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RESEARCH REPORT

Physical Therapy Student Stress During the COVID-19 Pandemic: A Qualitative Study

Anderson, Christina E. P. PT, DPT; Dutton, Lisa L. PT, PhD

Author Information
Journal of Physical Therapy Education: March 2022 - Volume 36 - Issue 1 - p 1-7
doi: 10.1097/JTE.0000000000000218

Abstract

INTRODUCTION

On March 11, 2020, the World Health Organization declared the outbreak of the novel coronavirus (COVID-19) a global pandemic.1 In response to concerns about a rise in mental health issues, the Centers for Disease Control and Prevention administered the Household Pulse Survey to collect data on a broad range of topics.2 To measure mental health status, the survey included the Patient Health Questionnaire and the Generalized Anxiety Disorder scale.2 Data gathered in spring 2020 indicated that, for adults in the United States, the prevalence of reported symptoms of depression or anxiety was 35.9% during the onset of the COVID-19 pandemic in 2020 as compared with 10.9% during the same period in 2019.2,3 Furthermore, the mental health of young adults, females, and racial minorities was disproportionately affected by the pandemic.2,4 While in the short-term, stress can result in transient physical and emotional symptoms,5 prolonged stress can lead to negative health consequences such as depression, anxiety, cardiovascular disease, and cancer.6 Furthermore, high stress levels have been linked to disrupted learning,7 poor academic performance,7 and burnout.8

LITERATURE REVIEW

Surveys conducted in the months after the onset of the COVID-19 pandemic revealed that college and university students were at high risk for mental health issues.9-11 For example, in a survey of undergraduate and graduate students at Texas A & M, 48.14% of respondents reported moderate-to-severe depression, 38.48% moderate-to-severe anxiety, and 15.8% an inability to adequately cope.11 Another pandemic survey, including students from 374 universities in the United States, reported that nearly half the respondents were classified as having moderate-to-severe depression.9 Additionally, more than 70% of the respondents in surveys conducted in Texas reported that their stress and anxiety had increased during the pandemic.10,11

These trends have been replicated through survey research in international populations of health care students. Researchers investigating the impact of COVID-19 on undergraduate medical and nursing students in Saudi Arabia, Australia, and Turkey reported that a significant portion of students were experiencing moderate-to-severe psychological distress, including feelings of depression, anxiety, emotional detachment, and exhaustion.12-16 One study was identified in the literature that explored whether the levels of perceived stress reported by health care students differed from that experienced by their peers in other disciplines.17 In this study, researchers found that Chinese medical students reported significantly higher levels of stress compared with nonmedical students.17 Research investigating health care students in the United States is more limited. In a survey of dental students in 6 countries, students reported moderate levels of stress, with the lowest stress levels identified for students in the United States.18 Similarly, Harries et al.19 surveyed US medical students during their clinical training and reported that the pandemic had moderate effects on their stress and anxiety.

Studies exploring stress in undergraduate students and students in the health professions, including medical, dental, nursing, and speech therapy, during the COVID-19 pandemic found academics to be a commonly reported source of stress.10,11,14,20-22 These stressors included concerns about academic performance,10,11,14,22 examinations,20 and increased workload.10,11,22 Students also described distress related to transitioning to an online learning environment and difficulty concentrating in this environment.10,11,21 Other stressors included worries about academic program changes, preparation for entering the workforce,14,20 and safety and risk of exposure in the clinical setting.14,23

Personal sources of stress related to the COVID-19 pandemic have also been commonly reported by students.10,11,14,20,21 A primary personal stressor involved concerns about personal health and the health of loved ones.10,11,14,20,21 Students also reported stress related to social isolation,10,11,14,20,21 finances,10,11 and changes in their living or working environment.10,11 Finally, students experienced stress related to uncertainty about their future plans21 as well as general uncertainty associated with the pandemic.11,14

In addition to the impact of the pandemic on mental health, studies have also identified stress-related impacts on learning. Medical students in Australia, China, and Saudi Arabia reported that COVID had a negative impact on their studies,14 enthusiasm for learning,17 and work performance.15 Though students more often highlighted the negative impacts of COVID, some students identified positive aspects such as greater flexibility in their schedule and more time to engage in self-care activities, including exercise, hobbies, and sleep as well as strengthened family relationships.11,14

Students described the use of both positive and negative coping strategies to deal with stress during the COVID-19 pandemic.10,13,14,20 Common strategies included social support, mindfulness and meditation, exercise, religious activities, establishing a routine, and learning to live with the current situation.10,13,14,20,21,24 Some students coped by distracting themselves through social media and movies,13,14 whereas others reported negative strategies such as drinking alcohol and smoking.10 One study found that resilience, adaptive coping strategies, and social support mitigated the link between COVID-related stressful events and acute stress disorder symptoms.25

In summary, nearly all the studies reported in the literature approached the topic of stress and mental health in college students during the pandemic through cross-sectional surveys and quantitative assessments of stress, depression, and anxiety. While these approaches are useful, they provide limited in-depth insight into the lived experience of students. Only one study that qualitatively explored students’ experience of stress during the pandemic was identified.10 In addition, most of the studies exploring this topic among health professions students have been conducted internationally with undergraduate student populations and none have explored pandemic-related stress among physical therapy students. Therefore, the purpose of this qualitative study was to explore the experience of stress, including sources of stress, effects of stress, and responses to stress, for Doctor of Physical Therapy (DPT) students during the onset of the COVID-19 pandemic.

METHODS

Participants

The participants in this study were part of a larger longitudinal, qualitative study exploring individuals’ experience of stress from entry into their DPT program through the first year of clinical practice. Purposive sampling was used to identify 3 physical therapist education programs in the Midwest United States, 1 of which was situated in a public university and the other 2 in private institutions. Students were informed about the study by their Director of Clinical Education using a provided script that described the study. Interested participants then contacted the researchers directly. Of those expressing interest, 3 students in each year of study were invited from each institution. When more than 3 students per year from an institution volunteered to participate, participants were purposefully selected to include male and female students and any further selections were made randomly. Nine first-year students consented to participate in 2020. Second- and third-year students who had participated in qualitative interviews the year prior were invited to continue in the longitudinal study. Of the 18 students who participated in 2019, 15 elected to continue and are included in this analysis. A sampling flowchart is provided in the Figure 1.

F1
Figure 1.:
Sampling Flowchart. Gray boxes identify participants included in the study reported here.

Research Design

This study used qualitative research methods. As this work was approached from an interpretive/constructivist epistemological perspective,26 a phenomenological approach was used to explore students’ lived experiences of stress in relation to their academic program and the onset of COVID. The phenomenological framework guided the development of open-ended interview questions and probes intended to explore the lived experiences of participants from their perspective27-29 and the essence of a phenomenon.26 The data analysis approach of thematic analysis fit with a phenomenological framework, in that the aim of this approach is to search for meaning within the data.30

Data Collection Procedures

After Institutional Review Board approval was obtained, participants were recruited as described above. After written consent, 60-minute, semi-structured interviews were conducted with each participant through video conference in April and May of 2020. To support credibility, both researchers participated in each interview, with one researcher leading the interview and the other taking observational notes and contributing clarifying questions. The researchers were female physical therapists working at an academic institution unaffiliated with those included in this study. One researcher holds a Ph.D. and has a record of conducting and publishing qualitative research. The other holds a DPT and is enrolled in an EdD program where she received graduate training in qualitative research. The interview questions were piloted and refined before use with 3 participants who were not included in the study. Specific probes were included in 2020 related to participants’ experience of stress in the midst of the pandemic. A sample of the guiding questions used in each interview is provided in Table 1. Each interview was recorded and transcribed verbatim. After the interview, participants were sent an electronic survey that included demographic questions. Students were also provided with information about support services available at their college or university. Member checks were conducted by sending transcripts back to each participant to review for accuracy.

Table 1. - Sample Guiding Questions and Probes
Sample Questions Sample Probes
Tell us about your current life circumstances.
For students who participated in the study in the prior year: What do you recall from the interview last year? Did participating in the interview last year influence your experience of stress?
How do you experience stress? What is an example of a time when stress was positive for you? Negative?
How has your experience of stress changed in the midst of the COVID-19 pandemic?
What causes you stress? What has been your greatest source of stress during PT school?
How have your sources of stress changed or remained the same since your interview last year?
How does stress affect you? Can you describe a time you were stressed and how you were feeling?
How has the impact of stress changed or remained the same since your interview last year?
How do you manage stress? How do you react when you are stressed?
What strategies do you use to manage stress?
How has your ability to manage stress changed in the past year? What has contributed to that change?
What factors related to the academic program affect your stress? Are there aspects of your academic program that add to your stress?
What does your academic program do to help you manage stress?

Data Analysis

The method of 6 interactive steps described by Braun and Clark30,31 served as a guide for thematic analysis of the data, and the NVivo 12 software program was used to support this process. First, the researchers independently reviewed and familiarized themselves with each transcript (step 1). Next, to improve dependability,28 initial codes were generated independently followed by a joint meeting to generate a coding template (step 2). Based on this template, each researcher independently coded all the transcripts and then met several times to refine codes, resolve questions and differences in coding, and recode the data. The codes were documented in a code book, which was revised throughout the data analysis process. Using inductive analysis, themes and subthemes were then constructed by analyzing, combining, and comparing codes (step 3). The data within each theme and subtheme were reviewed to ensure appropriate fit, and themes were reviewed for coherency in relation to the overall data set (step 4). Narrative descriptions for each theme and a final analysis of the findings were then completed (steps 5 and 6). A copy of the final code book is provided in the Appendix (Supplemental Digital Content 1, https://links.lww.com/JOPTE/A158).

RESULTS

The total sample included 24 students, most of whom were female, white, and between the ages of 20 and 24 years. Demographic characteristics for each participant are provided in Table 2. Four primary themes, representing the experience of stress for DPT students during the onset of the COVID-19 pandemic, resulted from the analysis of these data and codes and included Sources of Stress, Stress Management, Stress Modifiers, and Positive Aspects of COVID.

Table 2. - Participant Demographics
Participant Year of Study Age (y) Institution Gender Race/Ethnicity First Generation
S1 Y1 20–24 Public Female White No
S2 Y1 25–29 Public Female White Yes
S3 Y1 20–24 Public Female White No
S4 Y1 20–24 Private Male White No
S5 Y1 20–24 Private Male White No
S6 Y1 20–24 Private Female White Yes
S7 Y1 20–24 Private Male White No
S8 Y1 20–24 Private Female White No
S9 Y1 20–24 Private Female White No
S10 Y2 20–24 Public Female White No
S11 Y2 20–24 Public Female White No
S12 Y2 20–24 Private Male White No
S13 Y2 20–24 Private Female White Yes
S14 Y2 20–24 Private Male Hispanic Yes
S15 Y2 24–29 Private Female White No
S16 Y2  30–36 Private Female Asian No
S17 Y3 25–29 Public Female White No
S18 Y3 25–29 Public Male White No
S19 Y3 20–24 Public Female White No
S20 Y3 20–24 Private Female White No
S21 Y3 30–35 Private Male White No
S22 Y3 20–29 Private Female White No
S23 Y3  25–29 Private Male White Yes
S24 Y3  25–29 Private Male White No
Abbreviations: S = Student; Y = Year.

Sources of Stress

The most prominent theme identified from the data reflected sources of stress related to the pandemic and was associated with 4 subthemes, including Academic, Uncertainty, Personal, and Financial.

Academic

At the time of the interviews, participants had recently transitioned to a fully online learning environment in response to the pandemic. Students experienced both benefits, which will be discussed under the theme of Positive Aspects of COVID, and drawbacks associated with the online learning environment. Some participants found it difficult to stay focused and engaged when they were not physically in a classroom. For example, a first-year student (S3, Y1) noted that, “...pre-recorded lectures and…virtual interaction where it's not in person, um, has been stressful for me, and it's harder to focus...I'm...having a harder time retaining the material.”

Another common response was the identification of stress instigated by not having the opportunity to practice hands-on skills in a lab environment. Students felt that the online environment was not conducive to learning these skills. A first-year student (S6, Y1) described this difficulty as follows, “Um, being able to be in person and practice on somebody and get feedback like right away from, um, the professor or classmates. And now we're just not, we're not doing hands-on skills.” Students also worried that they would not be prepared for the clinical setting as shared by this student who stated, “…not having that hands-on experience and knowing that I'm going to be going into the clinic soon and I don't really feel prepared.” (S16, Y2)

Several participants experienced significant stress in making the transition to online learning. It required a great deal of adjustment and learning for both students and faculty as reflected by a student who commented:

You know, just this whole thing about how we needed to, like quickly move to an online format was hard at the beginning...Because no one really knew what that meant. So…the first week was a little difficult and stressful...And, you know, the professors were figuring out Zoom too... So we could tell how they were kind of, like, struggling too… (S12, Y2)

Students also reported that the workload was overwhelming during the first few weeks as faculty adjusted to assigning work in a new learning environment and tried to make up for lost time. This was described by a first-year student who stated:

...professors would give material for their class and not realize the magnitude of what they were giving us for the week, so we kind of got... you know, hours of pre-recorded lecture, and then hours of, um, Zoom or live lecture and assignments. (S3, Y1)

Several students experienced a shift in their stress levels after the week 1 or 2 in the online learning environment. They attributed this to their adjustment and the faculty figuring out better ways to deliver and organize content.

Uncertainty

A second commonly reported source of stress was uncertainty. This uncertainty was centered on matters such as academics, clinical education, board examinations, and finding a job. These concerns were particularly acute for third-year students. For example, the typical stress of preparing for the National Physical Therapy Examination was heightened when examination dates were cancelled. Participants also expressed high levels of stress related to the job search process as they learned about staffing and hiring changes in response to the pandemic. One student commented, “I would say it's higher now with just all the changes that each clinic's going through, and if, when they'll be hiring again…” (S17, Y3). Finally, a subset of students experienced stress due to general feelings of uncertainty about life in general. As this student shared, “It's been kind of tough for me with the... all the unknowns...I had...what I thought was a good picture in my head of what would be happening at this time, and it's completely different from what is happening.” (S20, Y3)

Personal

Participants reported personal sources of stress related to COVID that were unique to their individual situation and related to health, work, housing, and relationships. Several participants expressed concern about their health and the health of family members and a few reported stress related to job losses and reduced income. Other participants experienced housing changes in response to the pandemic as evidenced by the following comment, “Um, I had 24 hours to move out of my student housing and figure out where to live, so that was pretty stressful.” (S22, Y3). Feelings of isolation and boredom were common, and relationships were strained as students were unable to gather with family, significant others, or friends in the same manner as before the pandemic.

Financial

A small number of participants reported financial sources of stress. For some students, the stress experienced by financial hardship was lessened by strong family support. This was exemplified by a third-year student who stated:

I would say I'm more aware of the financial stress...Just because I know I'm going to have to be paying off the loans basically now (laughs). So there's that, and then with COVID kind of contributing to a slower job market...but also I'm fortunate that my parents will let me stay with them for a while, while I find a job.... (S23, Y3)

Stress Management

Participants’ stress management approaches, as encompassed in the second theme, relied primarily on cognitive interpretation and reappraisal, physical activity, and social support. Several students noted that the pandemic resulted in a situation in which there were many unknowns, and in response, they shifted their focus to long-term goals and aspects of life for which they were grateful. For example, a third-year student shared, “I just try to think of things that will for sure happen some day and just kind of try to focus less on when and just focus on the fact that like it will happen...” (S22, Y3)

A second-year student described her shift toward gratitude as follows:

Um, but then I just had to take some time to stop and really think about it and say, you know, ‘This is just one of those things that is unexpected. This is something that we can't blame on anybody.’...I need to change this from doom and end of the world to a little bit of gratitude. In the sense that, you know, wait a minute, it is a good thing that we are able to continue online and that our program is not at a standstill... (S13, Y2)

For physical activity and getting outside, several students made comments such as the following, “There's something about sunshine that just brings me joy and, like, deals with all of my stress, so I try to get outside, um, every day for a short amount of time…” (S9, Y1)

Finally, students noted that they were actively reaching out to friends and family for social support. This was exemplified by a student who described engaging in online games with friends and stated, “…I've also found it's been helpful to reach out to friends that I don't always get to see, and just kind of keep working on the communication bit of it.” (S20, Y3)

In some cases, these same strategies were hindered by the pandemic. Many students described having to find alternative ways to exercise because their gym facilities were closed or because their usual exercise routine was disrupted. Similarly, some students found connecting online did not offer the same level of support as in-person interactions.

Stress Modifiers

While stress management strategies were approaches that students actively engaged in, the third theme, Stress Modifiers, reflected external contextual factors that provided support and reduced distress. The primary stress modifiers identified by students were associated with the faculty and their academic cohort. For the faculty, many students highlighted that the faculty actively reached out to students to check in on them, made themselves available, and were willing to adjust course activities and assignments based on feedback. This was described by one student as follows:

I think one of the biggest things is, um, they took the time, once a week, we have a scheduled Zoom meeting with my whole class, as well as all the professors, if they're able. And it's just a time to talk. It's a time to bring up concerns. And now more than ever, they've been so good to listen to our concerns. (S11, Y2)

The level of perceived faculty support varied across the programs, with most students from 2 of the programs mentioning this modifier and significantly fewer students highlighting this factor at the third program. For peer support, students described several online means of staying connected. Most frequently this occurred with a small subset of their classmates with whom they had developed close relationships. Those who were living with other DPT students found this particularly helpful. As one student shared, “Yes, I live...with two other classmates, which has been probably the best thing for my sanity that I could ever have asked for…” (S15, Y2)

Similarly, several students who moved home during the pandemic highlighted the support of family. As one participant commented, “So, being back with my family, I think that's one of the things that's helped...they're able to like recognize when I might be spiraling, and kind of call me out on it.” (S8, Y1)

Positive Aspects of COVID

For many students, there were positive aspects associated with COVID that were both academic and personal. Academically, for some students, with the possible exception of missing hands-on laboratory activities, they found that COVID adjustments to their program and personal lives provided them with more free time, flexibility, and control of their learning and time. This was described by 2 students as follows:

Um, this is pretty nice for me to, like choose when I want to do the schooling. I can...study a lot more it seems. I get more time...throughout the day. I don't have to sit through a class before I study, you know? I can...watch lectures on my own...So, I feel since this I've had a lot less stress, which has been nice. (S12, Y2)

I'm able to learn at my pace. And so, if I need to take longer on a topic, I can take longer on that topic if I need to get through it quicker 'cause I'm understanding it, I can make the lecture quicker because it's prerecorded. (S7, Y1)

This flexibility extended to students’ personal lives as they noted that they had more time to exercise, devote to hobbies, and connect with friends and family.

DISCUSSION

The purpose of this study was to explore the experience of stress for DPT students during the onset of the COVID-19 pandemic. DPT students described sources of stress related to academics, uncertainty, personal circumstances, and finances. Academic challenges related to staying focused and engaged as described by these participants were similar to the moderate to severe difficulties with concentration and distractions in the home environment reported by university students.10,11 Similarly, these results also align with research that used surveys and semi-structured interviews and suggested that adapting to online learning and managing the academic workload were sources of stress and anxiety for undergraduate and graduate students in Texas during the onset of the COVID-19 pandemic.10,11 Concerns about reduced opportunities to learn and practice hands-on skills were similar to those reported for dental students in Malta20 and medical students in Australia.14 This is not surprising given the unique learning outcomes associated with psychomotor skills in the health sciences and physical therapy in particular.32 Future opportunities for students to strengthen and gain confidence in these skills may be particularly important for cohorts affected by the pandemic.

In contrast to some of the reported research,10,11 the DPT students who participated in this study did not describe increased stress related to fears that their grades would suffer during the pandemic. Despite significant academic challenges and stressors, these participants appeared confident that they would be able to successfully manage their studies. This may reflect the fact that DPT students in the United States typically matriculate with strong academic records33,34 and, therefore, may possess increased confidence in their ability to be successful under stressful circumstances.

The uncertainty, personal and financial sources of stress experienced by DPT students were similar to those identified by students generally10,11 and by medical students in particular.14,15 Financial concerns seemed to be less prominent in this sample than reported elsewhere.9-11 Hoyt and Cohen9 concluded that there was significant variability in how the pandemic affected college students’ financial well-being, and it may be that the respondents in this study were more similar to medical students, most whom indicated that the impact of COVID-19 on their finances was either neutral or positive.14 This variability in response may call for highly individualized approaches to supporting students in relation to pandemic-related financial stressors.

Many of the coping strategies shared by DPT students, including social support and physical activity, were similar to those documented elsewhere in the literature among university students and medical students.10,11,14 The DPT students in this study did not discuss using counseling services or engaging in negative coping strategies such as drinking or drug use. These activities have been reported by small percentages of students in other investigations.10,11,14 While some research suggests that mindfulness is a helpful coping strategy,21,24 this was not mentioned by participants in this study and may be an intervention that would be beneficial for DPT programs to implement.

A potentially important finding identified in this research involved aspects of the academic experience that served to reduce or modify stress. While the significance of support provided by family and friends has been identified by other researchers,10,11 this research illuminated the possible role of faculty and program structure as key stress modifiers. While preliminary, these results suggest that DPT programs, given their cohort nature, may have an opportunity to institute practices that may reduce stress for students both during times of crisis, such as a pandemic, and under more typical circumstances. In addition, the cohort structure also has the potential to provide additional peer support that is not present in non-cohort degree programs. Additional research is needed to confirm and further understand the impact of program structure on students’ experience of stress. Participants in this study had the opportunity to develop initial relationships with faculty and fellow students before the onset of the pandemic. The impact of pandemic-related changes to program delivery on the development of faculty and student relationships for students who matriculated into their programs in the fall of 2020 is unknown and an area that warrants further study.

Wang and Hegde11 reported that few respondents in their study were experiencing decreased stress during the pandemic. In their sample of undergraduates, students attributed this decrease to increased available time. While this factor was also reported by DPT students, the important roles of increased flexibility and agency over learning were significant and a finding that has future implications. It may be that as DPT programs consider lessons learned from the pandemic, one lesson might be that approaches that provide students with more flexibility in choosing when and how to engage with course material in contrast to the typical approach of significant required in-class seat time would have benefits for both student learning and stress levels.

There are several limitations associated with this study. For example, this investigation was embedded in a larger, longitudinal study with a broader purpose and assessed students' stress during the first months of the pandemic's onset. Further research is needed to fully explore the long-term impact of the pandemic on DPT students' experiences of stress. In addition, all the students included in this study had experienced some portion of their DPT education before the pandemic. The experience of these students may be different from those who began their DPT programs after the pandemic's onset. It is also possible that students were reluctant to share negative stress management strategies with the researchers who were physical therapists and future colleagues. Finally, most students participating in this study were White, and therefore, the transferability of the findings in this study may be limited for students of color.

CONCLUSION

In conclusion, DPT students identified sources of stress related to academics, uncertainty, personal factors, and finances. They actively used stress management approaches that were dominated by cognitive interpretation and reappraisal, social support, and physical activity. Important stress modifiers related to program faculty and peers were identified that have the potential to reduce stress for students both in times of crisis and under more typical circumstances. Finally, there were several aspects of the COVID-19 pandemic, related to both students’ academic programs and their personal lives, that were associated with reduced stress. These factors, which affected free time, flexibility, and control over learning, were associated with instructional delivery changes that programs may wish to investigate for retention and use in the future.

FUNDING

Nil.

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COVID-19; Stress; Health professions; Physical therapy; Student

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