program, when PCCS was again assessed (PCCS2). This assumption, coping stability over the 6-month period, was not evaluated in the study. Moreover, coping inventories like that used in this study can only record strategies of which individuals are consciously aware and willing to report; unconscious strategies were, therefore, not assessed.¹⁶ In addition, the study does not address causation. Correlation between behavior and PCCS may reflect use of the behavior in response to PCCS or the PCCS may change due to use of the behavior. Moreover, because the surveys were not anonymous, it is possible that students may not have honestly answered sensitive questions about substance use (social bias). In addition, a 3rd factor may be driving both the behavior and PCCS (the “tertium quid” effect). Additional studies are needed to explore these issues. Finally, student perspectives were assessed only at initial and 6-month landmarks in our chiropractic training program. Results cannot be readily generalized to students in subsequent terms, other chiropractic institutions, or other health care training programs.