• Research Article
  • Open access
  • Published: 06 April 2021

Health anxiety, perceived stress, and coping styles in the shadow of the COVID-19

  • Szabolcs Garbóczy 1 , 2 ,
  • Anita Szemán-Nagy 3 ,
  • Mohamed S. Ahmad 4 ,
  • Szilvia Harsányi 1 ,
  • Dorottya Ocsenás 5 , 6 ,
  • Viktor Rekenyi 4 ,
  • Ala’a B. Al-Tammemi 1 , 7 &
  • László Róbert Kolozsvári   ORCID: orcid.org/0000-0001-9426-0898 1 , 7  

BMC Psychology volume  9 , Article number:  53 ( 2021 ) Cite this article

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In the case of people who carry an increased number of anxiety traits and maladaptive coping strategies, psychosocial stressors may further increase the level of perceived stress they experience. In our research study, we aimed to examine the levels of perceived stress and health anxiety as well as coping styles among university students amid the COVID-19 pandemic.

A cross-sectional study was conducted using an online-based survey at the University of Debrecen during the official lockdown in Hungary when dormitories were closed, and teaching was conducted remotely. Our questionnaire solicited data using three assessment tools, namely, the Perceived Stress Scale (PSS), the Ways of Coping Questionnaire (WCQ), and the Short Health Anxiety Inventory (SHAI).

A total of 1320 students have participated in our study and 31 non-eligible responses were excluded. Among the remaining 1289 participants, 948 (73.5%) and 341 (26.5%) were Hungarian and international students, respectively. Female students predominated the overall sample with 920 participants (71.4%). In general, there was a statistically significant positive relationship between perceived stress and health anxiety. Health anxiety and perceived stress levels were significantly higher among international students compared to domestic ones. Regarding coping, wishful thinking was associated with higher levels of stress and anxiety among international students, while being a goal-oriented person acted the opposite way. Among the domestic students, cognitive restructuring as a coping strategy was associated with lower levels of stress and anxiety. Concerning health anxiety, female students (domestic and international) had significantly higher levels of health anxiety compared to males. Moreover, female students had significantly higher levels of perceived stress compared to males in the international group, however, there was no significant difference in perceived stress between males and females in the domestic group.

The elevated perceived stress levels during major life events can be further deepened by disengagement from home (being away/abroad from country or family) and by using inadequate coping strategies. By following and adhering to the international recommendations, adopting proper coping methods, and equipping oneself with the required coping and stress management skills, the associated high levels of perceived stress and anxiety could be mitigated.

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Introduction

On March 4, 2020, the first cases of coronavirus disease were declared in Hungary. One week later, the World Health Organization (WHO) declared COVID-19 as a global pandemic [ 1 ]. The Hungarian government ordered a ban on outdoor public events with more than 500 people and indoor events with more than 100 participants to reduce contact between people [ 2 ]. On March 27, the government imposed a nationwide lockdown for two weeks effective from March 28, to mitigate the spread of the pandemic. Except for food stores, drug stores, pharmacies, and petrol stations, all other shops and educational institutions remained closed. On April 16, a week-long extension was further announced [ 3 ].

The COVID-19 pandemic with its high morbidity and mortality has already afflicted the psychological and physical wellbeing of humans worldwide [ 4 , 5 , 6 , 7 , 8 , 9 ]. During major life events, people may have to deal with more stress. Stress can negatively affect the population’s well-being or function when they construe the situation as stressful and they cannot handle the environmental stimuli [ 10 ]. Various inter-related and inter-linked concepts are present in such situations including stress, anxiety, and coping. According to the literature, perceived stress can lead to higher levels of anxiety and lower levels of health-related quality of life [ 11 ]. Another study found significant and consistent associations between coping strategies and the dimensions of health anxiety [ 12 ].

Health anxiety is one of the most common types of anxiety and it describes how people think and behave toward their health and how they perceive any health-related concerns or threats. Health anxiety is increasingly conceptualized as existing on a spectrum [ 13 , 14 ], and as an adaptive signal that helps to develop survival-oriented behaviors. It also occurs in almost everyone’s life to a certain degree and can be rather deleterious when it is excessive [ 13 , 14 ]. Illness anxiety or hypochondriasis is on the high end of the spectrum and it affects someone’s life when it interferes with daily life by making people misinterpret the somatic sensations, leading them to think that they have an underlying condition [ 14 ].

According to the American Psychiatric Association—Diagnostic and Statistical Manual of Mental Disorders (fifth edition), Illness anxiety disorder is described as a preoccupation with acquiring or having a serious illness, and it reflects the high spectrum of health anxiety [ 15 ]. Somatic symptoms are not present or if they are, then only mild in intensity. The preoccupation is disproportionate or excessive if there is a high risk of developing a medical condition (e.g., family history) or the patient has another medical condition. Excessive health-related behaviors can be observed (e.g., checking body for signs of illness) and individuals can show maladaptive avoidance as well by avoiding hospitals and doctor appointments [ 15 ].

Health anxiety is indeed an important topic as both its increase and decrease can progress to problems [ 14 ]. Looking at health anxiety as a wide spectrum, it can be high or low [ 16 ]. While people with a higher degree of worry and checking behaviors may cause some burden on healthcare facilities by visiting them too many times (e.g., frequent unnecessary visits), other individuals may not seek medical help at healthcare units to avoid catching up infections for instance. A lower degree of health anxiety can lead to low compliance with imposed regulations made to control a pandemic [ 17 ].

The COVID-19 pandemic as a major event in almost everyone’s life has posed a great impact on the population’s perceived stress level. Several studies about the relation between coping and response to epidemics in recent and previous outbreaks found higher perceived stress levels among people [ 18 , 19 , 20 , 21 ]. Being a woman, low income, and living with other people all were associated with higher stress levels [ 18 ]. Protective factors like being emotionally more stable, having self-control, adaptive coping strategies, and internal locus of control were also addressed [ 19 , 20 ]. The findings indicated that the COVID-19 crisis is perceived as a stressful event. The perceived stress was higher amongst people than it was in situations with no emergency. Nervousness, stress, and loss of control of one’s life are the factors that are most connected to perceived stress levels which leads to the suggestion that unpredictability and uncontrollability take an important part in perceived stress during a crisis [ 19 , 20 ].

Moreover, certain coping styles (e.g., having a positive attitude) were associated with less psychological distress experiences but avoidance strategies were more likely to cause higher levels of stress [ 21 ]. According to Lazarus (1999), individuals differ in their perception of stress if the stress response is viewed as the interaction between the environment and humans [ 22 ]. An Individual can experience two kinds of evaluation processes, one to appraise the external stressors and personal stake, and the other one to appraise personal resources that can be used to cope with stressors [ 22 , 23 ]. If there is an imbalance between these two evaluation processes, then stress occurs, because the personal resources are not enough to cope with the stressor’s demands [ 23 ].

During stressful life events, it is important to pay attention to the increasing levels of health anxiety and to the kind of coping mechanisms that are potential factors to mitigate the effects of high anxiety. The transactional model of stress by Lazarus and Folkman (1987) provides an insight into these kinds of factors [ 24 ]. Lazarus and Folkman theorized two types of coping responses: emotion-focused coping, and problem-focused coping. Emotion-focused coping strategies (e.g., distancing, acceptance of responsibility, positive reappraisal) might be used when the source of stress is not embedded in the person’s control and these strategies aim to manage the individual’s emotional response to a threat. Also, emotion-focused coping strategies are directed at managing emotional distress [ 24 ]. On the other hand, problem-focused coping strategies (e.g., confrontive coping, seeking social support, planful problem-solving) help an individual to be able to endure and/or minimize the threat, targeting the causes of stress in practical ways [ 24 ]. It was also addressed that emotion-focused coping mechanisms were used more in situations appraised as requiring acceptance, whereas problem-focused forms of coping were used more in encounters assessed as changeable [ 24 ].

A recent study in Hunan province in China found that the most effective factor in coping with stress among medical staff was the knowledge of their family’s well-being [ 25 ]. Although there have been several studies about the mental health of hospital workers during the COVID-19 pandemic or other epidemics (e.g., SARS, MERS) [ 26 , 27 , 28 , 29 ], only a few studies from recent literature assessed the general population’s coping strategies. According to Gerhold (2020) [ 30 ], older people perceived a lower risk of COVID-19 than younger people. Also, women have expressed more worries about the disease than men did. Coping strategies were highly problem-focused and most of the participants reported that they listen to professionals’ advice and tried to remain calm [ 30 ]. In the same study, most responders perceived the COVID-19 pandemic as a global catastrophe that will severely affect a lot of people. On the other hand, they perceived the pandemic as a controllable risk that can be reduced. Dealing with macrosocial stressors takes faith in politics and in those people, who work with COVID-19 on the frontline.

Mental disorders are found prevalent among college students and their onset occurs mostly before entry to college [ 31 ]. The diagnosis and timely interventions at an early stage of illness are essential to improve psychosocial functioning and treatment outcomes [ 31 ]. According to research that was conducted at the University of Debrecen in Hungary a few years ago, the students were found to have high levels of stress and the rate of the participants with impacted mental health was alarming [ 32 ]. With an unprecedented stressful event like the COVID-19 crisis, changes to the mental health status of people, including students, are expected.

Aims of the study

In our present study, we aimed at assessing the levels of health anxiety, perceived stress, and coping styles among university students amidst the COVID-19 lockdown in Hungary, using three validated assessment tools for each domain.

Methods and materials

Study design and setting.

This study utilized a cross-sectional design, using online self-administered questionnaires that were created and designed in Google Forms® (A web-based survey tool). Data collection was carried out in the period April 30, 2020, and May 15, 2020, which represents one of the most stressful periods during the early stage of the COVID-19 pandemic in Hungary when the official curfew/lockdown was declared along with the closure of dormitories and shifting to online remote teaching. The first cases of COVID-19 were declared in Hungary on March 4, 2020. On April 30, 2020, there were 2775 confirmed cases, 312 deaths, and 581 recoveries. As of May 15, 2020, the number of confirmed cases, deaths, and recovered persons was 3417, 442, and 1287, respectively.

Our study was conducted at the University of Debrecen, which is one of the largest higher education institutions in Hungary. The University is located in the city of Debrecen, the second-largest city in Hungary. Debrecen city is considered the educational and cultural hub of Eastern Hungary. As of October 2019, around 28,593 students were enrolled in various study programs at the University of Debrecen, of whom, 6,297 were international students [ 33 ]. The university offers various degree courses in Hungarian and English languages.

Study participants and sampling

The target population of our study was students at the University of Debrecen. Students were approached through social media platforms (e.g., Facebook®) and the official student administration system at the University of Debrecen (Neptun). The invitation link to our survey was sent to students on the web-based platforms described earlier. By using the Neptun system, we theoretically assumed that our survey questionnaire has reached all students at the University. The students who were interested and willing to participate in the study could fill out our questionnaire anonymously during the determined study period; thus, employing a convenience sampling approach. All students at the University of Debrecen whose age was 18 years or older and who were in Hungary during the outbreak had the eligibility to participate in our study whether undergraduates or postgraduates.

Study instruments

In our present study, the survey has solicited information about the sociodemographic profile of participants including age (in years), gender (female vs male), study program (health-related vs non-health related), and whether the student stayed in Hungary or traveled abroad during the period of conducting our survey in the outbreak. Our survey has also adopted three international scales to collect data about health anxiety, coping styles, and perceived stress during the pandemic crisis. As the language of instruction for international students at the University of Debrecen is English, and English fluency is one of the criteria for international students’ admission at the University of Debrecen, the international students were asked to fill out the English version of the survey and the scales. On the other hand, the Hungarian students were asked to fill out the Hungarian version of the survey and the validated Hungarian scales. Also, we provided contact information for psychological support when needed. Students who felt that they needed some help and psychological counseling could use the contact information of our peer supporters. Four International students have used this opportunity and were referred to a higher level of care. The original scales and their validated Hungarian versions are described in the following sections.

Perceived Stress Scale (PSS)

The Perceived Stress Scale (PSS) measures the level of stress in the general population who have at least completed a junior high school [ 34 ]. In the PSS, the respondents had to report how often certain things occurred like nervousness; loss of control; feeling of upset; piling up difficulties that cannot be handled; or on the contrary how often the students felt they were able to handle situations; and were on top of things. For the International students, we used the 10-item PSS (English version). The statements’ responses were scored on a 5-point Likert scale (from 0 = never to 4 = very often) as per the scale’s guide. Also, in the 10-item PSS, four positive items were reversely scored (e.g. felt confident about someone’s ability to handle personal problems) [ 34 ]. The PSS has satisfactory psychometric properties with a Cronbach’s alpha of 0.78, and this English version was used for international students in our study.

For the Hungarian students, we used the Hungarian version of the PSS, which has 14 statements that cover the same aspects of stress described earlier. In this version of the PSS, the responses were evaluated on a 5-point Likert scale (0–4) to mark how typical a particular behavior was for a respondent in the last month [ 35 ]. The Hungarian version of the PSS was psychometrically validated in 2006. In the validation study, the Hungarian 14-item PSS has shown satisfactory internal consistency with a Cronbach’s alpha of 0.88 [ 35 ].

Ways of Coping Questionnaire (WCQ)

The second scale we used was the 26-Item Ways of Coping Questionnaire (WCQ) which was developed by Sørlie and Sexton [ 36 ]. For the international students, we used the validated English version of the 26-Item WCQ that distinguished five different factors, including Wishful thinking (hoped for a miracle, day-dreamed for a better time), Goal-oriented (tried to analyze the problem, concentrated on what to do), Seeking support (talked to someone, got professional help), Thinking it over (drew on past experiences, realized other solutions), and Avoidance (refused to think about it, minimized seriousness of it). The WCQ examined how often the respondents used certain coping mechanisms, eg: hoped for a miracle, fantasized, prepared for the worst, analyzed the problem, talked to someone, or on the opposite did not talk to anyone, drew conclusions from past things, came up with several solutions for a problem or contained their feelings. As per the 26-item WCQ, responses were scored on a 4-point Likert scale (from 0 = “does not apply and/or not used” to 3 = “used a great deal”). This scale has satisfactory psychometric properties with Cronbach's alpha for the factors ranged from 0.74 to 0.81[ 36 ].

For the Hungarian students, we used the Hungarian 16-Item WCQ, which was validated in 2008 [ 37 ]. In the Hungarian WCQ, four dimensions were identified, which were cognitive restructuring/adaptation (every cloud has a silver lining), Stress reduction (by eating; drinking; smoking), Problem analysis (I tried to analyze the problem), and Helplessness/Passive coping (I prayed; used drugs) [ 37 ]. The Cronbach’s alpha values for the Hungarian WCQ’s dimensions were in the range of 0.30–0.74 [ 37 ].

Short Health Anxiety Inventory (SHAI)

The third scale adopted was the 18-Items Short Health Anxiety Inventory (SHAI). Overall, the SHAI has two subscales. The first subscale comprised of 14 items that examined to what degree the respondents were worried about their health in the past six months; how often they noticed physical pain/ache or sensations; how worried they were about a serious illness; how much they felt at risk for a serious illness; how much attention was drawn to bodily sensations; what their environment said, how much they deal with their health. The second subscale of SHAI comprised of 4 items (negative consequences if the illness occurs) that enquired how the respondents would feel if they were diagnosed with a serious illness, whether they would be able to enjoy things; would they trust modern medicine to heal them; how many aspects of their life it would affect; how much they could preserve their dignity despite the illness [ 38 ]. One of four possible statements (scored from 0 to 3) must be chosen. Alberts et al. (2013) [ 39 ] found the mean SHAI value to be 12.41 (± 6.81) in a non-clinical sample. The original 18-item SHAI has Cronbach’s alpha values in the range of 0.74–0.96 [ 39 ]. For the Hungarian students, the Hungarian version of the SHAI was used. The Hungarian version of SHAI was validated in 2011 [ 40 ]. The scoring differs from the English version in that the four statements were scored from 1 to 4, but the statements themselves were the same. In the Hungarian validation study, it was found that the SHAI mean score in a non-clinical sample (university students) was 33.02 points (± 6.28) and the Cronbach's alpha of the test was 0.83 [ 40 ].

Data analyses

Data were extracted from Google Forms® as an Excel sheet for quality check and coding then we used SPSS® (v.25) and RStudio statistical software packages to analyze the data. Descriptive and summary statistics were presented as appropriate. To assess the difference between groups/categories of anxiety, stress, and coping styles, we used the non-parametric Kruskal–Wallis test, since the variables did not have a normal distribution and for post hoc tests, we used the Mann–Whitney test. Also, we used Spearman’s rank correlation to assess the relationship between health anxiety and perceived stress within the international group and the Hungarian group. Comparison between international and domestic groups and different genders in terms of health anxiety and perceived stress levels were also conducted using the Mann–Whitney test. Binary logistic regression analysis was also employed to examine the associations between different coping styles/ strategies (treated as independent variables) and both, health anxiety level and perceived stress level (treated as outcome variables) using median splits. A p-value less than 5% was implemented for statistical significance.

Ethical considerations

Ethical permission was obtained from the Hungarian Ethical Review Committee for Research in Psychology (Reference number: 2020-45). All methods were carried out following the institutional guidelines and conforming to the ethical standards of the declaration of Helsinki. All participants were informed about the study and written informed consent was obtained before completing the survey. There were no rewards/incentives for completing the survey.

Sociodemographic characteristics of respondents

A total of 1320 students have responded to our survey. Six responses were eliminated due to incompleteness and an additional 25 responses were also excluded as the students filled out the survey from abroad (International students who were outside Hungary during the period of conducting our study). After exclusion of the described non-eligible responses (a total of 31 responses), the remaining 1289 valid responses were included in our analysis. Out of 1289 participants (100%), 73.5% were Hungarian students and around 26.5% were international students. Overall, female students have predominated the sample (n = 920, 71.4%). The median age (Interquartile range) among Hungarian students was 22 years (5) and for the international students was 22 years (4). Out of the total sample, most of the Hungarian students were enrolled in non-health-related programs (n = 690, 53.5%), while most of the international students were enrolled in health-related programs (n = 213, 16.5%). Table 1 demonstrates the sociodemographic profile of participants (Hungarian vs International).

Perceived stress, anxiety, and coping styles

For greater clarity of statistical analysis and interpretation, we created preferences regarding coping mechanisms. That is, we made the categories based on which coping factor (in the international sample) or dimension (in the Hungarian sample) the given person reached the highest scores, so it can be said that it is the person's preferred coping strategy. The four coping strategies among international students were goal-oriented, thinking it over, wishful thinking, and avoidance, while among the Hungarian students were cognitive restructuring, problem analysis, stress reduction, and passive coping.

The 26-item WCQ [ 31 ] contains a seeking support subscale which is missing from the Hungarian 16-item WCQ [ 32 ]; therefore, the seeking support subscale was excluded from our analysis. Moreover, because the PSS contained a different number of items in English and Hungarian versions (10 items vs 14 items), we looked at the average score of the answers so that we could compare international and domestic students.

In the evaluation of SHAI, the scoring of the two questionnaires are different. For the sake of comparability between the two samples, the international points were corrected to the Hungarian, adding plus one to the value of each answer. This may be the reason why we obtained higher results compared to international standards.

Among the international students, the mean score (± standard deviation) of perceived stress among male students was 2.11(± 0.86) compared to female students 2.51 (± 0.78), while the mean score (± standard deviation) of health anxiety was 34.12 (± 7.88) and 36.31 (± 7.75) among males and females, respectively. Table 2 shows more details regarding the perceived stress scores and health anxiety scores stratified by coping strategies among international students.

In the Hungarian sample, the mean score (± standard deviation) of perceived stress among male students was 2.06 (± 0.84) compared to female students 2.18 (± 0.83), while the mean score (± standard deviation) of health anxiety was 33.40 (± 7.63) and 35.05 (± 7.39) among males and females, respectively. Table 3 shows more details regarding the perceived stress scores and health anxiety scores stratified by coping strategies among Hungarian students.

Concerning coping styles among international students, the statements with the highest-ranked responses were “wished the situation would go away or somehow be finished” and “Had fantasies or wishes about how things might turn out” and both fall into the wishful thinking coping. Among the Hungarian students, the statements with the highest-ranked responses were “I tried to analyze the problem to understand better” (falls into problem analysis coping) and “I thought every cloud has a silver lining, I tried to perceive things cheerfully” (falls into cognitive restructuring coping).

On the other hand, the statements with the least-ranked responses among the international students belonged to the Avoidance coping. Among the Hungarians, it was Passive coping “I tried to take sedatives or medications” and Stress reduction “I staked everything upon a single cast, I started to do something risky” to have the lowest-ranked responses. Table 4 shows a comparison of different coping strategies among international and Hungarian students.

To test the difference between coping strategies, we used the non-parametric Kruskal–Wallis test, since the variables did not have a normal distribution. For post hoc tests, we used Mann–Whitney tests with lowered significance levels ( p  = 0.0083). Among Hungarian students, there were significant differences between the groups in stress ( χ 2 (3) = 212.01; p < 0.001) and health anxiety ( χ 2 (3) = 80.32; p  < 0.001). In the post hoc tests, there were significant differences everywhere ( p  < 0.001) except between stress reduction and passive coping ( p  = 0.089) and between problem analysis and passive coping ( p  = 0.034). Considering the health anxiety, the results were very similar. There were significant differences between all groups ( p  < 0.001), except between stress reduction and passive coping ( p  = 0.347) and between problem analysis and passive coping ( p  = 0.205). See Figs.  1 and 2 for the Hungarian students.

figure 1

Perceived stress differences between coping strategies among the Hungarian students

figure 2

Health anxiety differences between coping strategies among the Hungarian students

Among the international students, the results were similar. According to the Kruskal–Wallis test, there were significant differences in stress ( χ 2 (3) = 73.26; p  < 0.001) and health anxiety ( χ 2 (3) = 42.60; p  < 0.001) between various coping strategies. The post hoc tests showed that there were differences between the perceived stress level and coping strategies everywhere ( p  < 0.005) except and between avoidance and thinking it over ( p  = 0.640). Concerning health anxiety, there were significant differences between wishful thinking and goal-oriented ( p  < 0.001), between wishful thinking and avoidance ( p  = 0.001), and between goal-oriented and avoidance ( p  = 0.285). There were no significant differences between wishful thinking and thinking it over ( p  = 0.069), between goal-oriented and thinking it over ( p  = 0.069), and between avoidance and thinking it over ( p  = 0.131). See Figs.  3 and 4 .

figure 3

Perceived stress differences between coping strategies among the international students

figure 4

Health anxiety differences between coping strategies among the international students

The relationship between coping strategies with health anxiety and perceived stress levels among the international students

We applied logistic regression analyses for the variables to see which of the coping strategies has a significant effect on SHAI and PSS results. In the first model (model a), with the health anxiety as an outcome dummy variable (with median split; median: 35), only two coping strategies had a statistically significant relationship with health anxiety level, including wishful thinking (as a risk factor) and goal-oriented (as a protective factor).

In the second model (model b), with the perceived stress as an outcome dummy variable (with median split; median: 2.40), three coping strategies were found to have a statistically significant association with the level of perceived stress, including wishful thinking (as a risk factor), while goal-oriented and thinking it over as protective factors. See Table 5 .

The relationship between coping strategies with health anxiety and perceived stress levels among domestic students

By employing logistic regression analysis, with the health anxiety as an outcome dummy variable (with median split; median: 33.5) (model a), three coping strategies had a statistically significant relationship with health anxiety level among domestic students, including stress reduction and problem analysis (as risk factors), while cognitive restructuring (as a protective factor).

Similarly, with the perceived stress as an outcome dummy variable (with median split; median: 2.1429) (model b), three coping strategies had a statistically significant relationship with perceived stress level, including stress reduction and problem analysis (as risk factors), while cognitive restructuring (as a protective factor). See Table 6 .

Comparisons between domestic and international students

We compared health anxiety and perceived stress levels of the Hungarian and international students’ groups using the Mann–Whitney test. In the case of health anxiety, the results showed that there were significant differences between the two groups ( W  = 149,431; p  = 0.038) and international students’ levels were higher. Also, there was a significant difference in the perceived stress level between the two groups ( W  = 141,024; p  < 0.001), and the international students have increased stress levels compared to the Hungarian ones.

Comparisons between genders within students’ groups (International vs Hungarian)

Firstly, we compared the international men’s and women’s health anxiety and stress levels using the Mann–Whitney test. The results showed that the international women’s health anxiety ( W  = 11,810; p  = 0.012) and perceived stress ( W  = 10,371; p  < 0.001) levels were both significantly higher than international men’s values. However, in the Hungarian sample, women’s health anxiety was significantly higher than men’s ( W  = 69,643; p  < 0.001), but there was no significant difference in perceived stress levels among between Hungarian women and men ( W  = 75,644.5; p  = 0.064).

Relationship between health anxiety and perceived stress

We correlated the general health anxiety and perceived stress using Spearman’s rank correlation. There was a significant moderate positive relationship between the two variables ( p  < 0.001; ρ  = 0.446). Within the Hungarian students, there was a significant correlation between health anxiety and perceived stress ( p  < 0.001; ρ  = 0.433), similarly among international students as well ( p  < 0.001; ρ  = 0.465).

In our study, we found that individuals who were characterized by a preference for certain coping strategies reported significantly higher perceived stress and/or health anxiety than those who used other coping methods. These correlations can be found in both the Hungarian and international students. In the light of our results, we can say that 48.4% of the international students used wishful thinking as their preferred coping method while around 43% of the Hungarian students used primarily cognitive restructuring to overcome their problems.

Regulation of emotion refers to “the processes whereby individuals monitor, evaluate, and modify their emotions in an effort to control which emotions they have, when they have them, and how they experience and express those emotions” [ 41 ]. There is an overlap between emotion-focused coping and emotion regulation strategies, but there are also differences. The overlap between the two concepts can be noticed in the fact that emotion-focused coping strategies have an emotional regulatory role, and emotion regulation strategies may “tax the individual’s resources” as the emotion-focused coping strategies do [ 23 , 42 ]. However, in emotion-focused coping strategies, non-emotional tools can also be used to achieve non-emotional goals, while emotion regulation strategies may be used for maintaining or reinforcing positive emotions [ 42 ].

Based on the cognitive-behavioral model of health anxiety, emotion-regulating strategies can regulate the physiological, cognitive, and behavioral consequences of a fear response to some degree, even when the person encounters the conditioned stimulus again [ 12 , 43 ]. In the long run, regular use of these dysfunctional emotion control strategies may manifest as functional impairment, which may be associated with anxiety disorders. A detailed study that examined health anxiety in the view of the cognitive-behavioral model found that, regardless of the effect of depression, there are significant and consistent correlations between certain dimensions of health anxiety and dysfunctional coping and emotional regulation strategies [ 12 ].

Similar to our current study, other studies have found that health anxiety was positively correlated with maladaptive emotion regulation and negatively with adaptive emotion regulation [ 44 ], and in the case of state anxiety that emotion-focused coping strategies proved to be less effective in reducing stress, while active coping leads to a sense of subjective well-being [ 17 , 27 , 45 , 46 , 47 ]

SHAI values were found to be high in other studies during the pandemic, and the SHAI results of the international students in our study were found to be even slightly higher compared to those studies [ 44 , 48 ]. Besides, anxiety values for women were found to be higher than for men in several studies [ 44 , 48 , 49 , 50 ]. This was similar to what we found among the international students but not among the Hungarian ones. We can speculate that the ability to contact someone, the closeness of family and beloved ones, familiarity with the living environment, and maybe less online search about the coronavirus news could be factors counting towards that finding among Hungarian students. Also, most international students were enrolled in health-related study programs and his might have affected how they perceived stress/anxiety and their preferred coping strategies as well. Literature found that students of medical disciplines could have obstacles in achieving a healthy coping strategy to deal with stress and anxiety despite their profound medical knowledge compared to non-health-related students [ 51 , 52 ]. Literature also stressed the immense need for training programs to help students of medical disciplines in adopting coping skills and stress-reducing strategies [ 51 ].

The findings of our study may be a starting point for the exploration of the linkage between perceived stress, health anxiety, and coping strategies when people are not in their domestic context. People who are away from their home and friends in a relatively alien environment may tend to use coping mechanisms other than the adequate ones, which in turn can lead to increased levels of perceived stress.

Furthermore, our results seem to support the knowledge that deep-rooted health anxiety is difficult to change because it is closely related to certain coping mechanisms. It was also addressed in the literature that personality traits may have a significant influence on the coping strategy used by a person [ 53 ], revealing sophisticated and challenging links to be considered especially during training programs on effective coping and management skills. On the other hand, perceived stress which has risen significantly above the average level in the current pandemic, can be most effectively targeted by the well-formulated recommendations and advice of major international health organizations if people successfully adhere to them (e.g. physical activity; proper and adequate sleep; healthy eating; avoiding alcohol; meditation; caring for others; relationships maintenance, and using credible information resources about the pandemic, etc.) [ 1 , 54 ]. Furthermore, there may be additional positive effects of these recommendations when published in different languages or languages that are spoken by a wide range of nationalities. Besides, cognitive behavioral therapy techniques, some of which are available online during the current pandemic crisis, can further reduce anxiety. Also, if someone does not feel safe or fear prevails, there are helplines to get in touch with professionals, and this applies to the University of Debrecen in Hungary, and to a certain extent internationally.

Naturally, our study had certain limitations that should be acknowledged and considered. The temporality of events could not be assessed as we employed a cross-sectional study design, that is, we did not have information on the previous conditions of the participants which means that it is possible that some of these conditions existed in the past, while others de facto occurred with COVID-19 crisis. The survey questionnaires were completed by those who felt interested and involved, i.e., a convenience sampling technique was used, this impairs the representativeness of the sample (in terms of sociodemographic variables) and the generalizability of our results. Also, the type of recruitment (including social media) as well as the online nature of the study, probably appealed more to people with an affinity with this kind of instrument. Besides, each questionnaire represented self-reported states; thus, over-reporting or under-reporting could be present. It is also important to note that international students were answering the survey questionnaire in a language that might not have been their mother language. Nevertheless, English fluency is a prerequisite to enroll in a study program at the University of Debrecen for international students. As the options for gender were only male/female in our survey questionnaire, we might have missed the views of students who do not identify themselves according to these gender categories. Also, no data on medical history/current medical status were collected. Lastly, we had to make minor changes to the used scales in the different languages for comparability.

The COVID-19 pandemic crisis has imposed a significant burden on the physical and psychological wellbeing of humans. Crises like the current pandemic can trigger unprecedented emotional and behavioral responses among individuals to adapt or cope with the situation. The elevated perceived stress levels during major life events can be further deepened by disengagement from home and by using inadequate coping strategies. By following and adhering to the international recommendations, adopting proper coping strategies, and equipping oneself with the required coping and stress management skills, the associated high levels of perceived stress and anxiety might be mitigated.

Availability of data and materials

The datasets generated and/or analyzed during the current study are not publicly available due to compliance with institutional guidelines but they are available from the corresponding author (LRK) on a reasonable request.

Abbreviations

Centers for Disease Control and Prevention

Coronavirus Disease 2019

Perceived Stress Scale

Short Health Anxiety Inventory

Middle East Respiratory Syndrome

Severe Acute Respiratory Syndrome

Ways of Coping Questionnaire

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Acknowledgments

We would like to provide our extreme thanks and appreciation to all students who participated in our study. ABA is currently supported by the Tempus Public Foundation’s scholarship at the University of Debrecen.

This research project did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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Szabolcs Garbóczy, Szilvia Harsányi, Ala’a B. Al-Tammemi & László Róbert Kolozsvári

Department of Psychiatry, Faculty of Medicine, University of Debrecen, Debrecen, Hungary

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Department of Personality and Clinical Psychology, Institute of Psychology, University of Debrecen, Debrecen, Hungary

Anita Szemán-Nagy

Faculty of Medicine, University of Debrecen, Debrecen, Hungary

Mohamed S. Ahmad & Viktor Rekenyi

Department of Social and Work Psychology, Institute of Psychology, University of Debrecen, Debrecen, Hungary

Dorottya Ocsenás

Doctoral School of Human Sciences, University of Debrecen, Debrecen, Hungary

Department of Family and Occupational Medicine, Faculty of Medicine, University of Debrecen, Móricz Zs. krt. 22, Debrecen, 4032, Hungary

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All authors SG, ASN, MSA, SH, DO, VR, ABA, and LRK have worked on the study design, text writing, revising, and editing of the manuscript. DO, SG, and VR have done data management and extraction, data analysis. Drafting and interpretation of the manuscript were made in close collaboration by all authors SG, ASN, MSA, SH, DO, VR, ABA, and LRK. All authors read and approved the final manuscript.

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Garbóczy, S., Szemán-Nagy, A., Ahmad, M.S. et al. Health anxiety, perceived stress, and coping styles in the shadow of the COVID-19. BMC Psychol 9 , 53 (2021). https://doi.org/10.1186/s40359-021-00560-3

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Review article, examining academics’ strategies for coping with stress and emotions: a review of research.

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  • Department of Educational and Counselling Psychology, McGill University, Montreal, QC, Canada

Existing research suggests that numerous aspects of the modern academic career are stressful and trigger emotional responses, with evidence further showing job-related stress and emotions to impact well-being and productivity of post-secondary faculty (i.e., university or college research and teaching staff). The current paper provides a comprehensive and descriptive review of the empirical research on coping and emotion regulation strategies among faculty members, identifies adaptive stress management and emotion regulation strategies for coping with emotional demands of the academic profession, synthesizes findings on the association between such strategies and faculty well-being, and provides directions for future research on this topic.

Introduction

Not unlike other professionals, post-secondary faculty (i.e., university or college research and teaching staff across ranks and tenure status) have consistently been found to report high levels of job-related stress ( Winefield et al., 2003 ). In the last few decades, higher education institutions worldwide have undergone fundamental changes. Major educational reforms, exponential expansion in student enrollment, escalating workloads, greater control by managers with respect to teaching quality and research productivity, and the movement towards commercialization have shifted the landscape of higher education into a competitive business ( Ogbonna and Harris, 2004 ; Biron et al., 2008 ; Rothmann and Barkhuizen, 2008 ; McAlpine and Akerlind, 2010 ). Subsequently, there is substantial pressure on academics to maintain high academic performance and productivity ( Catano et al., 2010 ; McAlpine and Akerlind, 2010 ).

Surveys carried out in the U.K. ( Tytherleigh et al., 2005 ; Kinman, 2014 ), Australia ( Winefield et al., 2003 ), and Canada ( Biron et al., 2008 ; Catano et al., 2010 ) suggest that these increased demands have contributed to high levels of job-related stress amongst academics. Most notably, a recent comparison of U.K. and Australian academics revealed that faculty suffered from higher levels of stress-related caseness (i.e., when some intervention is required) as compared with other university groups (e.g., post-secondary staff, support professonals; Kinman, 2014 ), with reported burnout by academics being comparable to that of school teachers and medical professionals for whom burnout levels are particularly high ( Watts and Robertson, 2012 ). Empirical evidence strongly supports the detrimental impact of stress on post-secondary faculty members’ physical (e.g., sleep problems, nausea, heart pounding) and psychological well-being (e.g., anxiety, depression, burnout, psychological distress)and professional competencies, as well as student attainment and institutional productivity ( Blix et al., 1994 ; Stevenson and Harper, 2006 ; Catano et al., 2010 ; Watts and Robertson, 2012 ; Barkhuizen et al., 2014 ; Kataoka et al., 2014 ; Shen et al., 2014 ; Salimzadeh et al., 2017 ).

A parallel line of research suggests that the academic profession elicits a wide variety of positive and negative emotions resulting from interactions with students, teaching and research-related activities, as well as organizational factors (e.g., Martin and Lueckenhausen, 2005 ; Postareff and Lindblom-Ylänne, 2011 ; Hagenauer and Volet, 2014a ). The emotion literature further underscores implications of emotions on our cognition, behavior, physical health, and psychological well-being (for meta-analytical summaries, see Houben et al., 2015 ; Lench et al., 2011 ). Importantly, these findings have been replicated in emergent research conducted with post-secondary faculty. For instance, a study of 175 Australian university teachers documented the impact of teaching-related emotions on instructional behavior: positive emotions concerning teaching was associated with student-focused teaching approaches and negative emotions instead linked to information transmission approaches ( Trigwell, 2012 ).

Similarly, a mixed-methods study of 18 U.S. faculty members showed that emotions predict faculty success in teaching and research as well as mediate the impact of perceived task value on teaching success and perceptions of academic control on research success ( Stupnisky et al., 2014 ). More precisely, faculty members who placed higher value on their teaching felt more enjoyment and pride in teaching and, in turn, experienced greater teaching success. As for research, the more faculty felt in control of their research, the more adaptive emotions they felt regarding research (e.g., enjoyment, pride) that, in turn, predicted greater research success. In the same vein, a study of 362 U.S. and Chinese college students found that students’ perceptions of university teachers’ positive emotions were significantly and positively correlated with students’ own positive emotions, behavioral and cognitive engagement, and critical thinking ( Zhang and Zhang, 2013 ).

As emotion and stress share overlapping dimensions, it is necessary to consider both their common and distinguishing features. Psychological stress is defined as “a particular relationship between the person and the environment that is appraised by the person as taxing or exceeding his or her resources and endangering his or her well-being” ( Lazarus and Folkman, 1984 , p. 19). While both stress and emotions are subject to appraisals of the personal significance of an emotional encounter, emotion is operationalized as a broader construct that encompasses negative experiences such as stress ( Lazarus, 1993 ). As such and as a subset of emotion, stress is more limited in scope and depth. While negative emotions are elicited when our goals are thwarted, perceived stress represents the belief that the challenges exceed one’s capabilities to cope with them ( Lazarus, 1993 ; Lazarus, 1998 ). In light of the above-mentioned common features, emotions and stress are reviewed together in the present paper.

Emotion regulation is defined as an everyday psychological process “by which individuals influence which emotions they have, when they have them, and how they experience and express these emotions” ( Gross, 1998b , p. 275). In contrast, coping refers to individuals’ efforts to manage stronger and more persistent negative emotions (i.e., stress) that involve “constantly changing cognitive and behavioral efforts to manage specific external and/or internal demands that are appraised as taxing or exceeding the resources of the person” ( Lazarus and Folkman, 1984 , p. 141). Emotional labor, on the other hand, involves the “process of regulating both the internal and expressive components of emotions according to an organization’s display rules” ( Grandey, 2000 , p. 97). As such, whereas emotion regulation involves managing both positive and negative emotions on a daily basis, and coping pertains to sustained efforts to combat strong negative emotions in response to significant stressors, emotional labor pertains specifically to the emotions one is expected to convey to others in occupational settings regardless of what one is internally experiencing.

Empirical evidence indicates that the ability to effectively manage stress and emotions has important consequences for health and adaptive functioning (e.g., Folkman and Moskowitz, 2004 ; Gross, 2002 ; Gross and Levenson, 1997 ; John and Gross, 2004 ; for meta-analytical summaries, Skinner et al., 2003 ; Aldao et al., 2010 ; Webb et al., 2012 ). However, although existing research highlights the relevance of coping and emotion regulation for functional and dysfunctional outcomes within work contexts in general (e.g., Murphy, 1996 ; Lawrence et al., 2011 ), the nature and significance of post-secondary academics’ coping and emotion regulation strategies is underexplored. Furthermore, the existing literature on coping and emotion regulation in post-secondary faculty is scattered with no reviews of empirical findings on the topic having been carried out to date. Given the stressful and emotion-laden nature of the academic profession as well as the increasingly problematic nature of stress and the impact of emotions in post-secondary faculty, a comprehensive review of empirical findings is required.

As such, the present review addresses this research gap by providing a comprehensive and descriptive review of quantitative and qualitative research findings on coping and emotion-regulation strategies as reported by post-secondary faculty. It is anticipated that findings from this review will generate insight into academics’ coping and emotion management strategies as well as the consequences of these strategies for well-being and productivity. Furthermore, the findings should shed light on the design and implementation of optimal faculty interventions for post-secondary institutions to equip their academic teaching and research staff with adaptive psychological strategies and maintain their well-being levels ( Implications of Faculty Emotion Regulation and Emotional Labor section for examples of potential interventions). Prior to presenting the method of the review and the main findings, a brief overview of relevant constructs and their corresponding theoretical frameworks are presented.

Constructs Under Review: Coping and Emotion Regulation

Coping strategies. A variety of conceptualizations have been utilized to describe the structure of individuals’ psychological strategies for coping with negative emotions, with models typically distinguishing between problem- and emotion-focused coping ( Folkman and Lazarus, 1980 , Folkman and Lazarus, 1985 ), engagement (active, approach) versus disengagement (avoidance, passive) coping ( Roth and Cohen, 1986 ; Tobin et al., 1989 ), and primary (assimilative) versus secondary (accomodative) control coping ( Weisz et al., 1994 ; Weisz et al., 1984 ; for detailed reviews, see; Skinner et al., 2003 ; Skinner and Zimmer-Gembeck, 2016 ). Problem-focused coping (e.g., strategizing for the purpose of goal attainment) consists of efforts to solve the problem through modifying or eliminating the source of stress whereas emotion-focused coping (e.g., wishful thinking) seeks to regulate distressing emotions in the face of adversity so as to manage the psychological impact of stress. Similarly, engagement coping (e.g., support-seeking) entails active attempts to directly deal with the stressful situation or related feelings whereas disengagement coping (e.g., social withdrawal) refers to efforts to physically and cognitively distance oneself from the stressor and associated emotions.

Whereas perceiving a situation as a challenge may induce positive emotions such as eagerness or excitement, interpreting it instead as personally threatening generates negative emotions such as anxiety or fear ( Folkman, 2008 ). This concept of cognitive appraisals is consistently highlighted in the coping literature due to one’s interpretations regarding the significance and meaning of a stressful encounter mediating the impact of such events on subsequent emotions ( Lazarus and Folkman, 1984 ; Lazarus, 2000 ; Folkman, 2008 ). Importantly, cognitive appraisals are also assumed to determine the types of coping strategies individuals adopt to manage their emotions in stressful situations. Specifically, appraisals of a stressful encounter being controllable tend to trigger problem-solving responses such as planning and strategizing, whereas perceiving the situation as uncontrollable provokes accomodating or emotion-focused strategis such as acceptance or positive thinking ( Aldwin, 2007 ; Skinner and Zimmer-Gembeck, 2016 ).

However, it is also important to note that the assumed emotional consequences of a coping strategy may not in fact be the same as the actual effects of that strategy in response to a specific stressor. As postulated by Lazarus and Folkman (1987) , although coping could be mainly classified as problem-focused or emotion-focused, “in reality any coping thought or act can serve both or many other functions” (p. 152). Coping strategies are thus not universally adaptive or maladaptive for emotional well-being and can be judged as such only after considering the context and the social and personal resources available to the individual, as well as how they influence one’s actions ( Aldwin, 2007 ; Skinner and Zimmer-Gembeck, 2016 ). Nonetheless, research attempting to identify adaptive and maladaptive strategies has found problem-focused coping, engagement coping, as well as primary and secondary control coping to be typically adaptive in that they are consistently found to be linked with better emotional well-being and functioning. In contrast, disengagement and emotion-focused coping are shown to be associated with more maladaptive emotions and behavioral outcomes ( Compas et al., 2001 ).

Given the overlap between coping and emotion regulation frameworks, it is necessary to consider both their convergences and differences. Compared with emotion regulation, coping is a broader construct. Although both coping and emotion regulation are regulatory processes that include controlled and purposeful (i.e., goal-directed) efforts to improve emotional well-being that change over time (i.e., are temporal processes), coping focuses on much larger periods of time (e.g., coping with bereavement over months). However, whereas coping includes only controlled processes, emotion regulation reflects a continuum of processes from conscious, effortful, and controlled regulation of emotions to automatic regulation that takes place without conscious awareness. Accordingly, coping is commonly understood as a form of emotion regulation in which one engages in response to prolonged stress. More precisely, whereas coping primarily focuses on decreasing negative emotions in stressful encounters, emotion regulation targets both expression and experience of positive and negative emotions in stressful situations as well as non-stressful situations. Finally, although coping is performed by the person encountering stress, emotion regulation could be either intrinsic (individuals regulate their own emotions) or extrinsic in nature (emotions are regulated by others; Compas et al., 2014 ; Gross, 1998b , Gross, 2013 ; Gross and Thompson, 2007 ; Koole, 2009 ; Skinner and Zimmer-Gembeck, 2007 ).

Emotion regulation and emotional labor. Regulation of emotions has been studied under two distinct, yet overlapping, research traditions: emotion regulation and emotional labor. The two constructs are comparable in that both focus on modifying feelings and expressions through the use of different strategies ( Gross, 2013 ; Grandey, 2015 ). As mentioned above, emotion regulation encompasses a heterogeneous set of processes whereby people seek to influence the types of emotions they experience, when these emotions are experienced, and how they are expressed ( Gross et al., 2006 ). Emotional labor, on the other hand, represents a subtype of emotion regulation that takes place within a given work context where “display rules” prescribe specific emotions that may or may not be publicly expressed ( Ashforth and Humphrey, 1993 ; Grandey, 2000 ; Gross, 2013 ; Grandey and Gabriel, 2015 ).

Regarding existing proposed frameworks concerning emotion regulation, Gross’ process model ( Gross, 1998a ; Gross, 1998b ) is the most commonly used (for a meta-analysis, Webb et al., 2012 ) and is used in the present review as the organizing structure to synthesize empirical evidence on faculty coping and emotion regulation. The model differentiates between two major forms of emotion regulation in terms of their timing during the unfolding of an emotion: antecedent-focused (i.e., preventative) and response-focused (i.e., responsive). The former strategies are activated before our appraisals initiate emotion response tendencies, and encompass four main strategy types. Situation selection (e.g., confrontation and avoidance) involves choosing or avoiding people, activities, or places that will lead to a situation that can generate the desired emotions. Situation modification pertains to efforts to alter the emotion-inducing situation in order to change its emotional impact, and includes strategies such as direct situation modification, help/support-seeking, and conflict resolution. Attentional deployment (e.g., distraction, rumination, mindfulness) entails managing emotions without modifying the situation by choosing which aspects of a situation to attend to. Cognitive change (e.g., self-efficacy appraisal, challenge and threat appraisals, and positive reappraisal) involves re-evaluating a situation and altering one’s appraisals of it ( Gross, 1998a ; Gross, 1998b ; Gross and Thompson, 2007 ; Peña-Sarrionandia et al., 2015 ). In contrast, response-focused strategies (e.g., emotion sharing, verbal/physical aggression, substance use, and expressive suppression) are activated after emotional responses have been developed and attempt to influence experiential, behavioral, and physiological emotional response tendencies ( Gross, 1998a ; Gross, 1998b ; Gross and Thompson, 2007 ; Peña-Sarrionandia et al., 2015 ).

Existing empirical evidence further indicates that different forms of emotion regulation are associated with notably different affective, cognitive, and social outcomes (for meta-analytical reviews, Aldao et al., 2010 ; Webb et al., 2012 ). For instance, expressive suppression has been shown to maintain or intensify the internal experience of the negative emotion, and also lead to lower positive emotions, higher physiological arousal, feelings of inauthenticity, depressive symptoms, pessimism, as well as decreased memory and negative social consequences. Suppression is additionally linked to job dissatisfaction and quitting intentions within occupational settings. In contrast, reappraisal has generally been found to lead to more positive and fewer negative emotional experiences and expressions, having few social costs and either no impact or positive effects on subsequent memory processes ( Gross and Levenson, 1997 ; Richards and Gross, 2000 ; Côté and Morgan, 2002 ; Gross, 2002 ; Gross, 2015 ; Gross and John, 2003 ; Sutton, 2004 ; Peña-Sarrionandia et al., 2015 ). Overall, emotion regulation processes that target early stages of emotion generation are more effective than the strategies that target emotional responses ( Sutton, 2007 ).

Concerning the construct of emotional labor, different conceptualizations have been proposed. Seminal work by Hochschild (1983) categorized emotional labor into two major forms: surface-acting and deep-acting. Surface-acting entails displaying emotions that one does not actually feel by revising one’s external expression of an emotion without modifying actual internal feelings. In contrast, deep-acting refers to consciously modifying feelings so as to express the desired emotions. Both types of emotional labor are aimed at displaying required emotions with different motives. Specifically, surface-acting involves modifying emotional expressions, whereas deep-acting entails internalizing the desired emotion to appear authentic. Building on Hochschild (1983) classification, subsequent research by Ashforth and Humphrey (1993) added a third form of emotional labor: genuine or natural emotional labor that involves the expression of naturally felt emotions such that the employees do not have to deliberately manage their emotions.

Based on the conceptualizations presented, emotion regulation can thus be understood as encompassing a broader and more pervasive set of behaviors as compared to emotional labor. Also, despite the similarities in the strategies proposed in the two conceptual frameworks, they can be differentiated in that emotion regulation addresses an individuals’ general dispositional approach to dealing with emotions and focuses on internal processes and individual differences, whereas emotional labor reflects a more specific examination of emotion regulatory processes in the context of displaying expected emotions in employment settings ( Wang et al., 2019 ). The two traditions could also be differentiated in their concentration on positive and negative emotions. Specifically, emotion regulation research has largely focused on response-focused processes (i.e., suppression) to inhibit the expression of undesired negative emotional responses. In contrast, emotional labor researchers have mainly concentrated on amplifying the expression of desired positive emotions (i.e., surface-acting; Taxer and Frenzel, 2015 ).

Overall, research findings suggest that emotional inauthenticity (i.e., faking or hiding emotions) and surface-acting are associated with adverse individual and organizational outcomes in the form of impaired well-being, job attitudes, and performance outcomes. However, deep-acting has been shown to be desirable in that it is positively associated with organizational attachment, emotional performance, and customer satisfaction (for meta-analytic findings, see Hülsheger and Schewe, 2011 ; Kammeyer-Mueller et al., 2013 ). Further, existing research has yielded mixed results regarding the impact of emotional labor on specific well-being indicators such as job satisfaction, with some studies reporting positive effects (e.g., Zapf, 2002 ) and others demonstrating negative relations (e.g., Kinman et al., 2011 ). Given the significance of coping and emotion regulatory processes for job performance and productivity, in general, and psychological well-being in particular, existing research on the ways in which post-secondary faculty cope with stress and emotions as well as the ways in which academics are affected by the strategies they adopt needs to be synthesized to shed light on how to promote their performance and protect psychological health.

Existing empirical research on the strategies used by post-secondary faculty to manage work-related stress and emotions were located through a comprehensive search of English language, peer-reviewed empirical investigations via four electronic databases (Educational Research Information Center (ERIC), Psychological Information (PsycINFO), Web of Science, and Scopus). The search terms used included: 1) population: “college” or “university” + “faculty” or “professors” or “academics” or “instructor” or “research staff” or “teaching staff” or “lecturer” or “educator”, 2) stress and emotion: “stress”+ “emotion” or “affect” or “mood”, 3) emotion regulation and coping: “coping” or “stress management” or “coping behavior” + “emotion regulation” or “emotion management” or “emotion control”, and 4) emotional labor: “emotion labor” or “emotional labor” or “emotional dissonance” or “emotional authenticity.” Since coping and emotion regulation among faculty are relatively under-researched and no review to date has examined these topics in post-secondary faculty, we did not limit the search to a specific time span. Further, the current review excluded studies of medical academics (e.g., physicians, nurses) as well as faculty who were also social workers due to the unique demands and pressures associated with their non-academic, service-oriented work conditions ( Le Blanc et al., 2001 ; Watts and Robertson, 2012 ). In addition to the database searches, snowball searches of references of the retrieved studies were conducted. As per the inclusion and exclusion criteria specific to the aim of the present review, 25 empirical publications were included, with six drawing on two datasets ( Amatea and Fong-Beyette, 1987 ; Amatea and Fong, 1991 ; Gates, 2000a ; Gates, 2000b ; Hagenauer and Volet, 2014a , Hagenauer and Volet, 2014b ), in which the stress management and emotion regulation strategies in post-secondary faculty were examined. All studies reviewed are included in Supplementary Appendix SA and identified with an asterisk in the reference list.

Prevalence and Outcomes of Coping and Emotion Regulation Strategies

The present section synthesizes and critically examines published empirical findings ( n = 22) concerning the coping and emotion regulation strategies (i.e., behaviors, cognitions, and perceptions) in which academics engage when facing stress and emotional encounters, as informed by the process model of emotion regulation proposed by Gross (1998a) . The studies examining academics’ coping with stress reviewed for this paper ( n = 13; Supplementary Table S1 ) can be categorized into three main groups according to their foci: 1) those primarily assessing the specific coping strategies faculty members employ to deal with stress ( n = 5; Abouserie, 1996 ; Brown and Speth, 1988 ; Devonport et al., 2008 ; Kataoka et al., 2014 ; Perlberg and Keinan, 1986 ), 2) those that report findings on coping styles among academics combined with general university staff and other occupational groups ( n = 3; Amatea and Fong-Beyette, 1987 ; Amatea and Fong, 1991 ; Gillespie et al., 2001 ; Narayanan et al., 1999 ), and finally, 3) those that explore the association between academics’ coping strategies and well-being outcomes ( n = 6; Dunn et al., 2006 ; Kataoka et al., 2014 ; Lease, 1999 ; Mark and Smith, 2012 ; Ramsey et al., 2011 ; Tümkaya, 2007 ). The review identified five empirical publications ( Gates, 2000a ; Gates, 2000b ; Hagenauer and Volet, 2014a , Hagenauer and Volet, 2014b ; Regan et al., 2012 ; Supplementary Table S2 ) that examined academics’ strategies in dealing with emotions, with four of the studies referencing two datasets ( Gates, 2000a ; Gates, 2000b ; Hagenauer and Volet, 2014a , Hagenauer and Volet, 2014b ). As for emotional labor and its consequences, six studies were identified ( Berry and Cassidy, 2013 ; Constanti and Gibbs, 2004 ; Mahoney et al., 2011 ; Ogbonna and Harris, 2004 ; Pugliesi, 1999 ; Zhang and Zhu, 2008 ; Supplementary Table S2 ).

As stress is a subset of emotion ( Lazarus, 1993 ), the research findings on both coping and emotion regulation strategies are synthesized using process model of emotion regulation ( Gross, 1998a ; Gross, 1998b ) as the guiding framework. Based on the evidence presented in the studies reviewed, faculty members apply a variety of coping and emotional management strategies, either before or after emotional events. The findings from the present review further align with the evidence from the broader emotion management research in showing different strategy types to yield significantly different outcomes for academics’ psychological adjustment ( Skinner et al., 2003 ; Folkman and Moskowitz, 2004 ; Compas et al., 2014 ). For instance, academics’ perceived ability to handle job stress, and appraisals of personal resources, were shown to significantly and negatively correlate with the level of stress and strain experienced ( Amatea and Fong, 1991 ; Blix et al., 1994 ). The strategies identified in the present review align directly with the afore-mentioned guiding framework, namely the process model of emotion regulation proposed by Gross (1998a) and can be categorized into antecedent- or response-focused according to Gross’s categorization. Although the primary objective of the current review is to synthesize the findings on the strategies academics use, the outcomes associated with those strategies are also considered to help put the proposed implications in context.

Antecedent-focused strategies. The antecedent-focused strategies academics use to regulate their emotions in order to minimize the aversive nature of potential stressors (as opposed to modulating behavioral or physiological responses to a given stressor) can be further categorized into situation selection, situation modification, attention deployment, and cognitive change.

Selecting the situation. The studies reviewed suggest that faculty choose or avoid some people, activities and places to generate desired emotional impact. For instance, focus group interviews from a sample of 178 faculty and general staff from 15 Australian universities identified situation selection by establishing tight role boundaries by avoiding non-essential student and staff contact or saying no to unnecessary demands to handle stressful experiences ( Gillespie et al., 2001 ). The review findings further suggest that some academic work experiences, such as interactions with students, provoke negative emotions of anger, irritation, and disappointment. Additionally, being anxious, apprehensive, helpless, inadequate, and overwhelmed were reported with respect to online teaching experiences ( Regan et al., 2012 ; Hagenauer and Volet, 2014a ). As such, university teachers reported adopting strategies to make it less likely that their negative emotions would be provoked. The six U.S. university teachers in Regan et al. (2012) focus group interviews reported a number of strategies to regulate the negative emotions of feeling stressed, restricted, and devalued while teaching online, including adequate technology training and support from the educational institution, synchronous office hours, and face-to-face or telephone interactions with students. Additionally, interview findings from the 15 Australian university teachers indicated that faculty reported making attempts not to get involved in the emotional issues of their students ( Hagenauer and Volet, 2014b ). Also, adopting student-centered teaching approaches to maintain productive and positive interactions with students, to create positive energy and to help circumvent the occurrence of negative emotions were reported. Furthermore, the 337 Japanese university teachers in ( Kataoka et al., 2014) survey study reported using behavioral disengaement as an effective stress mangemnet technique ( Kataoka et al., 2014 ).

As for the consequences associated with situation selection, regulating emotions through strategies such as behavioral disengagement was linked to lower psychological adjustment in the form of severe depression, anxiety, social dysfunction, somatic symptoms and insomnia ( Kataoka et al., 2014 ). Additionally, escape-avoidance (i.e., ignoring or avoiding problem) was found to be associated with higher levels of anxiety and depression and lower job satisfaction ( Mark and Smith, 2012 ), predict greater strain ( Lease, 1999 ), and partially mediate the association between maladaptive perfectionism and psychological distress ( Dunn et al., 2006 ). Moreover, proactive coping, defined as anticipating potential stressors as challenges and generating the psychololgical resources necessary to prepare for future stressors ( Scwarzer and Taubert, 2002 ), was found to be correlated with better physical and psychological health ( Amatea and Fong, 1991 ; Kataoka et al., 2014 ).

Modifying the situation. Examples of situation modification were reported by 135 female U.S. faculty, researchers, and university administrators in Amatea and Fong-Beyette (1987) study who opted to manage stress primarily by adopting strategies such as planning and strategizing across different types of work-life conflict situations. Similar findings were observed by the participants in Gillespie et al. (2001) study who identified planning and prioritizing as key stress management techniques. More recently, the sample of 10 U.K. faculty interviewed by Devenport et al. (2008) also unanimously reported strategies such as prioritizing, proactive planning, and time-management to avoid potentially stressful encounters to be invaluable in managing and controlling stress. Whereas proactive coping, such as planning, reduces the need for reactive coping, faculty reported that some circumstances of organizational constraints such as lack of control necessitate reactive coping ( Devonport et al., 2008 ; Kataoka et al., 2014 ). This finding supports the observation that coping is primarily determined by environmental factors ( Lazarus and Folkman, 1984 ).

A survey of 150 U.S. faculty members further identified strategies such as identifying the cause of the problem or finding more about the situation, as the most frequently used stress management responses ( Brown and Speth, 1988 ). This finding is consistent with a U.S. study that qualitatively compared coping strategies across three occupations (i.e., clerical workers, sales associates, and university professors; Narayanan et al., 1999 ). The study found that, compared to other professions, academics were more likely to engage in situation modification strategies such as taking direct action or discussing the problem with their chair or head of the department. Additionally, a qualitative field study of nine tenured U.S. university teachers (using observations, field notes and interview data) found that faculty reported using language and labels, such as telling students that it is OK to become confused while learning, and communicating their personal expectations to students about how the students should behave ( Gates, 2000b ). This was aimed at influencing students’ behavior and thereby reducing the possibility of triggering negative emotions in teachers. Strategies such as learning to recognize and understand stress were also identified to be effective in coping with stress ( Gillespie et al., 2001 ).

The findings from this review are consistent with the broader coping research (e.g., Lazarus, 1993 ; Aldwin, 2007 ; Skinner and Zimmer-Gembeck, 2016 ) in showing problem-focused coping to be an effective stress response among post-secondary faculty. For instance, the studies reviewed reported utilization of problem-focused coping to be linked to better psychological adjustment in the form of lower levels of stress, depression, and psychological distress as well as better job satisfaction ( Brown and Speth, 1988 ; Dunn et al., 2006 ; Mark and Smith, 2012 ). Similarly, active coping was negatively associated with social dysfunction and severe depression, whereas instrumental support was negatively associated with depression ( Kataoka et al., 2014 ).

Attention deployment. Faculty also reported selectively attending to the stimuli to cope with their emotional experiences. For instance, a quantitative study of 100 Israeli faculty memebrs ( Perlberg and Keinan, 1986 ) identified intellectual stimulation such as reading journals, magazines, and attending conferences as one of the most effective ways of coping with stress in that it helps faculty divert attention from daily stressors. Likewise, the university teachers in the Kataoka et al. (2014) study reported employing self-distraction to be effective in managing stress (e.g., engaging in other work or leisure activities in order to think about stressors less; Carver 1997 ). The findings from this review are consistent with the health impairment risks of self-distraction in linking the use of this strategy to severe depression, anxiety, social dysfunction, somatic symptoms and insomnia among academics ( Kataoka et al., 2014 ).

Cognitive change . Consistent with the empirical findings that advocate cognitive-restructuring (i.e., reappraisal) due to its commonly observed beneficial impact on negative emotional experiences ( Lazarus, 2000 ; Folkman and Moskowitz, 2004 ), academics reported applying reappraisal of specific situations to make it less likely for negative emotions to be triggered. For instance, the faculty members in Brown and Speth (1988) study reported reappraisal as a key coping strategy. It also appears that cognitive techniques that involve positive reappraisal of work situations may reduce faculty members’ stress and negative emotions. For instance, examples of cognitive change were reported by participants in ( Gates, 2000a ; Gates, 2000b ) studies who opted to positively reappraise stimuli, for instance by remembering positive interactions, to down-regulate negative emotions. A quotation from a university teacher, who helped a student adopt an effective learning strategy after failing on an exam, is illustrative: “He (the student) graduated with honors. When he walked away, for me that was a tremendous reward because, according to him, I had an impact. And that’s what I try to focus on” ( Gates, 2000b , p. 483). The participating university teachers further indicated that they try to redefine disruptive students as young and impressionable, or to think of a student who is doing poorly as developing, in order to manage feelings of anger, anxiety, frustration, and disappointment ( Gates, 2000a ; Gates, 2000b ).

Similarly, the faculty members in Regan et al. (2012) study reported changing their view of the instructor as transmitter of information to facilitator of knowledge to avoid the negative emotion of feeling devalued in online learning environments. Furthermore, faculty reported using cognitive strategies such as rationalization or acceptance by adapting their expectations. For instance, acceptance was the most commonly reported stress management strategy (58%) among the 414 academics, including faculty and research assistants, surveyed in Abouserie (1996) study. Faculty also used rational arguments in the form of self-talk to down-regulate negative emotions such as feeling annoyed: “They are still in that kind of school-girl, school-boy mode, which is pretty normal at this … this stage” ( Hagenauer and Volet, 2014b , p. 271). Also, acceptance of the specific situation by lowering their self-expectations and work standards helped teachers to reduce disappointment, frustration and stress ( Gillespie et al., 2001 ; Hagenauer and Volet, 2014b ). The participants in Abouserie (1996) study also reported lowering their expectations to decrease strain by trying to think that “I am only human being,” though it was not reported as a frequent way of coping. Similar findings were observed by the participants in Gillespie et al. (2001) study who identified practicing stress management techniques such as lowering their standards and self-expectations by withdrawing from voluntary service activities (e.g., leaving committees) as key stress management techniques. Furthermore, the teachers interviewed by Hagnauer and Volet (2014a) reported sharing humor and jokes to facilitate good rapport with students and thereby a relaxed classroom atmosphere.

Evidence from the studies reviewed suggests that cognitive change can yield significantly different outcomes for academics’ well-being depending on how adaptively this strategy is used. For instance, studies of 102 U.S. teaching faculty and 283 Turkish faculty members found utilization of humor to be significantly and negatively associated with burnout ( Tümkaya, 2007 ; Ramsey et al., 2011 ). In contrast, wishful thinking and denial were shown to be maladaptive in predicting lower psychological adjustment in the form of anxiety, depression, somatic symptoms and job dissatisfaction ( Mark and Smith, 2012 ; Kataoka et al., 2014 ). However, contrary to their expectations, they did not find positve reappraisal to be significantly linked to well-being among acadeimics. This finding seems to run counter to the existing empirical findings showing that coping via positive restructuring is related to better psychological health.

Response-focused strategies. According to ( Gross, 1998a ; Gross, 1998b ) model of emotion regulation, academics can also apply a variety of strategies intended not to change their exposure or perceptions of a given stressors (antecedent-focused strategies) but rather to alter the experiential, physiological, and behavioral reactions following from their emotional responses to a stressor (response-focused strategies).

Social support. One such strategy targeted at experiential facets is sharing emotions. For instance, the participants in Hagenauer and Volet (2014b) study indicated that, being aware of the effectiveness of emotion sharing, they expressed their positive and negative emotions with family members and departmental colleagues. However, they believed there were not many opportunities to share and discuss negative emotions and their triggers due to the lonely nature of university teaching profession. Abouserie (1996) also identified using emotion expression strategies such as trying to bring their feeling into the open to deal with stress (e.g., sharing their feelings with friends and others).

The current review also highlights support seeking as an effective stress management strategy among faculty. For instance, the faculty members in Perlberg and Keinan (1986) study reported seeking social support (i.e., talking with a friend or telling jokes) as one of the most effective ways of coping with stress. Similarly, the faculty in Devenport et al. (2008) study unanimously reported managing stress via emotional support as well as professional counseling or psychological services. Abouserie (1996) also identified support seeking through talking with colleagues, involving oneself with friends, and talking about the problem with colleagues as effective coping responses. Their findings support the assertion by Rimé (2007) who contends that emotion sharing is beneficial to psychological well-being due to the social bonds it fosters as well as transference of affection and warmth.

Additionally, the study by Gillespie et al. (2001) reported that the participants relied on social support from family or friends, as well as attending scholarly conferences, as a means of coping with stress. It appears that while preparing manuscripts and presenting in conferences can be stressful, it enabes faculty to discuss work-related problems with collaborators and others. Interestingly, the effectiveness of social support has also been found to be linked to the level of stress faculty experience. For instance, in a survey of 131 tenure-track U.S. faculty members, Lease (1999) found perceptions of social and environmental support from colleagues, administrators, and departmental support staff to be beneficial for psychological adjustment when work-role stressors (i.e., role ambiguity and role insufficiency) were perceived as low in magnitude.

In contrast, the beneficial effect of social support was not evident when faculty perceived high levels of stress resulting from the demands placed on them by their academic roles (e.g., role ambiguity, role conflict, role overload; see Rizzo et al., 1970). This finding thus indicates that social support may not be sufficient to address the psychological challenges posed by lack of clarity over academic roles and responsibilities. Perceived social support was also found to be correlated with better physical and psychological health ( Amatea and Fong, 1991 ; Kataoka et al., 2014 ) as well as negatively associated with maladaptive perfectionism and psychological distress ( Dunn et al., 2006 ).

Physiological strategies. Other emotion management strategies used to reduce stress included modifying one’s physiological state through practices such as deep breathing or expressive gestures aimed at dissipating (vs. internalizing) the emotional experience (e.g., glaring at disruptive students; Gates, 2000a ; Gates, 2000b ). Taking deep breaths allowed teachers to monitor their feelings and assess the consequences of their emotions ( Gates, 2000a ). Faculty also reported taking regular breaks from their work, regularly exercising, and seeking alternative therapies for stress relief (e.g., yoga, massage relaxing; Abouserie 1996 ; Gillespie et al., 2001 ). Such physiologically-oriented strategies are generally found to be beneficial for reducing stress, improving psychological well-being and sleep quality, as well as relieving physical symptoms in other populations (e.g., government employees, school teachers, general university staff; Hartfiel et al., 2012 , Klatt et al., 2009 ; Lin et al., 2015 ).

Other maladaptive strategies. The findings from this review further reveal that to handle stressful experiences some faculty resort to alcohol, substance use and self-blame (e.g., Gillespie et al., 2001 ; Kataoka et al., 2014 ). Consistent with the findings in the broader well-being literature ( Aldwin and Revenson, 1987 ; Single et al., 2000 ; Teesson et al., 2000 ; Skinner and Zimmer-Gembeck, 2016 ), use of these strategies by post-secondary faculty was linked to lower psychological adjustment in the form of severe depression, anxiety, social dysfunction, somatic symptoms and insomnia ( Kataoka et al., 2014 ). Additionally, 19.1% of the 414 academics in Abouserie (1996) study reported that they often retreated to their office, or opted not to go to work at all (10.7%); behaviors implying social withdrawal and stress-related job absenteeism, respectively.

Prevalence and Consequences of Emotional Labor Strategies

As mentioned above, Grandey (2000) likened Gross (2006) antecedent and response-focused types of emotion regulation to ( Hochschild, 1983) concepts of deep and surface-acting, respectively. However, Grandey did assert that emotion regulation processes cannot be directly equated with emotional labor strategies because surface-acting encompasses not only suppression but also amplification and faking of emotions. Furthermore, although deep-acting requires cognitive appraisal, the ultimate goal is not to improve personal well-being but to facilitate their efforts to better convey feelings that appear genuine to others. As such, the findings on faculty emotional labor are presented separately in the section below.

The studies reviewed suggest that academics view emotional labor as an intrinsic aspect of their work. Indeed, emotional labor is so inextricably linked to academics’ profession that for some, it equals professionalism—and to a greater degree than in many other professions ( Berry and Cassidy, 2013 ). Gates (2000a) asserted that faculty emotional management was essential for job satisfaction and effective teaching, and ultimately, student attainment. There are times when faculty express their genuinely felt emotions as well as times when they regulate (i.e., hide, fake, or minimize) their emotions to conform to contextually mandated display rules. As such, whether an emotion is appropriate for a given situation is determined by the tacit display rules of post-secondary institution. Research findings further indicate that academics’ engagement in emotional labor partly derives from the aforementioned changes in higher education organizations and the subsequent ever-intensifying expectations associated with those changes ( Gates, 2000a ; Ogbonna and Harris, 2004 ; Biron et al., 2008 ; McAlpine and Akerlind, 2010 ). Indeed, marketization of higher education has led some scholars to conceptualize students as customers ( Constanti and Gibbs, 2004 ), with academics being increasingly required to perform emotional labor to satisfy their job requirements and support student needs ( Ogbonna and Harris, 2004 ). For example, the following comment from one U.K. university teacher vividly describes the experience of conveying expected positive emotions to students despite internally feeling strong negative emotions: “Sometimes I feel like shouting at them (students) but I know what this will do to my teaching evaluations. I just stand there and pretend to be laughing even though I am fuming inside” ( Ogbonna and Harris, 2004 , p. 1197).

The studies reviewed further reveal that post-secondary faculty are particularly concerned with negative emotions and seek to down-regulate or suppress them (e.g., anger) to stay within the emotional boundaries of their profession. In contrast, faculty are more likely to openly express positive emotions such as enjoyment, humor, and happiness, as long as the display does not include intense emotional reactions ( Gates, 2000a ; Gates, 2000b ; Hagenauer and Volet, 2014b ). For instance, a national sample of 598 U.S. college and university faculty members ( Mahoney et al., 2011 ) consistently reported emotional suppression as a surface-acting emotional labor strategy. Similarly, a later mixed-methods study of 61 U.S. university teachers ( Berry and Cassidy, 2013 ) exploring use of emotional display, suppression, and faking strategies of emotional labor found that suppression was the most frequently used emotional labor strategy, followed by faking. Faculty also reported engaging in suppression of negative emotions, for example, masking or hiding negative emotions such as anger and disappointment during interactions with students, and instead expressing positive emotions (e.g., enthusiasm) or specific negative emotions (e.g., disappointment) that conveyed a belief in students’ potential ( Gates, 2000a ; Gates, 2000b ). Likewise, all participants in Hagenauer and Volet (2014b) study believed that negative emotions needed to be controlled in the classroom, either suppressed or expressed in a norm-accordant manner, in order to appear professional. They also reported suppressing negative emotions resulting from out of classroom issues such as high workload. These findings echo those of studies of school teachers ( Sutton, 2004 ; Aultman et al., 2009 ; Sutton et al., 2009 ).

Interestingly, although studies show academics to consistently report engaging in suppression of emotions, the reported reasons for this behavior vary considerably. While some academics do so for moral reasons, such as caring for their students ( Hagenauer and Volet, 2014b ) or fostering students’ social and emotional development ( Gates, 2000a ), for others emotion suppression is motivated by the belief that students are customers who need to be satisfied ( Constanti and Gibbs, 2004 ). In a qualitative study of 54 U.K. university lecturers, Ogbonna and Harris (2004) found that the participants performed surface-acting emotional labor more commonly than deep-acting, with interactions with students or one’s superiors being particularly likely to elicit surface-acting behavior. The authors further observed the most commonly reported form of deep-acting by faculty to involve the active and conscious attempt to arouse a given emotion. By contrast, Zhang and Zhu (2008) in a survey of 164 Chinese university lecturers found that, of the three dimensions of emotional labor, participants engaged the most in deep-acting and the least in surface-acting. The authors assert that this finding could be due to a prominent Chinese mentality of thinking through emotions and viewing teachers as parents who care for and nurture their students by trying to display appropriate emotions. The findings from the present review suggest that academics consistently engage in emotional labor aimed at 1) constructing an optimal learning environment, 2) nurturing positive student–teacher relationships, 3) serving as role models for their students, or 4) satisfying students and benefitting their post-secondary institutional expectations ( Gates, 2000a ; Gates, 2000b ; Constanti and Gibbs, 2004 ; Hagenauer and Volet, 2014b ).

Studies have further examined the empirical links between emotional labor and well-being as well as employment outcomes in academics ( Pugliesi, 1999 ; Ogbonna and Harris, 2004 ; Mahoney et al., 2011 ; Berry and Cassidy, 2013 ) including personal well-being outcomes such as work stress, psychological distress, and burnout as well as job-related outcomes such as job satisfaction, affective commitment, and career advancement. As for personal well-being consequences, research on post-secondary faculty has found faking of emotions to lead to greater job stress and psychological distress ( Ogbonna and Harris, 2004 ). Additionally, the requirement to suppress job-related stress and negative emotions has been linked to the experience of frustration ( Constanti and Gibbs, 2004 ). Similarly, a study of 2,069 U.S. academics (i.e., faculty and general university staff; Pugliesi, 1999 ) found self-focused emotional labor (e.g., deep-acting) to be less detrimental for job stress and psychological distress than other-focused forms of emotional labor (e.g., attempting to help coworkers feel better about themselves).

Similarly, Mahoney et al. (2011) found genuine expression of negative emotions, faking positive emotions, and suppressing negative emotions to predict greater emotional exhaustion, whereas genuine expression of positive emotions, faking negative emotions, and suppressing positive emotions predicted lower emotional exhaustion. Likewise, Zhang and Zhu (2008) compared the effects of deep-acting and surface-acting strategies in a sample of 164 Chinese university teachers and found that deep-acting predicted lower burnout, whereas surface-acting predicted greater burnout. These findings are aligned with studies of school teachers showing comparable links between emotional labor and burnout (e.g., Näring et al., 2006 ; Lorente Prieto et al., 2008 ) and underscore the potential consequences of emotional labor for personal well-being in faculty.

Additionally, research indicates that emotional labor may correspond with job satisfaction in faculty members, with the relations varying depending on the context and type of labor involved. For instance, Berry and Cassidy (2013) found that although university lecturers reported high levels of emotional labor, they nevertheless felt satisfied with their jobs. A possible explanation for this contradictory finding is that the sample of university lecturers reported that they felt they had some job autonomy. As feelings of job autonomy and control tend to predict better job satisfaction (e.g., Thompson and Prottas, 2006 ), it is possible that this aspect of faculty members’ occupational environment may have mitigated the otherwise negative effects of high emotional labor levels. In contrast, Pugliesi (1999) found that performing self-focused and other-focused emotional labor negatively predicted job satisfaction. Similarly, Mahoney et al. (2011) found genuine expression of negative emotions to predict lower job satisfaction, with genuine expression of positive emotions instead contributing to greater job satisfaction and affective commitment. These authors also found that faking positive emotions and suppressing negative emotions were negatively linked to job satisfaction, whereas faking negative emotions was positively related to job satisfaction.

Additionally, greater emotional labor was reported to benefit faculty with respect to organizational rewards such as career progression ( Ogbonna and Harris, 2004 ). A quotation from a university teacher is illustrative: “It’s about image—creating a brand of “me.” In my place careers are built on teaching portfolios. If you can create an image of yourself as a brilliant teacher—you’ve got it made. I have no problem with faking concern about students if it gets me another increment (point)” ( Ogbonna and Harris, 2004 , p. 1197). Although career growth has generally been linked to higher levels of job satisfaction and commitment (e.g., Maia et al., 2016 ), the sample of U.K. lecturers assessed by Ogbonna and Harris (2004) found high levels of emotional labor due to occupational expectations to correspond with low levels of job satisfaction. Ogbonna and Harris (2004) further found academics to report engaging in emotional labor to contribute to feeling a lack of collegiality and teamwork due to diminished social interaction and a corresponding lack of emotional support from colleagues. These findings are, in general, consistent with studies of school teachers that link higher levels of emotional labor to greater burnout, job dissatisfaction, and health problems (e.g., Kinman et al., 2011 ; Wrobel, 2013 ).

Summary of Review Findings

Post-secondary academic employment poses various stressors for faculty members who are expected to ensure high quality teaching, research, and service in an evolving occupational context. However, despite the emotion laden nature of academic work, there is remarkably little research on the emotional experiences of post-secondary faculty with respect to coping, emotion regulation, and emotional labor processes. Given the significance of these topics for well-being and academic performance, efforts to improve workplace quality in post-secondary institutions should not only emphasize academics’ teaching, research, and service behaviors, but also how they deal with their emotions. As such, the topics of coping, emotion regulation, and emotional labor merit a more prominent niche in studies of academics. To address this research gap, the present paper reviewed the fragmented empirical literature pertaining to the strategies used by post-secondary faculty to cope with stress and regulate their emotions as organized according to the process model of emotion regulation ( Gross, 1998a ; Gross, 1998b ) and emotional labor theories ( Hochschild, 1983 ; Ashforth and Humphrey, 1993 ; Grandey, 2000 ).

There is growing evidence that the academic work has been intensified as a result of the substantial changes to the context of higher education (e.g., Biron et al., 2008 ; McAlpine and Akerlind, 2010 ). Consequently, in order to adequately meet the multiplicity of organizational and occupational demands, faculty are required to show or exaggerate some emotions as well as minimize or suppress the expression of other emotions ( Ogbonna and Harris, 2004 ). Findings from these few studies suggest that academics regularly attempt to not only control their emotions in stressful educational settings, but also to display appropriate emotional responses even if the response is inauthentic. In other words, although published research has consistently established the link between greater emotional inauthenticity (i.e., surface-acting) and lower employee well-being, post-secondary faculty nonetheless regularly perform this type of emotional labor as part of their emotion-related job expectations and their potential benefits for student development and learning.

The findings of the present review, albeit from a limited empirical basis, reveal that post-secondary faculty adopt a variety of coping and emotion regulation strategies. This scant evidence further indicates that the coping and regulatory strategies academics employ have implications for their well-being as well as performance. More specifically, cognitive reappraisal, problem-solving, and social support were found to be adaptive in helping academics reduce stress and maintain their well-being. Conversely, study findings revealed emotion suppression to be prevalent yet have mixed effects among post-secondary faculty, with suppression showing both benefits (e.g., achieving teaching and learning goals, fostering positive interactions with students; Constanti and Gibbs, 2004 ; Gates, 2000b ; Hagenauer and Volet, 2014b ) as well as negative effects for academics (e.g., maintaining and intensifying negative emotions; Hagenauer and Volet, 2014b ). As an illustration, the university teachers interviewed in Hagenauer and Volet (2014b) study indicated that they “boil underneath” if they tried to completely conceal their emotions. Similarly, maladaptive coping responses such as escape, social isolation, and submission were found to be detrimental for psychological and behavioral outcomes in post-secondary faculty ( Brown and Speth, 1988 ; Lease, 1999 ; Dunn et al., 2006 ; Mark and Smith, 2012 ; Kataoka et al., 2014 ).

Additionally, the evidence from limited studies shows emotional labor in post-secondary faculty to have potentially negative consequences for their psychological and occupational well-being. Specifically, when engaging in surface-acting emotional labor, the disparity between truly experienced emotions and external expressions corresponds with higher psychological strain. Further, faculty who reported performing more emotional labor experienced higher levels of job stress, were at a greater risk of developing burnout, and were less satisfied with their work ( Pugliesi, 1999 ; Constanti and Gibbs, 2004 ; Ogbonna and Harris, 2004 ; Mahoney et al., 2011 ). Nevertheless, post-secondary faculty do report viewing emotional labor as an intrinsic element of their academic work ( Berry and Cassidy, 2013 ), suggesting positive links between emotional labor and job satisfaction. Additionally, some evidence suggests that emotional labor may not be entirely detrimental for faculty as it can be perceived by students and others as conveying professionalism and objectivity in the classroom, potentially resulting in career benefits (e.g., better teaching evaluations; Ogbonna and Harris, 2004 ). Furthermore, evidence of job satisfaction despite high levels of emotional labor ( Berry and Cassidy, 2013 ) suggests that fulfilling the emotional demands of faculty position does not necessarily come at the expense of job satisfaction. In conclusion, given the pivotal role of academics in knowledge creation and instruction (e.g., Atkins et al., 2002 ), impaired well-being and performance among faculty has clear implications for quality of academic work, student development, and institutional efficacy ( Lease, 1999 ; Gillespie et al., 2001 ).

Implications of Faculty Emotion Regulation and Emotional Labor

In sum, the findings presented underscore the importance of continued research on the varied types of coping strategies, emotion regulation behaviors, and emotional labor approaches used by faculty in response to academic challenges given clear links to both personal well-being and employment outcomes. Moreover, these findings suggest that post-secondary administrators and support personnel (e.g., department heads, faculty workshop coordinators) are well-advised to raise faculty awareness of the implications of their emotion regulation strategies, and highlight the need for further investigation into avenues for enhancing faculty coping and regulatory skills. Indeed, promoting adaptive emotion regulation is necessary for successful job performance and can help academics deal more effectively with stress and emotions, and thus directly decrease the level of job stress and indirectly protect their well-being and productivity. By implication, stress reduction and health protection in post-secondary faculty could be achieved not only by decreasing work demands, but also by developing their personal resources such as coping and emotion regulation skills ( Gates, 2000b ; Zhang and Zhu, 2008 ; Regan et al., 2012 ; Kataoka et al., 2014 ). University administrators aiming to equip faculty with effective regulatory skills and promote well-being are encouraged to develop related orientation content for new faculty, developing counselling and mental health support for faculty in general, as well as improving training for administrators to better identify and respond to mental health concerns in faculty.

Additionally, university administrators, policy makers, and faculty development programs are ideally positioned to understand the emotional aspects of their primary institutional resources’ work ( Gmelch et al., 1984 ). These stakeholders are thus especially encouraged to take active steps in developing and implementing interventions to raise academics’ awareness regarding coping and emotion regulation strategies and their associated consequences, to promote coping and emotion regulation skills, and to foster academics’ use of effective strategies for improving faculty well-being and performance. Despite the lack of research on academics, research evidence from other occupational groups (e.g., teachers) raises the possibility that training post-secondary faculty to develop more adaptive coping and emotion management skills might result in favorable outcomes that will, by extension, benefit the academic institutions ( Kotsou et al., 2011 ). For example, empirical evidence across occupational settings consistently demonstrates the efficacy of cognitive reappraisal stress management interventions such as cognitive behavioral therapy (CBT; for meta-analytical summaries, see Kim, 2007 ; Richardson and Rothstein, 2008 ; Van der Klink et al., 2001 ). Additionally, mindfulness-based stress reduction (MBSR) programs show a range of cognitive (e.g., enhanced working memory and attention), psychological (i.e., improvements in emotion regulation skills and self-efficacy, decrease in stress, anxiety, emotional exhaustion, and depression as well as increase in positive emotions) and physiological benefits (i.e., improved immune function) among K-12 students and teachers (e.g., Napoli et al., 2005 ; Poulin et al., 2008 ; Roeser et al., 2012 ), university students ( Freeman et al., 2015 ; Ford et al., 2018 ), other occupational groups (e.g., Janssen et al., 2018 ), as well as general population (e.g., Davidson et al., 2003 ; Hölzel et al., 2011 ).

As such, post-secondary administrators are recommended to consider integrating CBT and MBSR interventions into faculty development programs to facilitate adaptive emotion regulation, well-being, and performance in faculty members. Increased health and well-being among post-secondary faculty should, in turn, lead to greater occupational engagement and satisfaction as well as lower levels of faculty burnout and attrition. Increased faculty well-being should also support the formation of positive relationships with students that, in turn, promote students’ sense of belonging, engagement, learning, and achievement. Nonetheless, given research findings showing mindfulness training to be inappropriate for chronically stressed individuals due to negative effects of chronic stress on sustained attention and complex thought processes (e.g., Sapolsky, 1994 ; Arnsten, 1998 ), it is possible that CBT or MBSR may be ineffective for the chronically stressed faculty they are intended to serve. Hence, it is incumbent on administrators to also focus on long-term improvements to academic work environments to make them less emotionally demanding by reducing workloads (e.g., excessive teaching responsibilities faced by non-tenure-track faculty; Baldwin and Wawrzynski, 2011 ), facilitating balance between academic responsibilities (e.g., teaching releases to offset research or administrative demands; Stupnisky et al., 2015 ), clarifying role expectations (e.g., tenure expectations), as well as providing effective physical and mental health resources (e.g., gym memberships, vacation time) and stress management workshops ( Gillespie et al., 2001 ).

With respect to the present findings concerning emotional labor strategies, this review further suggests that higher education institutions are well-advised to encourage deep-acting strategies and discourage surface-acting as part of existing professional development initiatives aimed at improving teaching effectiveness. Moreover, given that social support was consistently found to protect faculty against job stress, institutional efforts to promote faculty collegiality (e.g., regular social events, departmental lecture series) as well as develop collaborative work spaces, team teaching initiatives, and faculty mentorship programs should contribute to greater connectedness, enhanced well-being, and improved teaching and research productivity.

Empirical evidence demonstrates the beneficial effects of such initiatives. For instance, studies of faculty members have shown implementation of mentorship programs to result in favorable outcomes such as higher retention rates, improvement in self-perceived abilities, and higher academic success rates as measured by number of peer-reviewed publications, leadership and professional activities, honors, and awards ( Zeind et al., 2005 ; Ries et al., 2012 ; Jackevicius et al., 2014 ). Additionally, existing studies highlight the potential benefits of team teaching initiatives for faculty members, including deepened pedagogical knowledge, improvements in teaching skills and effectiveness, higher motivation to teach, overcoming feelings of isolation by creating a sense of community, and enhanced conflict management skills ( Robinson and Schaible, 1995 ; Cohen and DeLoise, 2002 ; Kluth and Straut, 2003 ; Lester and Evans, 2008 ). Furthermore, social activities have been shown to foster integration and social cohesion in faculty members ( Lindholm, 2003 ) and particularly among pre-tenure faculty ( Fleming et al., 2016 ).

Limitations and Future Directions

The methodologies of the studies reveiwed had multiple limitations, many of which were recognized by authors of the respective studies. Firstly, 12 of the 22 studies employed only quantitative analyses and thus failed to capture the full complexity of academics’ lived experiences concerning their challenges and emotion regulation otherwise afforded by qualitative protocols ( Creswell and Creswell, 2017 ). Second, the few studies that investigated emotion regulation among faculty focused largely on negative emotions such as anger, burnout, and stress, thus neglecting the potential benefits of upregulation of positive emotions on well-being and performance ( Fredrickson, 2000 ; Fredrickson, 2001 ; Folkman, 2008 ; Fredrickson, 2013 ; Quoidbach et al., 2015 ). Third, the majority of the studies focused on how academics regulate their teaching-related emotions, thereby neglecting various other domains of academic work such as research, service, or administration. Considering recent empirical evidence regarding the domain specificity of emotional experiences in post-secondary faculty (e.g., teaching vs. research; Stupnisky et al., 2014 ), future studies are encouraged to explore the strategies academics employ to regulate their emotions in domains other than teaching.

Fourth, a majority of the studies reviewed drew on populations from single organizations thus raising concerns of generalizability to academics at large. Hence, future studies are encouraged to draw on larger numbers of academics from varied institution types (e.g., colleges, trade schools, universities; teaching vs. research intensive schools) to better ascertain the external validity of the study findings. Relatedly, although the studies reviewed were conducted across several countries (e.g., U.K., U.S., Canada, Australia, Japan), there are to date insufficient studies conducted within a given cultural context or geographical setting to allow for generalizations as to how cultural or geographic differences may moderate the prevalence and effects of emotion regulation and coping in faculty. Fifth, all but two studies ( Constanti and Gibbs, 2004 ; Gates, 2000a ; Gates, 2000b ) employed exclusively self-report measures that are susceptible to response biases warranting that future research also investigate academics’ coping and emotion regulation strategies using more objective assessments such as observations, experience sampling, and physiological markers ( Spector, 2006 ; Paulhus and Vazire, 2007 ; Pekrun and Bühner, 2014 ).

Finally, given that multiple studies reported data from aggregate samples that included both faculty and non-faculty participants (e.g., researchers, administrators, see Amatea and Fong-Beyette, 1987 ; Gillespie et al., 2001 ), it was not possible in these studies to more closely examine factors that pertain specifically to post-secondary faculty (e.g., thesis supervision, tenure pressures). Accordingly, further research on stress management and emotion regulation in post-secondary faculty specifically, as well as further differentiation between disparate types of faculty employment (e.g., non-tenure-track vs. tenure-track employment; Hall, 2019 ), are needed to better examine the role of coping, emotion regulation, and emotional labor among faculty in the context of modern academic employment.

Author Contributions

Conceptualization, RS; methodology, RS; writing—original draft preparation, RS; writing—review and editing, NCH, RS, and AS; supervision, AS; funding acquisition. RS.

This research was funded by Fonds de Recherche duQuébec-Sociétéet Culture (fund number: 192306).

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher’s Note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Supplementary Material

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/feduc.2021.660676/full#supplementary-material

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Keywords: post-secondary faculty, stress, coping, emotions, emotion regulation

Citation: Salimzadeh R, Hall NC and Saroyan A (2021) Examining Academics’ Strategies for Coping With Stress and Emotions: A Review of Research. Front. Educ. 6:660676. doi: 10.3389/feduc.2021.660676

Received: 29 January 2021; Accepted: 23 August 2021; Published: 20 September 2021.

Reviewed by:

Copyright © 2021 Salimzadeh, Hall and Saroyan. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Raheleh Salimzadeh, [email protected]

This article is part of the Research Topic

Teachers’ Emotion Regulation and Emotional Labor: Relationships with Teacher Motivation, Well-Being, and Teaching Effectiveness

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Research Article

University students’ strategies of coping with stress during the coronavirus pandemic: Data from Poland

Contributed equally to this work with: Anna Babicka-Wirkus, Lukasz Wirkus, Krzysztof Stasiak, Paweł Kozłowski

Roles Conceptualization, Formal analysis, Methodology, Project administration, Supervision, Visualization, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliation Institute of Pedagogy, Pomeranian University in Słupsk, Słupsk, Poland

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Roles Conceptualization, Data curation, Investigation, Project administration, Resources, Software, Writing – original draft, Writing – review & editing

Affiliation Institute of Pedagogy, Faculty of Social Science, University of Gdańsk, Gdańsk, Poland

Roles Investigation, Resources, Software, Supervision, Writing – review & editing

Affiliation Department of Material Criminal Law and Criminology, Faculty of Law and Administration, University of Gdańsk, Gdańsk, Poland

Roles Data curation, Software, Validation, Writing – review & editing

  • Anna Babicka-Wirkus, 
  • Lukasz Wirkus, 
  • Krzysztof Stasiak, 
  • Paweł Kozłowski

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  • Published: July 26, 2021
  • https://doi.org/10.1371/journal.pone.0255041
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Table 1

The COVID-19 pandemic has changed the functioning of universities worldwide. In Poland, the transfer to online teaching was announced without prior warning, which radically changed students’ daily functioning. This situation clearly showed the students’ helplessness and difficulties with coping with this new, stressful situation, highlighted in many previous studies. A sudden and far-reaching change in daily functioning caused anxiety, depression, and stress in this group. Thus, from a pedagogical and psychological point of view, it is pertinent to examine the students’ strategies of coping with stress caused by the COVID-19 pandemic. To this end, in 2020, a sample of Polish students was anonymously measured using the Mini-COPE questionnaire. Data was gathered from 577 students from 17 universities. The statistical analysis showed that during the coronavirus pandemic, Polish students most often used the coping strategies of: acceptance, planning, and seeking emotional support. Such factors as age, gender, and place of residence influenced the choice of specific strategies of coping with stress during the COVID-19 pandemic. The results also showed that the youngest students had the lowest coping skills. The results allow for concluding that the students’ maladaptive strategies of coping with stress, especially during the pandemic, may result in long-term consequences for their psychophysiological health and academic achievements. Thus, based on the current results and on the participatory model of intervention, a support program for students is proposed which would involve psychological, organizational, and instrumental support.

Citation: Babicka-Wirkus A, Wirkus L, Stasiak K, Kozłowski P (2021) University students’ strategies of coping with stress during the coronavirus pandemic: Data from Poland. PLoS ONE 16(7): e0255041. https://doi.org/10.1371/journal.pone.0255041

Editor: Shah Md Atiqul Haq, Shahjalal University of Science and Technology, BANGLADESH

Received: March 24, 2021; Accepted: July 9, 2021; Published: July 26, 2021

Copyright: © 2021 Babicka-Wirkus et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the manuscript and its Supporting Information files.

Funding: The author(s) received no specific funding for this work.

Competing interests: The authors have declared that no competing interests exist.

Introduction

University studies are a stressful period as they mean the transition to independent, adult life. Beginning studies can be stressful to many students, since it means the necessity to establish new relationships, develop new studying habits related to the chosen program, cope with overwork, learn time management, and often also change one’s place of residence [ 1 , 2 ]. In its later stages, university education is related to new, further stressors, such as concern over being able to find employment after graduation. Studies thus far show that many students struggle to cope with these stressors and that the incidence of stress among students is increasing [ 3 , 4 ]. Among other consequences, it has a negative impact on mental health [ 2 , 5 ]. In the US, around 10% of university students reported suffering from depression [ 2 ], and this proportion has increased to 15% since 2000 [ 6 – 9 ]. A significant causal factor behind this increase is the stress related to studying.

Stress is undoubtedly a part of students’ lives and it may impact their ways of coping with the demands of university life. Their daily responsibilities involve numerous challenges which lead to stress [ 10 ]. Results from various studies carried out thus far show a clear increase in mental health problems among students [ 11 ]. As some of them indicate, there is also an urgent need to assess the impact of the current pandemic on students’ mental health and wellbeing [ 12 ], which legitimizes carrying out such studies in various countries, including Poland.

In 2020, a new situation appeared which necessitates a different approach to stress and its causal factors–the SARS-CoV-2 virus. Data published by the Johns Hopkins University indicates that thus far, over 100 million people have become infected with COVID-19, and around 2.5 million have died [ 13 ]. The COVID-19 disease affects everyone, including students [ 14 , 15 ], since even those who have not been infected are subject to various restrictions which many countries have implemented to limit the spread of the disease. The reality of the pandemic has also negatively impacted the students’ quality of social life. Studying at a university is also a period of establishing new relationships and intense social life. This is facilitated by the fact that young people exhibit greater levels of extraversion and openness to experience than do older people [ 16 ]. Studies show that contacts with others positively influence quality of life [ 17 ]. Lack of regular contact with friends throughout all phases of the coronavirus pandemic, results in loneliness, which might not be fully mitigated by regular contacts via telephone or other means [ 18 ]. These conclusions are supported by evidence from studies carried out in Great Britain (with participants aged between 13 and 25 years), in which young people reported having lost support, daily routine, social ties, and experiencing anxiety, loneliness, and loss of motivation and aim. Higher incidence of depression and anxiety, both during as well as after periods of social isolation, was also confirmed [ 19 , 20 ]. This may lead to harmful social and psychological consequences [ 21 – 23 ].

In response to the pandemic, most countries have implemented severe restrictions in societal functioning which comprise many spheres of life: social, economic, cultural, and educational. They led to limited interpersonal contacts, changes in the mode of education (online teaching), and reduced economic activity. As a result, an economic recession has affected nearly all countries (including Poland) [ 24 ], which worsened the material conditions of many people (increased unemployment). This significantly impacts students, as it intensifies their concerns about being able to find or retain a job and thus support themselves during their studies and after graduation. Essen and Owusu showed that work and studies are the most frequent causes of stress for students [ 25 ]. Historical data shows that previous pandemics have negatively impacted young people’s material conditions, which had long-term consequences for their physical and mental health as well as academic achievement [ 26 ]. For many students, COVID-19 has additionally complicated their current plans and changed their mode of functioning.

More recently, Matthew H. E. M. Browning et al. identified a range of psychological consequences of the COVID-19 pandemic on students’ psychosocial functioning. All students in the sample indicated that the pandemic impacted them negatively, with 59% reporting a high level of psychological impact [ 27 ]. Other studies on the effects of the pandemic on student mental health also show greater stress, anxiety, depression symptoms, concerns for own and one’s family’s health, reduced social interactions, and increased concerns over academic achievements. Students try to cope with stress, seek support from others, and prefer either negative or positive coping strategies [ 11 , 28 ].

The COVID-19 situation, its rapid spread, insufficient preparation, and significant changes in everyday functioning, including university culture, may contribute to increased stress among students. When not managed properly, chronic stress leads to emotional and psychosomatic consequences which manifest through physical, cognitive, and emotional exhaustion as well as depersonalization and lowered professional–in case of students, academic–efficiency [ 29 ]. The consequences of stress lower efficiency, productivity, and engagement in life activities as well as the satisfaction with their results [ 30 , 31 ]. As Adler and Park point out, effective coping with stress might buffer the impact of stressful events on the physical and mental health, and individuals differ with regards to the coping strategies they use [ 32 ]. Therefore, the aims of the study were: identifying the students’ dominant strategies of coping with stress in the pandemic situation, assessing the influence of sociodemographic factors on the dominant coping strategies, and diagnosing differences in the students’ coping strategies depending on expected social support and its sources.

The stress and coping concept is the most popular study approach, also explaining the mechanisms mediating between personality and disease. Currently, the transactional model of stress by Lazarus and Folkman [ 33 ] is employed increasingly frequently. It posits mutual interactions between people and their environment. This model served as the theoretical basis of the current study. The perception of stress is a subjective and variable phenomenon. Particular attention is paid to the processes of coping with stress, which decide the positive and negative impact of stress on the individual. Using different strategies of coping with stress involves mobilizing cognitive and behavioral resources to meet the demands which are subjectively perceived as surpassing personal capabilities. The course of the coping process depends on personal resources and social support. It can also lead to various behaviors which have negative health effects (substance use) or are maladaptive [ 34 ]. Also, according to Lazarus and Folkman, coping with stress might be related to negative health behaviors [ 35 ]. Metzger et al. analyzed the frequency of negative health behaviors among students. They found that increased alcohol consumption and risky sexual behaviors are typical for people at risk for significant stress [ 36 ]. Styles of coping with stress are determined by gender, education, age, health, well-being, the nature of the stressful situation, personality factors, and others [ 20 ]. Efficient use of emotions allows for more effective problem solving, while venting anger and frustration and denial of reality are potentially destructive reactions to stress [ 37 ]. Expressing emotions might also lead to lower depression and hostility levels in stressful situations [ 38 ]. Some authors distinguish between emotion-focused and problem-focused coping styles, while others distinguish active and avoidant coping or identify maladaptive coping strategies (denial, substance use, venting of negative emotions) which allow for lowering subjectively experienced stress [ 39 – 41 ].

Research questions

The study concerned students’ strategies of coping with stress during the pandemic. The following research questions were put forward:

  • What strategies of coping with stress are most often used by students during the coronavirus pandemic?
  • What is the relationship between sociodemographic variables and the dominant coping strategies among students?
  • How does anticipated support differentiate the coping strategies used by students?

Study population and procedure

In 2019, 1.230 million students studied at around 400 universities in Poland. Sixty-five percent were full-time students. Seventy-three percent studied at public (national) universities. The number of foreign students is relatively low in Poland, being only 61 thousand in 2019. Moreover, a decisive majority—around 60%—of students in Poland are women [ 42 , 43 ]. This proportion reaches 65% for MA studies. Meanwhile, in the EU in general, women comprise around 54% of students [ 44 ].

In early spring of 2020, soon after online teaching was instituted, the questionnaire was distributed to students of four randomly chosen Polish universities. Those students who filled out the online questionnaire were also asked to share it with their acquaintances from other universities. Using snowball sampling method was determined by difficulties in reaching students directly, as well as by their reluctance, especially in the first phase of the pandemic in Poland, to take part in studies and fill out online questionnaires. Having students to invite their acquaintances to also take part in the study allowed for gathering a relatively large sample in a short time. There were no missing data, since the online platform did not allow for submitting incomplete questionnaires.

Participation in the study was voluntary. Informed written consent was obtained from every participant. Before participants started to fill out the online study questionnaire, they had to read the information about the project and its aims and checked the option ’I agree to take part in the study’. The data were analyzed anonymously. The research project and its procedure were approved by the Commission of Bioethics and Human Rights.

Using the snowball sampling method, data from 17 Polish institutions was obtained: universities, technical universities, medical universities, and higher vocational schools. This allowed for measuring coping strategies during the pandemic among students from various universities in various regions of Poland. However, it has to be noted that snowball sampling does not allow for generalizing the results to the entire student population in Poland. Nevertheless, based on the obtained data, certain trends in coping strategies among social sciences students can be shown.

The study took place in April-May 2020. Five hundred and seventy-seven complete questionnaires were collected. Table 1 shows the demographic characteristics of the sample divided by universities.

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https://doi.org/10.1371/journal.pone.0255041.t001

The data was divided into six groups based on the number of students from each given university who took part in the study. The largest group were the students from the University of Gdańsk (UG). Next, the sample comprised students from: Adam Mickiewicz University in Poznań (UAM) - 22.2%, University of Warsaw (UW) - 17.2%, Jan Kochanowski University of Kielce (UJK- 13.7%, and Pomeranian University in Słupsk (5.9%). Due to a low number of students from other universities, an additional group (different universities—DU) was created, which comprised 6.0% of the total sample.

Polish universities vary with respect to their size and educational profile. There are relatively few large universities with over 20 thousand people (roughly 20 out of 400). Most universities are of medium or small size. The largest university in Poland is the University of Warsaw. It also has one of the broadest selections of programs. A characteristic aspect of Polish universities is that they offer specific educational profiles, for example, universities focusing on medical education. Another example is the Pomeranian University, which specializes in teaching education. Table 2 shows basic characteristics of universities which were widely represented in the research sample [ 45 – 50 ].

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https://doi.org/10.1371/journal.pone.0255041.t002

In the current study, women represented 89.6% of the sample. Participants between 21 and 24 years of age and those living in large cities represented the largest group (59.5% and 36.7%, respectively) Over 80% of the participants were full-time students, which reflected the general population distribution of students in Poland [ 51 ]. Undergraduate students also represented a larger group.

The multidimensional COPE inventory by Carver et al [ 52 , 53 ] is one of the most popular measures of strategies of coping with stress. It can be used to measure dispositional (typical) and situational coping. The Mini-COPE inventory in a Polish adaptation by Juczyński and Ogińska-Bulik [ 54 ] was used in the current study. The internal consistency of the Polish version of the Mini-COPE was estimated based on a sample of 200 people aged between 25 and 60. The split-half reliability was 0.86 (Guttman’s coefficient = 0.87). The repeatability was satisfactory for the majority of the scales. The Polish version of the Mini-COPE comprises 28 items, which form 14 coping strategies. It is used to measure typical reactions in situations of intense stress. The main question is: What do you usually do when you are stressed by a problem? The coping strategies are described in statements such as “I work or do other things in order not to think about the problem.” Each statement is graded on a four-point Likert scale: 1 = very seldom, 2 = fairly seldom, 3 = fairly often, 4 = very often. Each of the 14 coping strategies is measured by two items.

The Mini-COPE inventory was supplemented with two other semi-open questions. The first concerned the type of support the students expected during the pandemic. The available answers were: psychological, emotional, financial, organizational support, no support needed, and other (to be filled out by the students if necessary). The second supplemental question concerned the sources from which the students expected support during the pandemic. In this case, the students could select the closest appropriate answer from among: family, friends, the university, the government, and other (to be filled out by the students if necessary). Fig 1 shows the distribution of the students’ answers to the supplementary questions about support.

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Regarding the source of support, 5.0% of the students chose “other.” This category comprised the following answers: significant other (0.9%), nobody (1.2%), psychologist/therapist (0.5%), myself (1.4%), all of the above (0.3%), and other combinations indicating two sources, for example, family and the government (0.7%).

Statistical analyses were carried out using the IBM SPSS Statistics 25.0 software. The program was used to calculate basic descriptive statistics together with the Kolmogorov-Smirnov test of normality. Additionally, the Cronbach’s α coefficient was used to calculate the reliability of the Mini-COPE scales. To compare coping strategies between two groups, Mann-Whitney’s U test was used. To compare a higher number of groups, a one-way analysis of variance (ANOVA) was used, and if variance was not equal between the groups, Welch’s correction was additionally applied. Tukey’s HSD test (if variance was homogenous) or Dunnett’s T3 test (if variance was heterogenous) was used for post hoc analyses. To estimate intergroup differences in coping strategies, Pearson’s r correlation analysis was carried out. The significance level was set at α = 0.05. In order to distinguish the groups of participants in terms of coping strategies, a two-step cluster analysis was carried out.

Students’ dominant strategies of coping with stress during the pandemic

Based on the descriptive statistics and the results of the Kolmogorov-Smirnov test of normality, it was concluded that neither of the analyzed variables assumed a distribution close to the Gaussian curve. Skewness values were within the <-2;2> range, which means that it was not significant [ 55 ]. Additionally, the Cronbach’s α coefficient was used to calculate the reliability of the Mini-COPE scales. The analysis showed satisfactory reliability for most of the scales. Relatively low reliability was obtained for the scales of acceptance, humor, self-distraction, and venting of emotions. Detailed results are shown in Table 3 .

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The dominant coping strategies among Polish students were: acceptance, planning, and seeking emotional support. The least frequent strategies were: substance use, denial, behavioral disengagement, and religious coping.

Pearson’s correlation analysis was used to examine the relationships between individual coping strategies in the current sample ( Table 4 ). Active coping was positively correlated with the following coping strategies: planning (strong correlation), positive reframing, religious coping, emotional support seeking, instrumental support seeking, self-distraction, venting of emotions, and self-blame (weak correlations). The higher the frequency of active coping, the higher the frequencies of the above strategies as well. Active coping was moderately and negatively correlated with behavioral disengagement, which means that the higher the frequency of active coping, the lower the frequency of behavioral disengagement.

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Another coping strategy—planning—was positively and weakly-to-moderately correlated with positive reframing, acceptance, religious coping, emotional support seeking, instrumental support seeking, self-distraction, and self-blame. A weak, negative correlation occurred between planning and denial, and a moderate one between behavioral activation—the higher the frequency of planning, the lower the frequency of denial and behavioral disengagement.

Positive reframing was positively and weakly-to-moderately correlated with acceptance, humor, religious coping, emotional support seeking, instrumental support seeking, and self-distraction. This coping strategy was also weakly and negatively correlated with behavioral disengagement and self-blame.

Acceptance was weakly and positively correlated with humor and negatively with denial, behavioral disengagement, and self-blame. In turn, humor was weakly and positively correlated with emotional support seeking, self-distraction, and substance use. A weak and positive correlation also occurred between religious coping and emotional support seeking, instrumental support seeking, and venting of emotions. Religious coping was also weakly and negatively correlated with substance use.

Another strategy—emotional support seeking—was strongly and positively correlated with instrumental support seeking. A weak and positive correlation occurred between the following coping strategies: self-distraction and venting of emotions. Emotional support seeking was weakly and negatively correlated with behavioral disengagement.

On the other hand, seeking instrumental support was weakly-to-moderately and positively correlated with self-distraction, venting of emotions, and self-blame.

Self-distraction was weakly-to-moderately and positively correlated with denial, venting of emotions, substance use, behavioral disengagement, and self-blame.

Denial, venting of emotions, substance use, behavioral disengagement, and self-blame were positively correlated with each other on a weak-to-moderate level (the relationship between behavioral disengagement and self-blame).

The remaining correlations between the coping strategies were not statistically significant.

Students’ strategies of coping with stress–cluster analysis

To distinguish groups of participants based on their coping strategies, a two-step cluster analysis was carried out. It allowed for distinguishing two clusters ( Fig 2 ) for which the silhouette value was 0.2, indicating a satisfactory quality of clustering. From among the coping strategies included in the model, the most important ones were: seeking instrumental support, seeking emotional support, and planning. These strategies differentiated the two clusters to the highest degree. The least important strategies were substance use, denial, and self-blame.

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Table 5 shows the comparison of the clusters with regard to the analyzed strategies. The analysis showed no statistically significant differences for denial, substance use, and self-blame. Differences for other coping strategies were statistically significant, with Cluster 1 participants scoring higher on active coping, planning, positive reframing, humor, religious coping, seeking emotional and instrumental support, self-distraction, and venting of emotions, and lower on behavioral disengagement compared to Cluster 2 participants.

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Sociodemographic factors and strategies of coping with stress

To estimate the gender differences in coping strategies, Mann-Whitney’s U test was used. The analysis showed statistically significant gender differences for humor, emotional support seeking, instrumental support seeking, self-distraction, denial, and venting of emotions. Men in the current sample reported using humor significantly more often than women, but they reported using religious coping, emotional support seeking, instrumental support seeking, self-distraction, and denial less frequently. The results of the analysis are shown in Table 6 .

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Gender differences could result from differences in gender role socialization [ 56 , 57 ]. Women are socialized to be more emotional and seek support in interpersonal relationships. On the other hand, men are socialized to cope with their problems on their own or use humor.

Using a one-way analysis of variance (ANOVA), coping strategy use was compared between age groups ( Table 7 ). The analysis showed statistically significant differences for six strategies: active coping, planning, positive reframing, venting of emotions, behavioral disengagement, and self-blame. To estimate the character of the intergroup differences, an additional post hoc analysis using Tukey’s HSD test was carried out when the variance was equal between the groups, and Dunnett’s T3 test, when the variance was unequal. This type of post hoc analysis was used due to the disproportions in the size of the compared groups. In the case of unequal variances, the Welch correction was also applied.

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18-20-year-olds reported statistically significantly less frequent active coping than did 25-30-year-olds ( p = 0.032) and those 31 and over ( p = 0.032). The youngest participants also reported less frequent planning than did 25-30-year-olds ( p = 0.039) and those 31 and over ( p = 0.045), while 21-24-year-olds reported significantly less frequent planning than 25-30-year-olds ( p = 0.015) and those 31 and over ( p = 0.030). The coping strategy of positive reframing was more frequent in the oldest group compared to the younger groups (p ≤ 0.013). Those 31 and over also reported significantly less frequent venting of emotions compared to 18-20-year-olds ( p = 0.007) and 21-24-year-olds ( p = 0.002). Behavioral disengagement differed significantly between the youngest and the oldest group ( p = 0.014), with the higher frequency of this strategy being reported in the 18-20-year-olds group. Those 31 and over reported less frequent self-blame than did 18-20-year-olds ( p = 0.036) and 25-30-year-olds ( p = 0.019).

The current data show that the oldest students used active coping strategies more often during the pandemic than did the younger students. The aim of these strategies is to solve the problem causing difficult internal tension rather than to avoid the situation altogether. This effect may be related to the older students having greater life experience, including academic experience, at 31 years of age.

In the next step, differences in coping strategy use depending on the place of residence were examined ( Table 8 ). To this end, a one-factor ANOVA was carried out. It showed significant intergroup differences for the following coping strategies: active coping, planning, humor, religious coping, denial, and substance use. Participants living in cities with over 100 thousand residents reported using planning significantly more often than those living in villages ( p < 0.001) or towns up to 20 thousand residents ( p = 0.006).

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Participants living in towns up to 20 thousand residents reported using humor significantly less frequently than those living in cities with over 100 thousand residents ( p = 0.021). Participants living in villages reported using religious coping significantly more often than those living in cities with over 100 thousand residents ( p = 0.004). This is related to a more traditional upbringing and culture in Polish rural regions, where religious rituals play a significant role. Participants living in cities with over 100 thousand residents reported using denial significantly less frequently than those living in villages ( p = 0.002) and in towns with between 20 and 100 thousand residents ( p = 0.034). Substance use was reported more frequently among participants living in biggest cities compared to participants living in villages ( p = 0.002). This is because various psychoactive substances are more easily available in large cities.

After the correction for multiple comparisons was applied, a post hoc analysis using Tukey’s HSD test did not reveal statistically significant intergroup differences in active coping.

To compare full-time and extramural students’ use of coping strategies, Mann-Whitney’s U test was used. It showed that extramural students reported using active coping and positive reframing more frequently, and humor, instrumental support seeking, self-distraction, venting of emotions, substance use, and self-blame less frequently compared to full-time students. The results of the analysis are presented in Table 9 .

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https://doi.org/10.1371/journal.pone.0255041.t009

Using a one-factor ANOVA, coping strategies were compared between students in different program years. The analysis showed significant differences for four strategies: active coping ( Fig 3 ), planning ( Fig 4 ), positive reframing ( Fig 5 ), and behavioral disengagement ( Fig 6 ).

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I U–I Undergraduate (n = 142), II U–II Undergraduate (n = 100), III U–III Undergraduate (n = 104), I G–I Graduate (n = 66), II G–II Graduate (n = 70), I-III M–I-III uniform Master’s studies (n = 64), IV-V M–IV-V uniform Master’s studies (n = 31).

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* Welch’s correction was applied.

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A detailed post hoc analysis showed that first year undergraduate students reported using active coping less frequently compared to second year graduate students ( p = 0.048), first-third year uniform Master’s students ( p = 0.009), and fourth-fifth year uniform Master’s students ( p < 0.001). Second year undergraduate students also reported using active coping less frequently than did fourth-fifth year uniform Master’s students ( p = 0.001), similar to third year undergraduate students ( p = 0.004). First year undergraduate students reported using planning less frequently compared to second year graduate students ( p = 0.006) and fourth-fifth year uniform Master’s students ( p < 0.001). Fourth-fifth year uniform Master’s students reported using planning more frequently than second year ( p = 0.018) and third year ( p = 0.007) undergraduate students. A significant difference in the frequency of using behavioral disengagement occurred between first year undergraduate students and fourth-fifth year uniform Master’s students ( p = 0.015). First year undergraduate students reported using behavioral disengagement more frequently than did fourth-fifth year uniform Master’s students. For positive reframing, after applying the correction for multiple comparisons, Dunnett’s T3 test did not show statistically significant intergroup differences. A statistical trend ( p = 0.053) was observed between third year undergraduate students and first year graduate students—first year graduate students reported a slightly higher frequency of using positive reframing than did third year undergraduate students.

Students’ strategies of coping with stress and the type and source of needed social support

A one-way ANOVA was used to estimate the differences in coping strategy use depending on the need for a given type of social support ( Table 10 ). The post hoc analysis showed that participants who indicated a need for psychological support reported using the coping strategy of positive reframing less frequently than those who did not indicate any need for support ( p = 0.027). Also, those who indicated a need for financial support reported using positive reframing less frequently than those who did not indicate any need for support ( p = 0.034). Those who did not indicate any need for support used the coping strategy of acceptance more frequently than those who indicated a need for psychological ( p = 0.013) and emotional ( p = 0.002) support. This is due to the fact that these individuals cope with the pandemic-related difficulties on their own. Those who indicated a need for financial support also used religious coping less frequently than those who indicated a need for emotional support ( p = 0.007). Participants who indicated a need for emotional support reported using the coping strategy of emotional support seeking more frequently than those who indicated a need for financial support ( p = 0.004) and those who did not indicate any need for support ( p = 0.034). Analogous differences were observed for instrumental support seeking. Participants who indicated a need for emotional support reported using this coping strategy more often than did those who indicated a need for financial support ( p < 0.001) and those who did not indicate any need for support ( p = 0.001). Those who did not indicate any need for support reported using self-distraction less frequently than those who indicated needing psychological ( p = 0.014) and emotional ( p = 0.003) support. Also, participants who did not indicate any need for support reported using the coping strategy of denial less frequently than did those who indicated a need for psychological ( p = 0.002) or emotional ( p = 0.002) support. Participants who did not indicate any need for support reported using venting of emotions less frequently than did those who indicated a need for psychological ( p < 0.001) and emotional ( p < 0.001) support, whereas participants who indicated a need for financial support reported using venting of emotions less frequently than did those who indicated a need for emotional support ( p = 0.003). Participants who indicated a need for psychological support reported more frequent substance use than did those who did not indicate any need for support ( p = 0.002). Participants also used behavioral disengagement more often than did those who indicated a need for financial ( p = 0.001) and organizational support ( p = 0.001), or did not indicate any need for support ( p < 0.001). In turn, those participants who indicated a need for emotional support reported using behavioral disengagement more frequently than those who did not indicate any need for support at all ( p = 0.006).

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https://doi.org/10.1371/journal.pone.0255041.t010

Participants who indicated a need for psychological support and emotional support reported using self-blame more often than did those who indicated a need for financial ( p < 0.001, p = 0.003 respectively). Self-blame is a cognitive judgment related to a belief that not making mistakes is extremely important. However, self-blame causes withdrawal from interpersonal relationships and prevents learning from one’s mistakes. Thus, normal sadness and guilt becomes transformed into depressive disorders [ 58 ]. In this case, seeking psychological support seems warranted. People seek to relieve their suffering and solve their problems through utilizing psychological consultations or therapy. However, in contrast to seeking emotional support from significant others within close relationships, individuals seeking psychological support may discount their own agency, responsibility for their decisions, and independent solution-seeking to a greater extent. Additionally, when describing the pandemic situation, it is worth to consider another context of self-blame, namely, the phenomenon of guiltless guilt, that is, guilt without any specific influence on a given situation which is the source of self-blame. This creates a vicious circle which depends psychological suffering [ 59 ].

A one-factor ANOVA also revealed significant differences between the groups distinguished by the source of expected support. These differences were significant for three coping strategies: religious coping ( Fig 7 ), substance use ( Fig 8 ), and self-blame ( Fig 9 ). A detailed post hoc analysis revealed that those participants who expected support from the government used religious coping less frequently than those who expected support from their families ( p = 0.043) or their universities ( p = 0.026). Participants who expected support from their families reported using the coping strategy of substance abuse significantly less frequently than those who expected support from their friends ( p = 0.013). In turn, participants who expected support from their friends reported using self-blame significantly more often than did those who expected support from the government ( p = 0.027).

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The aim of the current study was to examine the strategies of coping with stress among Polish university students during the coronavirus pandemic, as well as to assess the type of support they expected. An analysis of the empirical results allows for drawing conclusions on this topic.

The transactional model of stress [ 33 ] allowed for identifying a specific relation formed between an individual and their surroundings. The participants in the currents study found themselves in a stressful transaction in which they experienced a real risk in the form of the pandemic situation. Coping is a specific adaptative reaction chosen during the secondary appraisal. It emerges when an individual appraises the situation in terms of harm or risk, that is, as a difficulty. Students differed with respect to their tendency to use specific coping strategies, which does not mean that a given individual’s coping strategies are the same in every situation. Emotion-oriented coping strategies seek to reduce tension and unpleasant emotions which arise in reaction to stressful situations. They are unavoidable particularly when the individual has no influence on the external events. Problem-focused coping involves cognitive and behavioral efforts to reduce stress by trying to solve the problem [ 33 ]. Thus, the main condition for appropriate functioning is to develop optimal strategies of coping with stress.

The results of the current study showed that during the stressful situation of the pandemic, which can cause feelings of uncertainty and crisis [ 60 ], Polish students mainly chose such coping strategies as acceptance, planning, and seeking emotional support. The current studies showed that students more often use coping strategies which, according to Lazarus and Folkman’s theory [ 33 ] are emotion-focused (acceptance, seeking emotional support). On the other hand, planning is a problem-focused coping strategy. These three main strategies seem constructive as they direct people towards a future temporal perspective and might facilitate a reorganization of the values–goals–life plans triad driving the dynamic character of the personality [ 61 ], especially in decisive periods of personal crises [ 62 ]. It is also related to reframing one’s own life situation. Substance use, denial, behavioral disengagement, and religious coping were used the least frequently by Polish students to cope with stress during the pandemic.

Among all groups of people in education, students exhibited higher levels of emotional problems and pressure related to the changes in the educational and social situation during the pandemic than did primary and high school students [ 63 , 64 ]. Thus, it was important to assess their need for support and the sources they expect this support from. The results showed that 78% of the students needed support, while 22% did not express such needs. The greatest proportion of students—25%—needed emotional support. This type of support was mainly sought from family (38%) and friends (26%). Participants who expected emotional support simultaneously chose strategies of support seeking and religious coping. Their search for personal resources which would facilitate coping was oriented at close interpersonal relationships. They most likely allowed for conversations which supported another coping strategy preferred by this group, namely, venting and self-blame. Students seeking emotional support–in contrast to those seeking psychological support–likely maintained closer and deeper interpersonal relationships. On the other hand, psychological support was expected by 16% of the participants. They scored the lowest on the strategy of positive reframing. However, they scored higher on substance use, denial, and venting, as well as self-blame. Such a pattern of coping strategies suggests that use of professional psychological help is warranted. These participants showed such difficulties in coping with the pandemic situation that they concluded they should seek professional help from a psychologist.

Those students who expected organizational (18%) and financial (17%) support reported using different coping strategies than did those who expected emotional and psychological support. Such coping strategies as religious coping, support seeking, venting, substance use, behavioral disengagement, and self-blame were lower in this group. Rather, these participants were oriented at gaining concrete material support and support related to organizing their life in the city where they studied, and sometimes also worked to support themselves financially.

Further analyses showed that those students who indicated a need for emotional and social support reported using the coping strategies of positive reframing and acceptance of the pandemic situation less frequently. Need for emotional, organizational, and psychological support was related to typical stressors (studying, pressure to achieve high grades, pass exams, and qualify for scholarships) [ 65 , 66 ], which remained at similar levels during online teaching. However, it was also related to additional limitations stemming from the digitalization of the teaching process [ 67 ]. Moreover, the need for support was also increased by isolation, limitations in social relationships with peers, and limited possibilities for establishing new relationships and realizing affiliative needs [ 68 , 69 ]. Importantly, these needs concern direct relationships rather than telephone or online contact, as these do not fully mitigate loneliness and do not provide the same amount of support [ 18 ]. Seeking real, direct support, the students expressed a perspective of building psychological resilience and improving their emotional state, which corresponds with the results of Bernabé and Botia [ 70 ]. Students mainly expressed a need for emotional, organizational, and psychological support from their families and friends in order to maintain a high level of functioning, which might be explained through the perspective of the resilience theory [ 71 , 72 ]. This is because resilience is strongly related to, among others, perceived emotional support and close, safe relationships with one’s family and friends [ 73 , 74 ], which create networks of emotional and social support [ 75 , 76 ]. The ability to use support serves as a buffer for stress and its negative consequences. It can also prevent the deepening of the problems by providing resources for coping when stress occurs. Studies confirm that people with access to support show less reactivity to stress factors and enjoy higher mental health [ 77 ].

Next, it was showed that the chosen strategies of coping with stress were related to sociodemographic variables such as gender, age, and place of residence, which was confirmed by Cantor [ 61 ]. A detailed analysis revealed gender differences in the use of some specific coping strategies, which is also supported by other studies [ 78 – 80 ]. Women used the strategies of emotional and instrumental support seeking statistically significantly more often than did men. On the other hand, men used humor as a coping strategy more often than did women.

Regarding age, it was shown that younger people who began studying (18-20-year-olds) reported using active coping and planning statistically significantly less frequently than older students (21-24-year-olds, 25-30-year-olds, and those 31 and above). In turn, the higher frequency of using positive reframing and the lowest frequency of using venting of emotions was reported by the oldest students (31 and above). These age-related differences are difficult to relate to previous studies due to methodological differences [ 81 – 83 ]. The strategy of active coping, characteristic for older students, was positively correlated with planning (strong relationship), positive reframing, religious coping, and emotional and instrumental support seeking, which was confirmed by the cluster analysis. Cluster 1 results (statistically significantly higher active coping, planning, positive reframing, humor, religious coping, emotional and instrumental support seeking, self-distraction, and venting, and lower behavioral disengagement) correspond to this profile of active coping.

The youngest students (18–20 years old) did not choose active (adaptive) coping strategies, in contrast to the older students. It is worth noting that, as the youngest persons in the academic community, they have less life and experience and less environmental resources due to the fact that they did not yet develop close and deep social and emotional relationships. This is related to identity development [ 84 , 85 ]. Additionally, the university is a new setting for such students, which makes it more difficult for them to perceive it as a source of instrumental and organizational support. Thus, the youngest students in particular should be the recipients of complex (psychological, instrumental, possibly also spiritual) support from the university intended to shape appropriate adaptive conditions.

Comparing the full-time and extramural students with respect to their coping strategies, it was found that extramural students scored higher on active coping and positive reframing, and lower on humor, instrumental support seeking, self-distraction, venting, substance use, and self-blame compared to full-time students. It is worth noting that extramural students are usually older than full-time students. Thus, they are at a different developmental period in their lives. They often live with their own families, including their children. They attend classes only during the weekends and are most often employed and financially independent Thus, they have different areas of life activities and exhibit different strategies of coping with stress.

Analyzing the variable of place of residence, it was found that students living in cities with over 100 thousand residents used the coping strategies of planning, humor, and substance use more frequently than did students from smaller towns and villages. These results can be interpreter with reference to Bronfebrenner’s [ 86 ] ecological theory. Larger cities have more (both on the mesosystem and the exosystem levels) infrastructural resources, opportunities related to social life, and institutional offers (even during the periods of pandemic-related restrictions). Thus, people living in large cities were subjected to less social isolation during the pandemic than were the people living in rural areas. However, they used religious coping and denial less frequently, which was used more often by students living in villages. Studies on Polish students carried out before the pandemic using the Mini-COPE did not show differences in coping strategies related to place of residence.

The results of the current study allowed for the identification of coping strategies among students. This is important for the process of designing support strategies at universities. Our study also identified the mechanisms of active (adaptive) and passive (maladaptive) coping and directions of support seeking.

Taking into account the current results, future empirical studies can focus on more detailed examinations of the relationships between specific coping strategies used by students. Additional studies on the influence of the later stages of the pandemic on students’ mental health are necessary, as the consequences of this difficult situation may last for a long time, beyond the most intense period of the pandemic.

Strengths and limitations

The strengths of the current study include an examination of students’ strategies of coping with stress during the pandemic as a global situation which, to some extent, warrants the introduction of monitoring and prevention of the “post-COVID syndrome” in the context of students’ coping with stress and rebuilding social and emotional relationships.

The current results might also serve as a point of reference and comparison for further studies on coping strategies among students in other countries. In turn, this could support the development of local strategies of supporting students in organizing their academic careers and personal lives. This is especially important considering the fact that the occurrence of subsequent pandemics is only a matter of time, as was cautioned by the Director General of the World Health Organization, Tedros Adhanom Ghebreyesus. The UN resolution naming December 27 as the International Day of Epidemic Preparedness acknowledges the disproportional harm they cause in people’s lives and highlights the need for increased awareness, exchange of scientific knowledge, and searching for the best solutions on both the local and national levels. This message finds direct expression in the topic of the current study.

A limitation of the current study is the high proportion of female students of social sciences and humanities in the current sample. In Poland, these programs are more often chosen by women (73%) than men (27%) [ 87 ]. This resulted in a high gender imbalance in the current sample.

Recommendations for universities

The results of the current study lead to formulating several recommendations for universities regarding the organization of teaching in ways that consider the students’ psychosocial functioning to a greater extent. These suggestions include: implementing assessments of students’ psychosocial functioning in order to determine the potential need for emotional, social, and psychological support, and establishing psychological consultation points for students requiring such support.

It also seems warranted to introduce interpersonal training and stress coping workshops for individual student groups. Regarding organizational support, the current results are an argument for providing material support and career counseling in part-time employment for students.

The current results serve as a basis for designing a model of support and-self support solutions for students during the pandemic. The participatory model of intervention development [ 88 ] may be particularly useful in this regard. The Participatory Intervention Model (PIM), rooted in participatory action research, provides aa mechanism for integrating theory, research and practice and for promoting involvement of stakeholders in intervention efforts [ 88 ]. Based on this model, it seems pertinent to revise the role of the year mentor ( opiekun roku ; in Polish universities, students at each year of their academic program are assigned an academic teacher who meets with the students, acquaints them with the university’s structure and the program, etc.) by including screening assessments of the students’ expected sources of support. Additionally, the role of the university counselor should be created. It is worth noting that the youngest students in particular should be incorporated in the design process for such solutions. This is because the presented study shows that the youngest full-time students showed passive and maladaptive coping strategies. Support solutions designed through the participatory model of intervention should be useful for students, should address their specific needs, and should consider the students’ cultural, organizational, and social contexts, including the context of the pandemic and its consequences. Efforts towards designing adequate interventions may prove insufficient if no attempts are made to understand the students’ beliefs, motivations, practices, language, and culture. Such practices can help universities offer more comprehensive support to students of specific populations. Thus, the particular attention should be draw to the notion of acceptability within PIM, which reflects the perception of the beneficiaries (mainly the university inn this context) as partners in identifying problems and developing the offer of psychological, organizational, and instrumental support solutions created through the process of researching the specificity of the pandemic situation and post-pandemic adaptation. Identifying problems, as well as the scope and range of partnership between the university and its personal and infrastructural resources in planning psychological, organizational, and infrastructural support for students requires an evidence base.

The necessity of carrying out research that would lead to effective practical solutions through PIM is also underscored by Nastasi (et. al.) [ 89 ]. The study presented in this article fits this proposal. The current study results showed also that 10% of the sample expecting support from the university. This situation indicates that the current support offer could be insufficient in the context of the pandemic. Thus far, support given to students has been limited mainly to material support–financial support and academic scholarships. Verifying its role as a source of support and an important social environment for its students is also a significant new challenge for universities in the pandemic and post-pandemic reality.

Conclusions

Studies in this direction should continue in order to examine how students cope with subsequent stages of studying both during the pandemic as well as after its end.

Despite the limitations indicated above, the current results contribute to understanding the social and emotional changes related to the coronavirus pandemic, especially in the area of higher education. Studies on stress and coping among students carried out thus far have not sufficiently considered a range of factors such as the study system (paid vs. free), sources of institutional support (scholarships, student loans, material support), unemployment, or job prospects after graduation. Additionally, similarities and differences in the experience of stress and coping strategies between students in various countries (ethnic and cultural differences) have not been researched to an appropriate degree.

The current study indicates, among others, that younger students who are in the beginning stages of their academic careers cope with stress less effectively. This is largely a consequence of the fact that they do not yet possess appropriate life experience, and thus do not have sufficient competences in coping with difficult situations. This suggests that university administrations should pay particular attention to this group. An obligatory course on coping skills should be recommended for the first year curriculum. This could improve students’ competences, wellbeing, and resilience.

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https://doi.org/10.1371/journal.pone.0255041.s001

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Assessment of academic stress and its coping mechanisms among medical undergraduate students in a large Midwestern university

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  • Published: 27 July 2020
  • Volume 40 , pages 2599–2609, ( 2021 )

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  • Nitin Joseph   ORCID: orcid.org/0000-0002-3639-510X 1 , 2 ,
  • Aneesha Nallapati 2 , 3 ,
  • Mitchelle Xavier Machado 2 , 3 ,
  • Varsha Nair 2 , 3 ,
  • Shreya Matele 2 , 3 ,
  • Navya Muthusamy 2 , 3 &
  • Aditi Sinha 2 , 3  

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Academic stress is the most common mental state that medical students experience during their training period. To assess academic stress, to find out its determinants, to assess other sources of stress and to explore the various coping styles against academic stress adopted by students. Methods: It was a cross sectional study done among medical students from first to fourth year. Standard self-administered questionnaires were used to assess academic stress and coping behaviour. Mean age of the 400 participants was 20.3 ± 1.5 years. 166(41.5%) of them were males. The academic stress was found to be of mild, moderate and severe level among 68(17%), 309(77.3%) and 23(5.7%) participants respectively. Overall coping with stress was found to be poor, average and good among 15(3.8%), 380(95%) and 5(1.2%) participants respectively. Passive emotional ( p  = 0.054) and passive problem ( p  = 0.001) coping behaviours were significantly better among males. Active problem coping behaviour ( p  = 0.007) was significantly better among females. Active emotional coping behaviour did not vary significantly between genders ( p  = 0.54). Majority of the students preferred sharing their personal problems with parents 211(52.7%) followed by friends 202(50.5%). Binary logistic regression analysis found worrying about future ( p  = 0.023) and poor self-esteem ( p  = 0.026) to be independently associated with academic stress. Academic stress although a common finding among students, the coping style to deal with it, was good only in a few. The coping behaviours were not satisfactory particularly among male participants. This along with other determinants of academic stress identified in this study need to be addressed during counselling sessions.

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Introduction

Academic stress has been reported to be the most common mental state that medical students experience during their training period (Ramli et al. 2018 ). It is on the rise among them probably due to increasing course requirements (Ramli et al. 2018 ; Drolet and Rodgers 2010 ). Kumaraswamy ( 2013 ) observed that the issues known to precipitate academic stress were excessive assignments, peer competition, examinations and problems related to time management. University students, for the life phase they are going through, also have to deal with many other stresses such as detachment from the family, building of self-identity and issues concerning adolescence period and those in relation to student-workers. The stress of the medical student is also connected to the relationship with the patient in the clinical period.

Some amount of academic stress is beneficial as it brings about healthy competition with peer group, promotes learning and helps to excel in academics (Malathi and Damodaran 1999 ; Afolayan et al. 2013 ). Lumley and Provenzano ( 2003 ) however reported that, excess of academic stress adversely affects academic performance, class attendance and psychological well-being of students. If it is not identified early and managed, it can cause depression, anxiety, behavioural problems, irritability, social withdrawal and physical illnesses (Adiele et al. 2018 ; Deb et al. 2015 ; Verma et al. 2002 ; Chen et al. 2013 ).

In addition to assessment of academic stress among under graduate medical students, it is also essential to analyze the various stress coping mechanisms adopted by them. This will help researchers in suggesting appropriate intervention strategies for the benefit of the students. Students in turn can educate their patients in future to identify stress and suggest measures to deal with it.

Previous studies have reported that medical students used active coping mechanisms (Al-Dubai et al. 2011 ; Chawla and Sachdeva 2018 ; Gade et al. 2014 ; Abouammoh et al. 2020 ), positive reframing (Al-Dubai et al. 2011 ; Chawla and Sachdeva 2018 ), planning (Chawla and Sachdeva 2018 ; Wu et al. 2018 ), positive reappraisal (Wu et al. 2018 ), emotional support (Chawla and Sachdeva 2018 ; Gade et al. 2014 ), peer discussions (Oku et al. 2015 ) and acceptance (Al-Dubai et al. 2011 ; Chawla and Sachdeva 2018 ) as means for coping stress. There were minimal reports of usage of avoidance strategies for coping stress among medical students (Al-Dubai et al. 2011 ; Chawla and Sachdeva 2018 ).

Royal College of Psychiatrists ( 2011 ) reported that students with secure attachments to family and those residing in a supportive community are in a better position to handle stress. Therefore assessment of various determinants of academic stress is essential to frame most suitable remedial measures for the benefit of the affected. This study was hence done to assess academic stress, to find out its determinants, to assess other sources of stress and to explore the various coping styles adopted by medical students to deal with academic stress in a coastal city in south India.

Materials and Methods

This cross sectional study was conducted in the month of March 2018 at a private medical college in Mangalore. The institutional ethics committee approval was taken before the commencement of the study. Permission to conduct the study was taken from the Dean. Sample size of 364 participants was calculated at 95% confidence intervals (CI), 90% power and the proportion of medical students with average level of academic stress taken as 51.4% based on the findings of Mostafavian et al. ( 2018 ). A non-response rate of 10% was added to arrive at the final sample size which was calculated as 400 participants. A total of 100 students of Bachelor of Medicine and Bachelor of Surgery course from first year to fourth year were therefore chosen to participate in this study using simple random sampling method.

The students were briefed about academic stress and the objectives of this study, in the classroom setting, and written informed consent was taken for their participation. In order to maintain anonymity, the filled in consent form were first collected back from the participants. Later the questionnaires were distributed by the investigators. It was a semi-structured questionnaire containing both closed and open ended questions. It was pre-tested in a group of ten students before its use in the current study. No changes in the questionnaire resulted following the pre-testing and the data collected in this phase were not included in the final study.

Data Collection Tools

Academic stress was assessed using the academic stress inventory tool for university students prepared by Lin and Chen ( 2009 ). They had reported the alpha value of Cronbach’s reliability test for this questionnaire as 0.90. The questionnaire was slightly modified during the content validation phase in this study to incorporate questions on career related issues along with few other minor changes. This questionnaire contained 35 items which were designed in a five point Likert scale. The responses in the scale were “completely disagree,” “disagree,” “neutral,” “agree,” and “completely agree”, with scores ranging from one to five points respectively. Cumulative scores ranging from 35 to 81, 82 to 128 and 129 to 175 were considered as mild, moderate and severe levels of academic stress respectively.

The coping techniques employed by the respondents was assessed using the academic stress coping style inventory developed by Lin and Chen ( 2010 ). The Cronbach’s alpha value of internal consistency for the stress coping style questionnaires was reported by them to be 0.83. It was shortened during the content validation phase to result in 25 questions designed again in Likert’s five-point scale. Scores were ranging from 5 for “completely agree” to 1 for “completely disagree”. Overall coping with stress was rated as poorly adoptive when cumulative score of the participant ranged from 25 to 58, average when it was 59 to 92 and good when it was 93 to 125.

Coping behaviour were grouped as active emotional coping, active problem coping, passive emotional coping and passive problem coping behaviours. Active emotional coping behaviour involved individuals adopting the attitude of emotional adjustment like positive thinking emotions and self-encouragement, when faced with academic stress. Active problem coping behaviour involved dealing academic stress by focussing at the centre of the problem and finding a solution themselves by being calm and optimistic or by searching assistance from external sources. Passive emotional coping behaviour involved constraining emotions, self-accusation, getting angry, blaming others or God or by giving up. Passive problem coping behaviour involved procrastinations, evasive behaviours or going into alcohol or drug abuse while facing academic stress (Lin and Chen 2010 ).

The overall alpha value of Cronbach’s reliability test for the academic stress and coping style inventory questionnaire used in this study was calculated to be 0.901, indicating excellent reliability.

Statistical Analysis

The data entry and analysis were done using IBM SPSS for Windows version 25.0, Armonk, New York. Statistical tests like Chi square test, Fisher’s exact test, Student’s unpaired t test and Karl Pearson’s coefficient of correlation were used for analysis. All the determinants of academic stress significant at 0.15 level were placed in the multivariable model. Backward stepwise elimination procedure was done to identify the independent determinants of academic stress in the model at the last step. p value 0.05 or less was used as the criterion for significance.

A total of 400 students participated in this study and all of them gave satisfactorily filled forms. Their mean age was 20.3 ± 1.5 years and median age was 20 years with an Inter Quartile Range (19, 22) years. As many as 166(41.5%) of them were males. Out of the total participants, 45(11.2%) were local residents, 51(12.8%) were outsiders but within the same state, 262(65.5%) were from other states within India, 35(8.8%) were non-residential Indians and the rest 7(1.7%) were foreigners. Medium of schooling among 388(97%) students was English.

Among the participants, 67(16.7%) were currently staying at their home or rented apartment while the rest 333(83.3%) were staying in the hostels or were staying as paying guests. Majority of them [228(57%)] were staying with their friends. Among others, 118(29.5%) were staying alone, 46(11.5%) with their parents, 7(1.8%) with their relatives and one with her elder sibling.

With respect to lifestyle habits, majority of the participants [249(62.2%)] went to college by walk, and majority [339(84.7%)] slept for 6 to 8 h on an average per day. (Table 1 ).

Sources of Stress among Participants

Majority of students either agreed or strongly agreed that some teachers provided so much of academic information, making it difficult for students to assimilate knowledge [177(44.2%)]. Fear of failure in the exams was the other major cause of academic stress [206(51.5%)]. (Table 2 ).

Majority of students either agreed or strongly agreed that by missing few lectures, they felt anxious about falling short of attendance towards the end [204(51%)]. They also regretted having wasted time set apart for studies [240(60%)]. (Table 3 ).

Overall the level of academic stress was found to be mild among 68(17%), moderate among 309(77.3%) and severe among 23(5.7%) participants. The mean academic stress score was found to be 100.6 ± 19.7. Gender wise variation in academic stress levels was noticed. It was of mild, moderate and severe level among 29(17.5%), 129(77.7%) and 8(4.8%) males and among 39(16.7%), 180(76.9%) and 15(6.4%) females respectively (X 2  = 0.472, p  = 0.79).

The other non-academic sources of stress reported by participants were lack of sufficient vacations [130(32.5%)], staying away from family [103(25.7%)], worrying about future [70(17.5%)], low self-esteem [52(13%)], having trouble with friends 39(9.7%)], facing financial difficulties [33(8.2%)], interpersonal conflicts [28(16.7%)], conflicts with roommates [26(6.5%)], issues with partners [23(5.8%)], sleeping disorders [21(5.2%)], transportation problems [20(5%)], problems in the family [18(4.5%)], searching a partner [17(4.2%)] and lack of parental support [5(1.2%)].

14(3.5%) participants had underlying chronic morbidities. These morbidities were allergic rhinitis among 3, migraine among 3, polycystic ovarian disease among 3, menorrhagia among 2 and allergy, peptic ulcer, hypothyroidism, and impaired glucose tolerance in one student each.

Coping Strategies Adopted by Participants

Majority of the participants [294(73.5%)] either agreed or strongly agreed that they tried to think or do something, that would make them feel happier and relaxed when they were stressed. (Table 4 ).

Overall coping with stress was found to be poor among 15(3.8%), average among 380(95%) and good among 5(1.2%) participants.

The mean coping with stress score was 75.2 ± 9.2. The mean score of various coping behaviours like active emotional coping (items 1 to 6), active problem coping (items 14 to 18), passive emotional coping (items 7 to 13) and passive problem coping (items 19 to 25) were found to be 21.7 ± 3.4, 13.2 ± 2.7, 18.6 ± 4.6 and 18.3 ± 4.2 respectively. (Table 4 ).

Mean active emotional coping score among males ( n  = 166) was 21.5 ± 3.5 and among females ( n  = 234) was 21.8 ± 3.3 (t = 0.613, p  = 0.54). Mean passive emotional coping score among males (n = 166) was 19.1 ± 5.0 and among females (n = 234) was 18.2 ± 4.1 (t = 1.933, p  = 0.054). Mean active problem coping score among males (n = 166) was 12.8 ± 2.8 and among females (n = 234) was 13.5 ± 2.5 (t = 2.711, p  = 0.007). Mean passive problem coping score among males (n = 166) was 19.1 ± 4.4 and among females (n = 234) was 17.7 ± 3.9 (t = 3.412, p  = 0.001).

The various measures adopted by participants to deal with stress were sharing problems with others [223(56.2%)], meditation [132(56.8%)], performing yoga [50(12.8%)], sleeping [29(7.5%)], practicing Tai Chi [13(3.5%)] and listening to music [11(3%)]. Other methods like watching television and exercising were reported by 8(2.2%) participants each, aromatherapy and sports by 5(1.3%) each, eating favourite food and consuming alcohol by two each and browsing through the internet by one participant.

Majority of the students preferred sharing their personal problems with parents 211(52.7%), followed by friends 202(50.5%), siblings 71(17.7%) and others 26(6.5%).

Eight(2%) participants reported using medications for the management of stress. One of them had taken Lorazepam tablets while another Sertraline tablets. The rest of them did not specify the medications.

Reasons like lack of sufficient vacations and worrying about future were found to have highly significant association with academic stress among participants ( p  ≤ 0.001). (Table 5 ).

Coping with stress was average/good among 328(98.8%) participants with moderate/severe levels of academic stress in comparison to 57(83.8%) with mild level of academic stress ( p  < 0.00001).

Similarly correlation of academic stress scores with stress coping scores was found to be significant (r = 0.467, p  < 0.001). Also correlation between academic stress scores with passive emotional (r = 0.513, p < 0.001) and passive problem (r = 0.401, p < 0.001) coping behaviours were found to be significant. However academic stress was not significantly correlated with active emotional (r = − 0.036, p  = 0.468) and active problem (r = 0.072, p  = 0.149) coping behaviours.

Binary logistic regression analysis found worrying about future ( p  = 0.023) and poor self-esteem ( p  = 0.026) among participants to be significantly associated with academic stress after adjusting the confounding effect of other variables in the model. (Table 6 ).

For calculating unadjusted Odds Ratio and 95% CI, participants staying with friends/alone were compared with those staying with parents/siblings/relatives (reference value), participants reporting speed of internet connection at place of stay as average/poor were compared with those reporting good connectivity (reference value).

An interesting fact about this study was that the response rate was total. This supports the importance of this study which addresses a felt need of every medical student.

Academic stress of moderate to severe level were reported among 83% participants in this study. In other studies done among medical students, academic stress was reported among 50% (Dyrbye et al. 2008 ), 53% (Bamuhair et al. 2015 ), 61% (Zamroni et al. 2018 ) and 74.6% (Mostafavian et al. 2018 ) participants. Academic stress among university students of other courses were reported among 48.8% (Reddy et al. 2018 ), 70.7% (Sharififard et al. 2014 ) and 73% (Adiele et al. 2018 ) participants. From these comparisons, it was obvious that academic stress was high among the participants in this study probably because of cultural factors.

There was no association between academic stress and gender of participants in this study as also reported by Mostafavian et al. ( 2018 ) and Zamroni et al. ( 2018 ). However several other studies done among university students reported females to have significantly greater academic stress than males (Adiele et al. 2018 ; Bamuhair et al. 2015 ; Reddy et al. 2018 ; Al-Sowygh et al. 2013 ).

Academic stress was found to be more among medical students in the first year (Nakalema and Ssenyonga 2014 ; Abdulghani 2008 ) or in the final year (Bamuhair et al. 2015 ). This was in contrast to the findings in this study were no such association was observed.

Place of residence was not associated with academic stress in this study and also in the study done among medical students in Iran by Mostafavian et al. ( 2018 ).

Academic stress in the present study was found to be least among participants who were staying with their parents, siblings or relatives. This may be because, number of students at this setting are outsiders. Studying over here, might also be their first occasion of moving out of their home environment. They therefore may be lacking their previously learnt support system such as banking on their family members and childhood friends during difficult times, as also observed by Kumar and Nancy ( 2011 ). They now have to find solutions to various problems by themselves, or by being dependent looking out for newer social contacts. If they were staying with their family members, perhaps they might have received the necessary emotional support during examinations and other stressful situations. The other benefits like getting hygienic food, good living conditions and people to take care of one’s health would have been best when family members were around. The observations in this study were however contradicting the observation of Mostafavian et al. ( 2018 ) who observed that the academic stress was significantly more among those living at their houses compared to those at dormitories.

As many as 60% participants regretted having wasted time set apart for their studies. Poor time management was found to be associated with academic stress by other researchers too (Misra and McKean 2000 ; Macan et al. 1990 ). Good time management skills involves prioritization of activities and judicious usage of time available for organization of the tasks to be completed. Time management was found to determine academic performance by Misra and McKean ( 2000 ). Moreover those with sound time management behaviour were found to have fewer psychological and physical symptoms related to stress (Misra and McKean 2000 ; Macan et al. 1990 ). Lammers et al. ( 2001 ) reported that close to half of the students had notable weaknesses in their time management skills.

Fear of failure in exams and falling short of attendance towards the end were the reasons for academic stress among more than half the participants in this study. Teachers can play an important role in alleviating examination related fears and anxieties by conducting frequent mock examinations (Sharma et al. 2011 ). Meeting individual students’ needs (Aherne et al. 2016 ), to find out the reason for missing classes, time scheduling of activities and providing constructive feedback to students (Sharma et al. 2016 ) are the other recommended strategies advised by previous researchers. Abouserie ( 1994 ) stated that the amount of guidance and support offered by teachers would be a key factor in determining the stress levels of students in any institution. Students themselves have opined that social support from teachers and peer groups, consulting services, and various extracurricular activities are the most useful strategies to deal with stress (Chang et al. 2012 ). As opined by the student community themselves, every institution need to offer them psychotherapy sessions, trainings for reducing emotional tension and opportunities to improve social intelligence (Ruzhenkov et al. 2016 ).

Issues like worrying about future and poor self-esteem among participants in this study were significantly associated with academic stress in the multivariable analysis model. These problems may be related to issues like concern about clearing the increasingly competitive entrance exams and also about the fear of them not being able to pursue the specialty of their choice in future. To address such sensitive problems, there is a need of the placement of a professional counsellor at various professional colleges. Pressley and McCormick ( 1995 ) also suggested that the learning environment within classrooms should be non-competitive, collaborative and task-oriented and not performance oriented, so as to create a stress free learning environment.

Having said this, the course work at medical schools should not be too light either. Kanter ( 2008 ) suggested that this approach can affect the quality of education. Rather students need to be trained in the right way to directly solve the problems related to academic stress by themselves being a part of a self-help program (Chen et al. 2013 ; Aherne et al. 2016 ).

The various sources of academic stress among medical students listed in other studies were, vastness of curriculum as reported by 61.6% (Anuradha et al. 2017 ), 82.2% (Bamuhair et al. 2015 ), and 82.3% (Oku et al. 2015 ), fear of failure in examination by 61.8% (Anuradha et al. 2017 ), frequency of examination by 52.2% (Anuradha et al. 2017 ), lack of recreation and inadequate holidays by 51.8% (Anuradha et al. 2017 ) and by 76.4% (Oku et al. 2015 ), sleep related problems by 64.3% (Bamuhair et al. 2015 ), worrying about future by 78.2% (Bamuhair et al. 2015 ), family problems by 54% (Bamuhair et al. 2015 ), interpersonal conflicts by 57.1% (Bamuhair et al. 2015 ), low self-esteem by 51.7% (Bamuhair et al. 2015 ) and transportation problems by 56.2% participants (Bamuhair et al. 2015 ).

Coping with stress was found to be average among 95% participants in the present study. Almost three-fourth of the participants in the present study tried to think or do something that would make them feel happier and relaxed when they were stressed. Coping methods commonly used by students in previous studies were effective time management, sharing of problems, planned problem solving, going out with friends, social support, meditation and getting adequate sleep. Even emotion-based strategies to cope stress like self-blaming and taking self-responsibility have been reported (Wolf 1994 ; Supe 1998 ; Stern et al. 1993 ; Redhwan et al. 2009 ).

Coping with stress in this study was better among participants with higher levels of academic stress which was similarly observed among Saudi Arabian medical students by Bamuhair et al. ( 2015 ). This suggests that students who perceived greater academic stress where in a position to apply coping strategies against it in a much better way. However the significant correlation between academic stress scores and passive emotional and passive problem scores indicates that the coping behaviour adopted by participants to deal with stress was not satisfactory. Therefore counselling the participants to adopt active coping behaviours is very essential at this setting. In a study done in Ghana by Atindanbila and Abasimi ( 2011 ), wrong or inadequate coping strategies were practiced by university students resulting in reduction of academic stress by mere 4%. Bamuhair et al. ( 2015 ) observed that 32.1% medical students felt too often that, they could not cope with stress. Therefore coping strategies against academic stress among university students in other parts of the world was not satisfactory either. The coping strategies adopted are generally found to vary depending on socio-cultural factors like region, social group, gender, age, and by individuals’ previous experiences as per the WHO/EHA ( 1998 ).

Passive emotional and problem coping behaviours were significantly more among males. This meant that males adopted a number of unhealthy behaviours to deal with academic stress. Unpleasant social coping behaviour was found to reduce social support and increase loneliness by Kato ( 2002 ). Felsten ( 1998 ) observed that specifically procrastination as a coping behaviour was found to result in depression in both men and women.

Female students on the other hand had significantly better active problem scores under coping behaviour. They were hence more mature and composed than the male participants in analysing the centre of the problem in a calm and optimistic manner, and in finding solutions for the same. Bamuhair et al. ( 2015 ) observed that the mean of coping strategies score was significantly higher among females. Females were also found to be better at time management compared to their male counterparts (Misra and McKean 2000 ; Khatib 2014 ). Males therefore need to be counselled about healthy coping behaviours in dealing with academic stress.

Al-Sowygh et al. ( 2013 ) observed that the denial and behaviour disengagement as stress coping strategies were reported to be significantly more among females while self-blame was reported to be more among males. Bang ( 2009 ) reported that the coping mechanism of choice is related to the differences in the roles expected from gender. Males are expected to deal stressful situations by their outward actions while females are expected to focus on emotions and seek social support. Soffer ( 2010 ) stated that women usually choose health-promoting behaviours while men prefer health-risky behaviours.

There was no association between age of participants with the perceived level of academic stress or with the level of adaptability to cope with it in this study supporting the observations of Bamuhair et al. ( 2015 ).

Limitations

This was a cross-sectional study conducted in a single medical college. Therefore the findings of this study cannot be generalized to all medical students across India.

The results of the study reflect important insights into the nature of stress faced by the medical students and the ways they deal with the same. Academic stress was found to be common and was of moderate level in more than three-fourth of the participants. Level of coping with stress was found to be average among 95% of them. Worrying about future and poor self-esteem were independently associated with academic stress among students. Male participants adopted more of unhealthy means of coping with academic stress. Therefore they need to be educated regarding the healthy coping methods. Counselling sessions and other students’ support systems need to be more organized to cater to the issues like career guidance, healthy coping behaviours, time management and to improve the self-esteem among the affected. Attention should also be paid to make the study environment in the classrooms more stress free without excessive academic load. Educating students about unpleasant consequences of stress is equally important. Teachers can also play a constructive role in mentoring and guiding students regarding choosing the right measures to cope with stress. Interactive academic sessions on stress control can further encourage medical students to single out each and every problematic issue. This would accomplish the aim of reducing the academic stress, adopting healthy academic stress coping behaviours, improving academic performance and minimizing anxiety among those with forethoughts about their future professional careers.

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Acknowledgements

We authors thank all the medical students of who took part in this study.

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This manuscript has been read and approved by all the authors, the requirements for authorship as stated earlier in this document have been met, and each author believes that the manuscript represents honest work.

Nitin Joseph: guarantor of this research work, design, literature search, tool preparation, manuscript preparation, revising the work critically for important intellectual content.

Aneesha Nallapati: data collection, data analysis, statistical analysis, interpretation of data, revising the work critically for important intellectual content.

Mitchelle Xavier Machado: data collection, data entry, literature search, manuscript preparation, manuscript editing, revising the work critically for important intellectual content.

Varsha Nair: concept of this study, data collection, data entry, manuscript editing, revising the work critically for important intellectual content.

Shreya Matele: data collection, literature search, manuscript editing, revising the work critically for important intellectual content.

Navya Muthusamy: data collection, literature search, manuscript editing, revising the work critically for important intellectual content.

Aditi Sinha: data collection, literature search, manuscript editing, revising the work critically for important intellectual content.

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Joseph, N., Nallapati, A., Machado, M.X. et al. Assessment of academic stress and its coping mechanisms among medical undergraduate students in a large Midwestern university. Curr Psychol 40 , 2599–2609 (2021). https://doi.org/10.1007/s12144-020-00963-2

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How medical students cope with stress: a cross-sectional look at strategies and their sociodemographic antecedents

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Medical training can be highly stressful for students and negatively impact their mental health. Important to this matter are the types of coping strategies (and their antecedents) medical students use, which are only characterized to a limited extent. A better understanding of these phenomena can shed additional light on ways to support the health and well-being of medical students. Accordingly, we sought to determine medical students’ use of various coping reactions to stress and how their gender and year of study influence those behaviours.

A total of 400 University of Saskatchewan medical students were invited to complete an online survey. Using the Brief COPE inventory, we assessed students’ reported use of various adaptive and maladaptive coping strategies. Descriptive and comparative statistics were performed, including multivariate analysis of variance, to explore how gender and year influenced coping strategies.

The participation rate was 49% (47% males and 53% females). Overall, the students’ coping strategies were mostly adaptive, albeit with a few exceptions. Females used more behavioural disengagement, while males used less emotional and instrumental support. Additionally, third years used more denial to cope with stress than students in any other year.

Conclusions

While few studies report significant sociodemographic effects on medical student coping, our findings raise the possibility that males and females do engage in different coping strategies in medical school, and that the clinical learning environment in third year may provoke more dysfunctional coping, compared to pre-clinical stages of training. Potential explanations and implications of these results are discussed.

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During medical school, students’ mental health is known to be at significant risk [ 1 , 2 ]. Hence, there is an active search to better understand and promote their health and well-being. While the prevalence of distress has been established among medical students [ 1 , 2 , 3 ], less is known about the types of coping behaviours they engage in to mitigate distress throughout their medical education [ 4 ]. A better grasp of this is important, because how medical students cope not only predicts their mental health [ 5 ] and academic performance [ 6 ], but the quality of patient care they go on to deliver [ 7 , 8 ]. In view of this, the present study adds to the literature by exploring the extent that students use various coping strategies in medical school and whether those strategies vary as a function of gender and year of training. We start by examining the extant literature on stress and coping, both in and outside of medical education. We then show how often medical students use various coping strategies to deal with stress, and to what extent their gender and year of training explain the observed variance in those outcomes. A discussion of results follows, including potential implications in medical education. Our hope is that this research may advance our understanding of student stress and coping in medical school, as well as guide the optimization of supports for medical students, in ways that maximize their health and well-being.

Coping has been extensively studied and conceptualized in various ways in the literature [ 9 , 10 ]. Here we define coping as a conscious volitional effort to regulate one’s emotions, thoughts, and behaviours, in response to stress [ 11 ]. While it is well-established that coping can be categorized into two main types: problem-focused and emotion-focused [ 12 ], there is also a consensus of a second-order dimension of coping—namely, adaptive (i.e., “active”) and maladaptive (i.e., “passive” or “avoidant”) [ 13 , 14 , 15 ]. Adaptive coping involves flexible approaches to solving problems and/or managing their related emotions (e.g., through strategizing, reappraisal, and emotional regulation and expression) [ 10 ], whereas maladaptive coping involves behaviours that are less constructive and fruitful (e.g., ruminating, venting, confrontation) and avoidant (e.g., abandonment, social isolation, and inhibiting or suppressing one’s emotions) [ 16 , 17 ]. These dimensions of coping, which provide a framework to help contextualize the adaptivity of strategies used by medical students, are categorized and defined below (see Table  1 ).

Stress and coping in medical school

Medical students deal with many types of stressors in medical school: intense academic demands and workloads, challenging curricular aspects and learning environments, personal life events, and psychological pressures that are difficult to cope with [ 19 , 20 , 21 , 22 ]. In fact, in a recent study concerning medical student resilience and the roles of coping styles and social support, it was found that 49% met criteria for burnout, 17% had moderate to severe depression, and 23% responded that developing depression was due to their inability to cope [ 23 ]. Studies like these highlight how important healthy coping behaviours are for medical students, in being able to overcome the stressors they face in medical school [ 3 , 24 ].

Research in medical education supports the proposed relations between adaptive and maladaptive coping styles, with positive and negative mental health outcomes, respectively. For example, more active (e.g., seeking social support) versus passive and avoidant (e.g., drinking alcohol) coping strategies have be shown to be key mediators of medical students’ burnout during medical school, as measured by the Maslach Burnout Inventory (Student Version) [ 25 ]. Other studies are complimentary, showing that when medical students utilize more adaptive coping behaviours, it relates to lower levels of distress and higher resilience [ 4 , 23 ]. Nonetheless, sociodemographic antecedents (e.g., year of study, gender, ethnicity) of medical students’ coping behaviours are not well characterized and there has been a call for more research on the specific types of coping strategies they use, in order to buffer stress [ 4 , 26 ].

Gender differences in coping

Within the general population, studies have reported significant gender differences in coping behaviours—for instance, that females tend to experience more chronic stress and consider stressors as more threatening than males [ 27 , 28 , 29 ]. Studies also suggest that females vent more emotions and rely on more social support to cope with stress (e.g., instrumental and emotional support), while males may use more passive and/or avoidant methods of coping, like alcohol or drugs [ 30 , 31 ]. Other research has found that females tend to use more maladaptive coping strategies than males, such as self-distraction, denial, and behavioural disengagement [ 10 ]. Interestingly, these differences have largely been attributed to social norms and gendered constructs, rather than actual sex differences [ 32 , 33 ]. Hence, workplace climates can dramatically shape coping behaviours, based on how accepted and reinforced those “masculine” (i.e., agentic and instrumental) or “feminine” (i.e., communal and emotional) traits tend to be [ 34 ]. Indeed, the extant literature on social roles and gender differences in health, stress, and coping, supports this notion [ 27 , 35 , 36 , 37 ].

Despite a consensus of what generally constitutes adaptive vs. maladaptive coping reactions, and that gender roles play a part, the literature remains mixed regarding specific gender differences in coping. It is also worth noting that most studies have looked at gender as a binary construct and there are really no studies that have taken into consideration non-binary gender classifications, in terms of coping. While some traits that are considered “masculine” have been associated with primarily adaptive coping strategies [ 38 ], others have reported positive and negative associations (e.g., with seeking social support) [ 38 , 39 ]. Further, while females are found to experience higher distress than males, studies have also linked masculinity to distress, through unhealthy stress appraisals and disengagement coping [ 40 ]. Whether these delineations reflect unique sample characteristics or under-reporting on surveys remains unclear. Some have suggested that it more likely reflects an equalization of gender roles, due to increasing female representation in the workplace [ 29 , 41 ]. Thus, an evolution in gender role attitudes and environments may also explain gender-related coping differences, particularly among physicians [ 42 ]. This leads us to consider whether gender differences in stress and coping might too be evolving in medical education—where more females are now enrolled than males for the first time in recent history [ 43 ].

Gender and medical student coping

In keeping with the broader literature, gender differences in coping strategies among medical students are also somewhat enigmatic. For instance, a recent study looking at latent profiles of coping among medical students found that gender was not a significant correlate of coping styles [ 4 ]. Various other studies are also in agreement with this notion, that coping differences do not differ among male and female medical students [ 24 , 44 , 45 ]. In contrast, however, others have found significant gender differences in coping among medical students—for example, that females preferred to study and sleep, while males preferred to spend time with friends, play sports, or isolate themselves [ 19 ]. Interestingly, some studies have also found male medical students to score higher in distress than females, which related to more maladaptive coping strategies like self-blaming, denial, and substance use [ 46 ]. This finding is somewhat distinct from other areas in the literature, where females tend to score higher in distress. Since many of these investigations were conducted in Eastern vs. Western nations, further research is required to determine the extent that cultural and environmental factors contribute to how male and female medical students cope.

Environmental considerations in medical student coping

As mentioned, other important determinants of how medical students cope are curricular and environmental factors [ 21 ]. Indeed, there is a growing body of evidence supporting that the further medical students get in their education, the more emotionally taxing it might be. This could be because clinical students encounter situations they will have never experienced before (e.g., patient deaths, delivering bad news, child abuse), or because they may be relatively disconnected from social networks they had in place during pre-clinical years, which served as a buffer for dealing with stress. Alternatively, changes in coping could reflect the uncertain nature of the stressors clinical vs. pre-clinical students face. For instance, after adjusting for gender, ethnicity, and school, one study reported worsening student perceptions of the learning environment in third year of medical school (when clinical rotations start), with some recovery after “match day” in fourth year (when students learn of their residency placements) [ 47 ]. These findings correlate with other reports in the literature, showing that medical students in later vs. earlier years of training tend to use more avoidant, maladaptive coping strategies, which tend to emanate when stressors are perceived as uncontrollable [ 25 , 48 , 49 ]. Hence, how students cope likely depends on the unique environments and stressors they face in each year of medical training. While differences in distress are well-documented among medical students in pre-clinical vs. clinical years [ 3 , 50 ], how their respective coping behaviours might also differ remains relatively unclear.

Current study

The present study aims to extend prior research by exploring what types of specific coping strategies medical students report using to buffer stress in medical school, and how their gender and year of training influence those coping behaviours. Considering the extant literature on these topics, as well as the uniquely stressful nature of medical school (which includes many challenges that learners may view as more or less controllable) [ 51 , 52 ], our hypotheses are twofold. First, females will use more maladaptive coping strategies (e.g., venting, behavioural disengagement, and/or self-blame) [ 10 ], while males will use fewer adaptive ones (e.g., seeking emotional and instrumental support) [ 19 ]. Secondly, medical students in clerkship (third and fourth years) will use more maladaptive coping strategies (e.g., denial, self-distraction, self-blame) compared to those in pre-clerkship (first and second years) [ 25 , 48 , 49 ].

Participants & procedure

A cross-section of 400 medical students, from all 4 years of the medical program at the University of Saskatchewan, were invited to complete an online survey, toward the end of the 2019 school year. The survey included information about the study and measured how frequently students used various coping strategies in medical school (see Measures). Participation was voluntary and responses were anonymous, to maintain confidentiality and minimize response bias.

Of note, the 4-year medical program at the University of Saskatchewan—much like the majority of medical programs in Canada—separates its curriculum into two main components: pre-clerkship (years 1 and 2) and clerkship (years 3 and 4). Students in pre-clerkship learn mostly through classroom-based modules, small group sessions, clinical integration (weekly skills practice and experiential patient encounters), and regular examinations (both written and clinical). In contrast, students in clerkship primarily work in clinical environments (e.g., clinics and hospitals). Duties at this stage tend to provide more independence but include challenging national board examinations, longer, mandatory work hours, and higher patient responsibilities.

Ethical approval

This research received ethics approval from the University Research Ethics Board. All participants provided informed consent.

The survey contained questions related to the medical students’ year of study (1–4) and gender identity (“male,” “female,” or “other”), followed by the Brief COPE inventory, which was oriented to reflect students’ experiences in medical school. Of note, there were no major social events that occurred during the academic year, which we felt could influence results.

The Brief COPE (Carver [ 14 ])

The Brief COPE is a 28-item scale containing 14 two-item factors. It measures how frequently people use a range of distinct coping reactions to stress (active coping, planning, acceptance, positive reframing, emotional support, instrumental support, humour, religion, denial, venting, self-distraction, behavioural disengagement, and self-blame). Items were presented in a retrospective manner (i.e., looking back throughout the year) and participants indicated how frequently they used each coping strategy on a scale, ranging from 0 ( I haven’t been doing this at all ) to 3 ( I have been doing this a lot ). Thus, for each of the 14 COPE factors, the mean score could range from 0 to 6, as an average of each subscale’s two items. Mean subscale scores were calculated by adding item scores together. As Carver recommends [ 14 ], the wording of the scale was modified for this study, to fit the population of students and challenges they face in medical school. For instance, whereas part of the original Brief COPE's stem read, “We want to know to what extent you’ve been doing what the item says,” we added, “…since starting your year in medical school.”

The Brief COPE has been validated in health-related research and its subscales have been shown to have satisfactory reliability (with Cronbach’s alpha’s from 0.50 to 0.90) [ 14 ]. Prior exploratory and confirmatory factor analyses support Carver’s proposed 14-factor structure of coping [ 53 , 54 ], along with its higher order (adaptive and maladaptive) categorization [ 10 , 12 , 55 , 56 , 57 ]. Hence, studies support the usefulness of the situational version of the Brief COPE (used in the present study), for the valid and reliable assessment of the 14 specific coping responses to stressors. Accordingly, we assessed the medical students’ reported use of every strategy, without attempting to create new variables or reduce the data’s dimensionality (i.e., through principal components or factor analysis). Instead, we draw on the supporting literature to help identify which strategies the students report using that might be healthy vs. dysfunctional, in a medical education context.

Statistical analyses

The software SPSS version 24.0 was used for our statistical analyses. All data were standardized and met the assumptions of normality, linearity, and homoscedasticity. Descriptive statistics determined the students’ mean scores for each coping strategy. Relationships between the coping factors were assessed using Pearson correlations. We then explored whether students’ coping strategies varied as a function of gender and year of study, using one-way multivariate analysis of variance (MANOVA) with post-hoc unpaired t -tests (or pairwise comparisons) and 95% confidence intervals, to see where the differences lay. Levene’s test of equal variances and Bonferroni’s p -value correction were used where appropriate. Partial eta squared ( η p 2 ) values were provided as effect sizes for the MANOVA (where .01 is considered small, .06 is medium, and .14 is large). Cronbach’s alphas were calculated and ranged from 0.49–0.93, which were deemed to be acceptable based on prior studies using the separate Brief COPE subscales [ 58 , 59 , 60 ].

Descriptive statistics

The response rate of the students was 214/400 (54%). However, surveys from 17 participants were insufficiently completed and thus were excluded from the analyses. This left a total of n  = 197 participants (49%)—92 who identified as “male” (47%), 105 as “female” (53%), and none as “other.” The sample consisted of 70 (36%) first years, 57 (29%) second years, 35 (18%) third years, and 35 (18%) fourth years. The mean age was 25.9 years ( SD  = 3.7) with a range of 21–44 years. As seen in Table  2 below, the sample’s Brief COPE subscale scores are listed in descending order of reported use (see Measures for interpretation).

As Table  2 illustrates, the Brief COPE subscale scores suggest that the medical students use predominantly adaptive (e.g., active coping, emotional support, positive reframing) rather than maladaptive (e.g., denial, behavioural disengagement, substance use) coping strategies, in response to stressors they face in medical school. Interestingly, however, several strategies that are generally considered maladaptive also appear fairly frequently—for instance, venting, self-blame, and in particular, self-distraction. These patterns informed the next step, which explores how the different coping strategies correlate.

Variable relationships

Table  3 shows the intercorrelations for all study variables. Overall, the strength of relationships are low to moderate range and are in the expected directions. For instance, coping strategies that are generally considered adaptive (i.e., planning, acceptance, emotional and instrumental support, positive reframing, humour, and religion) positively relate to one another and negatively correlate with coping methods that are typically considered maladaptive (e.g., denial, substance use, behavioural disengagement, self-blame, self-distraction). Interestingly, however, we find other less expected patterns among this sample of medical students—for example, with venting (which positively relates to acceptance, planning, emotional and instrumental support, and humour), and the positive relations between instrumental support and self-blame, humour and substance use.

With respect to demographics, results indicate a weak but significant positive correlation between age and planning. Point biserial correlations also suggest that females use significantly more behavioural disengagement to cope, while males use significantly less instrumental and emotional support to cope. The correlational analyses did not detect a significant relationship between students’ year of training and the types of coping strategies they use.

Sociodemographic effects on medical student coping

Though no significant correlations were identified between year and coping, our a priori hypotheses were that coping differences would likely be influenced by students’ gender and year of training. Thus, a one-way MANOVA was used to assess the effect of gender and year on each of the Brief COPE subscales. Levene’s tests indicated equal variances for all coping factors across gender and year subgroups ( p ’s > 0.05). Interestingly, the MANOVA found a significant effect of year on denial, F (3,181) = 3.16, p  = 0.03, η p 2  = .05. Follow-up pairwise comparisons revealed that third year students reported the highest use of denial, which differed significantly from fourth years, who reported the lowest use of this strategy ( MD  = .61, SE  = .21, p  = .03). Additionally, there was a notable effect of year on behavioural disengagement that approached but did not achieve statistical significance, F (3,181) = 2.64, p  = .051, η p 2  = .04. Follow up pairwise comparisons again confirmed that third years scored highest, this time differing most from first years, who scored lowest ( MD  = .63, SE  = .24, p  = .052). The second MANOVA confirmed significant gender effects on several of the medical students’ coping strategies. Specifically, males sought less emotional support, F (1, 181) = 16.57, p  < .001, η p 2  = .08, as well as instrumental support, F (1,181) = 13.84, p  < .001, η p 2  = .07, and females used more behavioural disengagement to cope, F (1, 181) = 8.65, p  = .004, η p 2  = .04. Of note, the effect sizes of students’ year and gender on each coping strategy are considered small to medium.

The present study is among the first to assess how a subset of Canadian medical students cope in response to various stressors in medical school, and how their gender and year of study impact those coping behaviours. As was hypothesized, we found significant associations between both sociodemographic antecedents and the students’ reported coping strategies. Specifically, females reported greater use of behavioural disengagement and males reported less reliance on emotional support and instrumental support. Moreover, we found that third year students reported the most use of denial to cope than all other years. Potential explanations and implications of these findings are discussed, with suggestions for future research below.

Medical students’ overall coping

As mentioned, the Brief COPE measures fourteen distinct coping responses to stress—some adaptive for health and well-being and others less so [ 14 ]. While we cannot comment generally on how students cope with stress, our findings suggest that the coping strategies adopted by the medical students were primarily healthy, rather than dysfunctional (see Table  2 ). Breaking things down further, this notion is substantiated by the students’ relatively equal use of problem-focused (e.g., planning, active coping, seeking instrumental support) and active, emotion-focused (e.g., seeking emotional support, positive reframing, humour) coping strategies, compared to their less frequent use of passive and avoidant ones (e.g., denial, substance use, behavioural disengagement).

In support of Carver’s 14-factor structure of coping [ 14 ], many of the individual coping strategies did not correlate with one another, in the present study. This was to be expected, given that the Brief COPE is comprised of coping reactions that are said to be distinct (i.e., which neither directly relate much, nor oppose each other, but rather co-exist). Hence, they are assessed individually and in relation to each other, and more as a way of identifying overarching patterns, since each coping strategy is broadly understood to be adaptive or maladaptive. In line with this notion, most of the coping behaviours that the medical students reported using which are considered adaptive or maladaptive do intercorrelate, respectively. Accordingly, the number and potentially weak or moderate strength of the significant correlations are not considered a shortcoming, but rather a testament to the importance of studying all 14 strategies, to fully capture how medical students cope with stress.

Interestingly, despite the above findings, several frequently used strategies did emerge that might not be as adaptive—for instance, students’ use of self-blame, self-distraction, and venting. This might be explained by previous studies showing that, while certain coping strategies like planning, active coping, and instrumental support consistently relate to better health outcomes than dysfunctional strategies [ 4 , 14 , 61 ], other coping methods are not always as stable or predictable [ 13 ]. A fitting example of this was the medical students’ reported use of venting, which positively related to mostly adaptive coping strategies (e.g., emotional and instrumental support, humour, planning, and acceptance) and not maladaptive ones that it has commonly been associated with (e.g., denial, self-blame, substance use) [ 14 , 62 ]. This might be explained by medical students associating the humorous telling of frustrating or unusual experiences they encounter in medicine, as venting, which differ from other workplace settings, in the wide range of experiences and novelty they present to early medical learners. In support of this, Park et al. [ 63 ] explained that even avoidant and/or emotion-focused coping strategies may become useful—particularly when a stressor is felt to be overwhelming or out of one’s sense of control. Either way, it lends support to the idea that some emotion-focused coping strategies may be more or less adaptive depending on the situation [ 64 , 65 ]. Though there is little consensus about which coping strategies are in fact most effective, studies do generally support this premise regarding controllability [ 66 , 67 ].

Another interesting finding was that the medical students’ use of self-blame positively related to them seeking instrumental support. Other studies have also reported this finding in the literature [ 62 ]. Hence, while our overall results suggest that medical students wish to cope adaptively with the high demands of medical school, it is possible that they also blame themselves for not always being able to achieve that goal. And, based on our correlational data, they may resort to self-distraction or other means to cope. As others have explained, self-blame may thereby work as a double edged-sword, given it can stimulate active coping behaviours, such as seeking instrumental support, or conversely lead to guilt and feelings of depression [ 62 ]. This could be explained by the difference between guilt vs. shame, where guilt is more motivating for corrective action, while shame is more pathogenic as it relates to the self [ 68 ]. This link between active coping, self-blaming, and self-distraction in medical school, is a subject for further research.

Put together, the patterns of the above findings align with others in the literature, highlighting specific coping strategies and their frequency of use among medical students [ 69 , 70 ]. They also suggest that medical students may use more active or problem-focused types of coping (e.g., planning) to deal with stressors that they view as solvable (e.g., studying hard to pass a tough exam) and potentially more passive and/or avoidant methods of coping (e.g., venting, denial, self-distraction, behavioural disengagement) to deal with challenges they feel are uncertain and more daunting (e.g., matching to their residency program of choice). The overlap between coping and resilience is also a consideration here, but one that is beyond the scope of this paper.

Coping differences by year of training

Of note, the only coping strategy that was found to vary by students’ year of study was denial (refusing to accept or face the reality of a situation), which was highest among third years and lowest among fourth years. While it did not achieve statistical significance, our data also suggest that third years might resort to more behavioural disengagement. As mentioned, coping with these strategies tends to predict distress in the long-term [ 14 ]. These patterns, which align with other studies in the medical education literature [ 49 , 70 ], may reflect the fact that third year represents a very challenging stage for medical students—when they face many more imminent stressors (e.g., more patient care, stressful board examinations, competitive electives, long work hours, sleep deprivation, and higher worry about the future) [ 48 , 51 , 71 , 72 ]. Our and others’ findings further suggest that fourth year likely relieves medical students of many of these uncertainties, thereby removing their need to use passive and avoidant coping strategies, such as denial [ 47 ].

In terms of why third years may be using more denial to cope, it could be related to feelings of helplessness—for instance, about the uncertainty of securing competitive electives and the process of matching to residency, in the year ahead. Indeed, studies show that when a person feels they have little or no control over the outcome of a situation, they will tend to engage in more avoidant and/or emotional coping styles, as a stress-protective mechanism [ 12 , 56 ]. It therefore follows that denial might be higher among third year medical students because they perceive less autonomy during this stage of their training—something others have emphasized the importance of for physicians and medical students alike [ 73 , 74 , 75 ]. Support for this theory comes in a recent study which showed that, among a four-year sample of medical students, third years reported the highest autonomy frustration and perceived stress compared to the other 3 years [ 76 ]. An alternative explanation might be that third years are placed into situations they have simply never encountered before (e.g., dying patients, witnessing or delivering bad news) that may feel surreal and be harder to cope with actively and adaptively at first, compared to fourth years, who have likely experienced, reflected on, and acclimated to these types of challenging encounters. Fourth years may also have less of these experiences to adapt to over their year, compared to new clerkship students. As with venting, self-distraction, and self-blame, more research is needed to determine if and how long it might be before maladaptive coping strategies, such as denial, shift from being stress-protective for medical students to being psychologically harmful.

With respect to gender differences, another interesting finding of this study was that female medical students reported more use of behavioural disengagement (giving up trying to deal with a situation), while males reported less reliance on emotional support (seeking comfort and understanding from others) and instrumental support (getting advice from others) to cope. Once more, these forms of social support are considered healthy and adaptive, whereas behavioural disengagement tends to predict maladjustment over time [ 14 ]. While various studies purport no gender-based coping differences among medical students [ 24 , 44 , 45 ], our findings align with other studies that do, both within and outside of medical education—for instance, that male medical students used more isolating (i.e., less social) coping strategies than females [ 19 ], and that females used more behavioural disengagement than males, respectively [ 10 ].

As previously mentioned, the literature suggests that any gender differences in coping are most likely due to socialized gender roles [ 32 , 33 ]. Thus, our findings that females used more behavioural disengagement, while males used less social support to deal with stress, may reflect gender stereotypes that are reinforced within the medical culture. Accordingly, it could be that male medical students prefer to be independent and not to reach out for social support (e.g., to peers or programs) because doing so might conflict with traditional ideals of what it means to be male (e.g., toughness, independence, and emotional control). Conversely, female medical students may behaviourally disengage because of pressures to demonstrate traditional female traits (e.g., politeness and nurturance), which preclude them from feeling that they can be bold or exert more assertiveness. Indeed, studies suggest that gender-based norms are reinforced in medicine (e.g., via instructor evaluations) and may contribute to distress for female medical students [ 77 ]. These are worthy considerations in medical education, given academic stress and stigma around mental health are proven determinants of students’ well-being [ 23 , 52 , 78 ].

Implications in medical education

Findings from this study may have several important implications in medical education. The first is the need to address gender stereotypes in medicine, that can have potentially detrimental consequences for medical students. For some males, these pressures might mean not seeking external supports and feeling like they need to “tough it out” on their own. For some females, it might mean disengaging or tempering their self-expression, due to a social construction that assertiveness is not a feminine trait. The extent that these gendered constructs may be contributing to additional, unnecessary distress for medical learners is worth exploring.

Another implication is the positive association we found between age and planning, which positively correlated with other adaptive coping strategies (e.g., acceptance, positive reframing, emotional and instrumental support) and negatively correlated with various maladaptive ones (e.g., behavioural disengagement). This suggests that those who are older when they enter into medical school—who likely have prior life experience beyond an educational setting—are potentially better equipped to cope more proactively with stress, such as in clinical settings. If true, providing early support of medical students who are younger and/or who have less experience—for example, in recognizing the benefit of planning ahead (e.g., with study schedules, extra-curricular activities, course rotations, and elective planning)—may help them cope more adaptively with stressors they face, as they progress in their medical education. That said, further research is warranted to assess whether age-related differences in coping are not unique to our institution, but a consistent finding in other medical programs.

Although we did not have a concurrent measure of wellness or distress, findings from this study also suggest that medical students may use a variety of coping strategies that may be viewed as dysfunctional in the main, but in the context of medical school, may in fact be stress protective. For example, our finding that venting emotions (which is often considered maladaptive [ 10 , 15 ]) positively related to seeking emotional support, instrumental support, acceptance, and humour (which are largely adaptive for well-being [ 14 , 15 ]) suggests that both male and female medical students may find venting therapeutic. Given the social nature of medical school and that students share the same types of stress, it stands to reason that venting to each other may help them come to terms with stressors they feel are mutually troubling (e.g., performance pressures during courses, exams, or clinical rotations). The weak but significant positive correlation we found between venting and acceptance supports that idea. While it remains unclear how duration of coping strategy (e.g., venting) impacts whether it becomes maladaptive for medical students, creating physical spaces (e.g., lounges) for them to congregate—where they can feel free to vent and decompress—is nevertheless recommended.

Finally, our finding that students in third year reported more use of denial (which is generally considered dysfunctional [ 14 ]) than all other years is concerning. We would argue this reflects the uncontrollability of the stressors that third year presents, which can be unfamiliar and disarming for medical students. Although no other coping differences were found between medical students in different years, our analyses did reveal a significant positive correlation between denial and various other maladaptive coping strategies (e.g., substance use, self-blame, and behavioural disengagement). Hence, while we felt reassured that students’ use of denial did show a decrease in fourth year, being aware that denial may be high in third year and that it may pose risks (i.e., in terms of using other maladaptive coping behaviours) may be important for people in positions that support medical students during this time.

As mentioned, a potentially important avenue for achieving this may involve finding ways to facilitate more autonomy for medical learners during their clerkship (e.g., see Neufeld and Malin [ 79 ]). Studies suggest that promoting medical learner autonomy may also reduce their perceived stress and increase their ability to be mindful and resilient, which are also key to healthy coping and well-being [ 76 , 80 , 81 ]. Because third year inevitably involves more administrative tasks (i.e., organizing clinical electives and residency applications), which are increasingly being recognized as underrated sources of stress for medical students, we would also echo others’ suggestions to focus on addressing systems-level changes in medical education [ 52 ]. Doing so might help to support senior medical students—particularly around career planning and residency preparation—as they move towards graduation and starting residency.

Limitations & future research

The present study has limitations which may help to guide future research. First, while the response rates were satisfactory for sample representativeness and statistical power, the unequal sample sizes across year subgroups, combined with our reliance on self-report data, both create the potential for response bias. That said, various studies concerning four-year medical programs also point to third year as a highly stressful time for students [ 48 , 82 ], and demonstrate that medical students (and females in particular) tend to experience more stress and cope less adaptively during this time period [ 45 , 76 ]. Nonetheless, caution is recommended when interpreting the results from this study, and cohort studies as well as qualitative approaches will be very helpful in enriching these findings and determining their underlying causality.

A second point of mention is that this study relies on a cross-sectional, quantitative (i.e., reductionist) approach and was conducted at a single institution, which limits generalizability and prevents conclusions about temporal patterns of coping (i.e., across years). Thus, while our demographic findings have potential implications in medical education, there is some potential for cohort effects. Additionally, while different gender options (e.g., non-binary gender and transgender) were considered, in retrospect, we recognize that we may not have used the most appropriate approach to measure this. For example, had many students selected ‘Other’ for gender, it would have made drawing conclusions about gender-based differences in coping more complex to disentangle. Future studies would therefore benefit by including a more inclusive range of options to explore these matters further.

Finally, we focused not on coping as a predictor of mental health outcomes, but on how frequently medical students used specific coping strategies and how they are influenced by their gender and year of study. While our results suggest that these demographic antecedents are indeed important determinants of medical students’ coping responses, further studies are needed to confirm these findings. Others may also wish to examine other factors that could influence coping (e.g., psychological diagnoses, prior work experience, ethnicity, marital and socioeconomic status, and career-related goals), as well as include concurrent measures of academic performance and/or positive (e.g., subjective well-being) and negative (e.g., perceived stress) mental health. This might help to capture not only the types of coping strategies medical students use during medical school, but how those strategies relate to their health and functioning.

This study contributes to a growing body of research on stress and coping among medical students. Our findings intimate that female medical students may engage in more behavioural disengagement, while males may utilize less emotional and instrumental support. Our results also suggest that third year learning environments may potentiate more maladaptive coping strategies, such as denial, compared to those in other years. Thus, while further research is needed to validate these findings, the presents study adds a new perspective to the debate on how medical students cope with stress in medical school and what the role of gender and year of study are in that relationship. We hope this study provides an impetus for medical educators to create supports that address gendered constructs of coping, as well as learning environment interventions in third year, that foster the well-being of medical students.

Availability of data and materials

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

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Neufeld, A., Malin, G. How medical students cope with stress: a cross-sectional look at strategies and their sociodemographic antecedents. BMC Med Educ 21 , 299 (2021). https://doi.org/10.1186/s12909-021-02734-4

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This research examined how three coping strategies could support students in Further Education who have difficulties expressing themselves and some students who Self-harm.

The first strategy is the ABC Chain Analysis which encourages students who either Self-harm or had emotional outbursts to reflect on how to respond differently. The second strategy is a Happy Bag and Music. Students identified objects and downloaded music that reminded them of happier times. The third strategy: the Safety Plan is a detailed, individual plan of safe places, people and experiences for the participants.

Data collection involved: learning journals, questionnaires, observations and interviews. Using different data collection techniques allowed the students varied opportunities to express their opinions.

Peer pressure and relationship difficulties mostly affected the group. Findings concluded that all three strategies were effective methods to support students, with the Happy Bag proving the most popular. Arguably, the Chain Analysis and Safety Plan are more cognitive than practical, and may be more effective for students who do not have learning difficulties, but further research would be required. The group reported that being able to empower themselves to cope with difficult situations was very helpful. These findings have proved useful for colleagues’ professional development in supporting students with these issues.

Introduction and Background:

“O the mind, mind has mountains; cliffs of fall

Frightful, sheer, no-man-fathomed” (Hopkins, 1918, p.858).

Hopkins’ poem , No Worst, There is None , evokes the complexities of our minds and highlights how different each individual perspective can be as no two mountains are ever the same. Thinking of this inspired me to examine ways of enhancing individual support for students. As Senior Lecturer (Inclusiveness) at a College of Further Education I was aware that provision for students with physical disabilities and specific learning difficulties was in place. However, there is less support available for students with mental health issues. Earlier in my career I trained as a Registered Nurse and my training in Mental Health brought a different professional perspective when working with vulnerable young people in an educational environment. I feel that mental health, and particularly Self-harm, is an area of support that people are still cautious speaking about and practitioners may find it difficult to cope with this barrier to learning (Mental Health Foundation, Truth Hurts, 2006, p.86).

As an educator it is important to understand the complexities of the students’ minds, and where they are having difficulties in learning to look across the interagency divide to find ideas from health professionals for supporting students. In my role I need to consider inclusive education as a problematic notion (Forlin et al, 2013, p.6) as it ‘ lacks a tight conceptual focus ’ (ibid). My focus and the purpose of the study was to research ways that provision for students who may Self-harm could be established and to use the information to provide support for students. Education Scotland promote the Curriculum for Excellence which ‘aim s to achieve a transformation in education in Scotland by providing a coherent, more flexible and enriched curriculum ’ for young people. It:

“recognises the need to shape the curriculum to meet the needs of students, to listen to their views, to involve them as far as possible in shaping their learning and to involve them in promoting their own learning, progress and achievement” (Education Scotland, 2002).

Therefore, Education Scotland advocates that teaching practitioners have to look at students’ support needs holistically. Moreover, it suggests that teachers should consider Students’ Health and Wellbeing as outlined by Experiences and Outcomes (2003) in the context of the Curriculum for Excellence, ensuring:

“each establishment, working with partners, should take a holistic approach to promoting health and wellbeing” (p.79).

In the context of mental health issues, Education professionals are urged to liaise with outside partnerships to meet the needs of all students.

Current legislation and policies

The Scottish Government (2012a) in A Guide to Getting It Right For Every Child , describe the Getting It Right For Every Child (GIRFEC) approach as involving all Scottish services for children and adults, and promoting professionals working together to help them reach their full potential and to meet their needs.  The Scottish Government (2012b) developed a ‘maturity model’, to help organisations assess how they are implementing the GIRFEC approach, and highlighted some of the key steps involved in the process:

“The maturity model (and the National Performance Framework) includes a range of internal reporting and compliance mechanisms aimed at establishing and maintaining clear management responsibility and accountability for implementing GIRFEC”.

GIRFEC seeks to meet the needs of all children by spreading innovation across the public sector, building stronger improvement capability, developing clear aims, improving priorities designed explicitly to achieve those aims and promoting transparent measurement of progress (The Scottish Government, 2012a). This model advocates enhanced collaboration of professional partners.

The Mental Capacity Act (Great Britain, 2005) provides a framework to protect vulnerable people over the age of 16.  Furthermore, the Disability Discrimination Act protects against discrimination that could affect people with mental illness, in relation to less favourable treatment and inequitable provision of services (The Disability Rights Commission, 2006). More recently, the Equality Act brought together existing laws to prohibit discrimination against people with protected characteristics. Notably, disability is one of the specified protected characteristics and some Self-harming behaviours are included (Great Britain, 2010). The Mental Health Strategy for Scotland 2012 -2015 Commitment 10: stipulates:

“We will work with clinicians in Scotland to identify good models of Learning Disability CAMH (Child and Adolescent Mental Health) service delivery in use in different areas of Scotland or other parts of the UK” (The Mental Health Strategy for Scotland, 2012).

The Scottish Government is looking for ways to increase partnerships between agencies to enhance recovery. Additionally, the recent report, Scotland’s Mental Health: Children and Young People (2013) found that: ‘ Mental Health problems generally increased with age with the exception of conduct problems and hyperactivity/inattention ’ (The Scottish Government, p.93).  Therefore, the requirement to increase support strategies for students as they mature is fundamental.

Mental health and Self-harm

“The term ‘ mental health ’ is […] used to refer to concepts of mental wellbeing, mental health problems and mental disorders” (Clare and Maitland, 2014 cited by Rothi, Leavey and Best, 2007 p1218). According to Dr Lynne Friedli:

“Mental health is a fundamental element of the resilience, health assets, capabilities and positive adaptation that enable people both to cope with adversity and to reach their full potential and humanity” (Friedli, 2009, p.5) .

This highlights complications associated with mental health as social and environmental issues can affect anyone, and all of us respond to and cope differently with situations. The National Institute for Health and Care Excellence (NICE) guidelines (National Collaborating Centre for Mental Health, 2004) use the following definition of Self-harm: ‘ Self-poisoning or self-injury, irrespective of the apparent purpose of the act .’ The National Self-harm Network (NSHN, 1998) notes that: ‘Self-injury is frequently the least possible amount of damage and represents extreme self-restraint’.  Swales (2005, p.5) advocates this by declaring that Self-harm is a manifestation of emotional distress. It is not necessarily the case that ‘ an act of Self-harm is an attempt or even indicator of intent to die by suicide ’; it can be seen as a form of self-preservation. Swales’ suggestion may appear paradoxical: if a person is in extreme emotional distress, and is aware that harming themselves will reduce this; they are forfeiting their physical health to protect their mental health.

Klonsky (2007) also recognises how Self- harm is a coping strategy in a review of 18 studies on Self-harm. He found that ‘ affect-regulation ’ was mentioned in all studies. People who self-injured commonly spoke about stopping ‘bad feelings’, relieving feelings of anxiety or terror, and reducing anxiety and despair (Klonsky, 2007, p.1049). According to the ‘Hidden Pain Report’ self-injury is of least frequency or intensity when people are contented (Heslop and Macaulay, 2009 , p.3). This confirms that Self-harm frequently occurs due to emotional distress. Whatever the reasons, Self-harm can be dangerous and people need to speak about it so that different coping strategies can be tried.

The charity MIND outlines that ‘ Self-harm can involve: cutting, burning, scalding, hitting or scratching, breaking bones, hair pulling , swallowing toxic substances or objects ’ (MIND, Webpage on Self-harm, 2007, p.4).  The act of Self-harm and reasons for it vary greatly and are highly individualised. Penumbra, a charitable organisation for those who Self-harm, outlines in the service information leaflet that not only are the types of Self-harming varied, but the reasons why are also wide-ranging:

“The reasons behind such harm may be diverse and complex and may include the feeling of being cleansed, the physical expression of emotional pain and escape from feelings of emptiness and numbness to name a few” (Harrower, 2012, p.2).

The leaflet further stipulates that Self-harm is not a form of attention seeking (ibid). The charity MIND similarly explains that ‘ Self-harm can be about trying to stay alive – a coping mechanism for survival, and escape from emotional pain ’ (MIND, 2010, p.6). Self-harming is surrounded by a lot of misconceptions.

Educators need to know that students are more likely to Self-harm if they have difficulties expressing themselves emotionally and articulating themselves. A dedicated Self-harm service in Manchester found that about 50% of patients were found to be illiterate or to have very low levels of literacy (15% illiterate and most had an average reading age of 7–8 years) (Royal College of Psychiatrists, 2010, p.90).  Self-harm releases the pressure physically for people who have difficulties communicating verbally.

Moreover, it also has consequences for health departments as well as teaching practice.  Self-harm affects 150,000 people attending emergency departments each year: 80% self-poisoning; 20% self-injury (Mental Health Foundation, Truth Hurts, 2006).  1 in 5 young people may Self-harm and 1% of the adult population may have experience of Self-harm, (ibid).  The highest prevalence for females is in the 19-24 age group, and for males it is the 25-34 years age group. The current rates in the UK are 3:1 female to male, but gaining parity.  0.5 - 2% will die by suicide in first year; 5% after 9 years. Some studies suggest 1 in 10 people who Self-harm for 10 years plus will die by suicide (Samaritans, 2002). 10% of patients admitted to hospital following Self-harm commit suicide within 10 years, (Pope, 2012).    Given the statistics above, the evidence suggests that much greater support is required.

The need for more research

Alarmingly, in the ‘Truth Hurts’ report (Mental Health Foundation, 2006), it was found that many young people do not feel that the professionals they deal with, and/or the services on offer, are meeting their needs (or indeed even recognising what they need) (Brophy, 2006, p.76). The support for these individuals needs to be examined. Even more perturbing to note from Armson’s report ‘ Youth Matters - A Cry for Help ’: 43% of young people knew someone who has Self-harmed, but one in four had no idea what to say to a friend who was Self-harming or feeling suicidal. Most worryingly, 41% of young people believed that Self-harm is selfish and 55% think that it is stupid (Armson, 2000, p.6). Therefore, peer support may not always be effective support. Furthermore, ‘Truth Hurts’ outlined that evidence suggests that rates of Self-harm in the UK are higher than anywhere else in Europe (Brophy, 2006, p.5). This is added to the escalating concern that Self-harm is a relatively common and a possibly increasing problem among young people in the UK (Gunnell, Shepherd and Evans, 2000), affecting 7–14% at some point in their life (Hawton and James, 2005, p.891). This is a potentially large number of young people requiring support.

Moreover, of the people in the UK who die by suicide, only about 25% were in contact with mental health services in the 12 months before they died, although it is generally acknowledged that most had a diagnosis of a mental disorder at the time of their death (Bertolote and Fleischmann, 2002, p.22). This highlights the importance for staff who teach young people to be aware of and acknowledge students when they witness the after-effects of Self-harming.  Educators need to help students to speak and develop emotional coping strategies. The ‘Truth Hurts’report stipulates that:

“UK Departments for Education should have lead responsibility for awareness, staff education and training, and mental health promotion strategies in schools and in both higher and further education” (Brophy, 2006, p.9).

Coming initially from a medical background as a Registered Nurse, and more recently working in education, I feel that I have a good understanding of both systems and the ability to engage with both.

Learning theories and approaches

I considered various learning theories in order to make the learning about Self-harm meaningful. I chose three principal learning theories to complement the coping strategies I intended to introduce to my students. These learning theories impacted upon my research approach and became the synergy between the teaching and research as it ensured a pedagogical approach to learning while supporting students with medical difficulties. The approaches used were:

1) Multiple Intelligence Theory- developed in 1983 by Howard Gardner proposes ‘ eight different intelligences to account for a broader range of human potential in children and adults ’ (Gardner, 1983, p.19). Gardner advocates: 

“Each human being is capable of seven relatively independent forms of information processing, with individuals differing from one another in the specific profile of intelligences” (Gardner and Hatch, 1989, p.4).

This highlights that people learn differently and in various ways.

2) Maslow’s Hierarchy of Needs: is normally displayed as a pyramid with the basic needs at the bottom and more complex needs at the top. Maslow believed that everyone has the potential to achieve self-actualisation and indicates that social hindrances deny the achievement of this state for all (Rogers, 2002). Maslow (1954) asserted that if physiological and safety needs are met, self-actualisation can be achieved. Various factors such as: poor motivation, low self-confidence and lack of self-esteem are important barriers to all learning. We can help students develop these goals through ensuring that they realise they are in a safe environment.

3) Rogers’ Theory of Humanistic Learning : focuses on Empathy, Positive Regard and Congruence. The more these three core conditions are shown by teachers to students, the more a student learns. This theory highlights what an important role and challenge we have as teachers and why we really need to know our students and their specific requirements. The teacher is to model appropriate behaviour, not replicate inappropriate behaviour, and teach students how to cope appropriately with difficulties they encounter (Rogers and Freiberg, 1993, p.90). The teacher can become a facilitator for helping students develop their learning and coping methods. This theory places the teacher as the fundamental catalyst in the learning process, and highlights the role of education as significant for the recovery process for students with mental health difficulties, as education allows people to form new friendships and creates motivation and goals.

The Current Study

I attended a seminar held by Edinburgh University where the Clinical Nurse Specialist for Lothian suggested ways to support people who Self-harm and these coping strategies were recommended for use by non-medical practitioners.  I chose the following three behaviour modification strategies to support learners who Self-harm: (1) The Chain Analysis/ABC (ABC: Antecedent, Behaviour, Consequence) where a chain leading to the problem is identified and choices that could have been made leading up to these events are considered. By conducting the Antecedent-Behaviour-Consequence (ABC) observation ‘ correlations can be made as to what the student is trying to achieve from the students’ inappropriate behaviour (Hilsmier et al, 2014, p.6). This has the potential to be an effective measure to empower the learner to change their behaviours. 

The second strategy was to create a ‘Happy Bag’ and Music collection . Students collected items in a bag such as photos of special people and downloaded 10 songs on a recording device to listen to when upset. These items could be accessed to remind the student of better times. Recent research suggests that the ‘ recall of positive memories play an important role in mood regulation ’ (Joormann, Siemer and Gotlib, 2007, p.484). Music and happy memories can therefore affect a person’s mood.

The final strategy: A Safety Plan (a list of activities that will make them feel better, prepared when the student is feeling well) would be of benefit in difficult situations and enable them to take control of their emotions. The safety plan reduces ‘ emotional temperature ’ (Brent et al, 1996, p.1146) and reduces Self-harm.  Ougrin et al. (2012) concur with these strategies and advocate them as ‘ concrete tools that youths could use at times of acute stress ’ (p.340). These three specific coping strategies formed the basis of this practitioner based research.

My Objectives were:

  • To support students who Self-harm.
  • To identify coping strategies for students to deal with difficult situations.
  • To document how effective these coping strategies were.
  • To use objectives 1, 2 and 3 to develop inclusive practice for students who have difficulties coping, by educating other staff members.

I used the following Research Questions:  1. Are coping strategies effective? 2. Which are most effective?  3.How do they help? This helped me to focus on what I set out to achieve. 

The Participants

The decision to investigate these strategies followed a conversation in class when a student mentioned that she had a history of Self-harming. Three other students then stated they Self-harmed and one student showed her arm where she had recently cut in several places. The discovery that four students in a class of nine Self-harmed was highly significant and I felt a professional responsibility to offer some support. All students in the class had been diagnosed with various specific learning difficulties, and all were between 16-19 years old. In qualitative research, the participants are usually recruited to a research project because of their exposure or experience of the research topic. This type of sample tends to ensure a richness and explore meaning in the data gathered, and is known as purposeful sampling (Fossey et al, 2002, p.726). By including students with communication difficulties, who did not physically Self-harm, I endeavoured to highlight how peer support can not only have a ‘ powerful positive value for those offering as well as those receiving the support ’ (Scottish Executive, 2006, p.6), but furthermore how the coping strategies could be used for the benefit of all, and to evaluate whether humanistic learning is occurring within the group.

Research Design

An interpretivist approach was adopted for my research. Interpretivism is a qualitative approach that is discursive and descriptive, acknowledging that there are multiple variables to every given situation. Interpretivist research focuses on achieving and understanding how people create and maintain their social worlds (Neuman, 2000, p.512), an important and appropriate approach to evaluating support for students with mental health difficulties.  My research involved reflecting on what I found in my own practice and was therefore practitioner based. I reported in the first person for this practitioner research, as it would be a falsity to use a grammatical form which implies distanced objectivity to describe a project in which I was deeply personally involved as a teacher and researcher.

My reflections from what I found from my own practice were therefore the starting-point for this research. I then selected data collection methods which would triangulate the data (Hammersley, 2008, p.25), by including questionnaires, classroom observations and the students’ own personal reflections through their learning journal sites and interviews. By using varying data collection devices I was able to gather a much richer, more diverse and detailed scope of information, and students’ multiple intelligences could be respected through offering choice around their method of participation in the research. I was also able to develop themes as they emerged from the different sources.

I used learning journals for this research as other students would not be able to access and read what each individual wrote in these on-line diaries. Most learners are now ‘ digital natives ’, which the educational system has tried to adjust to (Prensky, 2001, p.1). I felt that using a medium students are familiar with would give them an opportunity to reflect in a more personal, honest and open manner without fear of being ridiculed by peers. I used the data collected from the learning journals to assess how these strategies worked for students and to find out how and in what way they used them. According to Jennifer Moon (2006, p.27) ‘ Journals increase the sense of ownership of learning’ and ‘acknowledge the role of emotion in learning ’. I tracked what each student put in their ‘ Happy Bag ’ and collated information over an eight week period of how and when they used the coping strategies and whether they were effective. The questionnaires were an effective method for collating any concerns students had and were a good way to find out past experiences, previous methods of coping emotionally and the level of willingness to embrace these coping strategies.

Structured Interview Questions ( Appendix 1 ) were conducted, after piloting them with staff, and collecting the information from the questionnaires so that I could gather more detailed responses for some of the answers. I used a dictaphone recording and made notes about nonverbal responses. Students were freer to speak without barriers as some of them have severe literacy difficulties. Researchers, consciously or unconsciously, depending on their own experiences, draw conclusions and choose to focus on specific points which may not exactly mirror the reality of the occurrence (Nunkoosing, 2005). The interviewer therefore needs to be aware and responsive to the interviewee’s interest in specific aspects of his or her life. I used the data collected from interviews to enhance my understanding of how these coping strategies were benefiting students.

By deciding to employ structured observations to demonstrate the findings of the study I considered the different approaches. Over an eight week period, I observed the students as they communicated about their strategies in a naturalistic classroom setting, and I took notes on what I witnessed. The practice of observation ‘ privileges the visible and the audible ’ (Gordon et al. 2005, p.128).  When observing I constantly moved around the group to make sure the less boisterous and less noticeable were given full attention. I felt that this information was very valuable as a way of accessing the non-verbal forms of communication which I specifically focused on. I used an observational prompt tool (Fasse, Holbrook and Gray, 1999) of specific questions to assist me in developing qualitative and informative field notes ( Appendix 2 ), to standardise my reflections, undertaken over a 20 minute period each week as the class reflected together on what they thought of the coping strategies.

I selected these methods of research as they resonate with the underpinning approaches to learning, described earlier: Multiple Intelligences, the humanistic approach to learning and Maslow’s hierarchy of needs. Using triangulation (Hammersley, 2008, p.25), meant that I had different forms of evidence. My Triangulation approach (figure1):

Figure 1 Triangulation – Data Collection methods used in this research

Ethical Considerations

I was very much aware of how ethically sensitive this study was, and I went to extensive lengths to ensure the project was as ethical as possible.   All participants were involved in the discussions about setting up the study. I asked all the participants to sign a written consent form and I reassured them that their contribution would be treated confidentially, they could withdraw at any stage and that they would remain anonymous. All decisions regarding the ethical conduct of the research were made with reference to the Scottish Educational Research Association (SERA) Ethical Guidelines for Educational Research (2005) and Social Research Association (SRA) Ethical Guidelines (2003).  The study was given internal ethical clearance prior to the data collection phase.

I gained permission for the research to proceed from the University Ethics Committee and my manager. I attended a study day at Edinburgh University Counselling Service to seek advice about supporting students who Self-harm. I attended a Self-harm workshop run by Penumbra in Aberdeen. I spoke to staff at the charity ‘Momentum’, who supported the research and felt it was ‘ very beneficial ’.  I had an extensive list of external support for students, as I was very aware that there was a potential to cause distress. It was very beneficial to meet with professionals who deal with Self-harm, and this furthered my knowledge and ethical considerations.

The students and I agreed to use the three coping strategies over a period of eight weeks. In Week 1, I explained the three coping strategies and introduced students to the learning journals. I gave out the initial questionnaire and did so again on week eight. I interviewed the students during weeks two and seven. Each week I gave the students time to complete their learning journals on how they were progressing with the coping strategies. Over the eight week period, I observed and made notes of students, each week, during a twenty minute class discussion on the coping strategies. I encouraged the participants to write in a narrative style in their learning journals as I felt they were comfortable using this style, and it encourages detail.

Findings and Discussion

The Chain Analysis Strategy:

Seven out of the nine students reported that they would continue to use the Chain Analysis strategy once the eight weeks were completed. At the end of the study students found it humorous when they re-read how initially they found it so difficult to articulate how they felt about situations. It was clear they had become much better at expressing their feelings after participating in the project even though ‘ young people tend not to be as likely as adults to give long answers to open-ended questions ’ (Harden et al, 2000, p.5). The initial monosyllabic answers, where I had to encourage more detail, began to expand without my interference within both interviews and the journals - students began to open up and reflect on how they dealt with situations.  Student 7 wrote “ I did not know that my feelings were causing me to react so strongly to so many things ”. It was interesting that what appeared to mostly upset all the students were family issues and peer comments and arguments, regardless of whether they Self-harmed or not. This is an illustration of the lower layer of Maslow’s Hierarchy of Needs, confirming that if students are missing emotional support it can affect their self-actualisation. Student 1 confided that he had issues about his sexuality, causing him a lot of emotional outbursts. He found it comforting to be able to speak honestly about his feelings. The learning journal gave him a chance to voice his worries and enabled him, through the Chain Analysis strategy, to see that his behaviour was not helping his situation. He eventually spoke to the group and used one of our observation discussions to express how he felt.  For others, they also found the Chain Analysis useful for the moments that they did not quite manage to deal with a situation: all was not lost. Student 5 stated that she was not as hard on herself now when she “ got angry as [she] knew [she] could learn from it ”.  She felt that she could “ handle arguments better the next time ” indicating her reflection and move towards self-actualisation.

The Happy Bag and Music Collection

All of the students stated they thought that the coping strategies were a good idea. The data shows all the students found the Happy Bag coping strategy was the most popular.  Another student wrote; “ I use my Happy Bag all the time now and it gives me time to think things through without over reacting ”. The “ Happy Bag ” technique was the most popular coping strategy. By using three different strategies I wanted to demonstrate the recognition of unique personalities and multiple intelligences. I wanted the project to have greater meaning and impact using this multi-faceted approach. Campbell, McNamara and Gilroy (2006, p.94), caution researchers that if they are ‘ insiders ’ (i.e. teachers in the class) they often understand the significance of what is happening as they are very much in tune with the context, but as they are so familiar it may be difficult to see anything new in events.  Student 4 put a photograph of his recently deceased grandfather in the Happy Bag and stated that he now felt he was “ looking out for me when things get tough ”. The humanistic approach to learning of empathy, positive regard and congruence was established and without it I would never have gained an insight into the students’ fundamental worries. The students all agreed that they liked to be in control of what they could put in their Happy Bags and which strategies to use.

The Safety Plan:

The Safety Plan was the least popular of the three coping strategies. Five of the nine students felt this was the one they were least likely to use, but four liked to use it. This may have been because it was more of a time commitment to begin with. I was surprised when I found Student 7 was worried about her father, who was in prison, and she was angry with him. She used her Safety Plan to talk about what worried her and how she liked to forget about her cares and this, she feels, caused her to Self-harm.

Bibby details that: ‘ Teachers withdraw from difficulties presented by doing emotional work with so many people every day ’ (Bibby, 2009, p.53). Some teachers, as Bibby suggests, do not give students opportunities to discuss their barriers to learning. The class had opened up a learning space and created a situation whereby emotional issues came to the forefront and were addressed.

Collation of Data from Learning Journals:

These seven issues emerged from the nine participants on-line journals: 

Figure 2 Collation of Data from Learning Journals

Relationships with family and peers appeared to be problematic for all of the students interviewed and were reflected in all their journal entries. Students found the learning journal very useful as the weeks progressed, to recapture what they had previously felt and thought about the Happy Bags and Music, the Safety Plan and the ABC Chain Analysis. Student 1 wrote: “ I cannot believe how my confidence has improved over the last 8 weeks. I wish we could go on all year ”. Every student wanted to continue to use the strategies after the 8 weeks were completed.

The interviews used an open process, whereby I looked for general themes from the students’ answers. A lot of themes were already identified in their journals.  Initial open coding found ten themes (Newby, 2010, p.469). However, two themes: (1) The difference between male and female reactions and (2) using stress balls instead of hurting themselves as a coping strategy, would require further evidence, so they were not pursued. I looked for comparisons within the data and in my literature review, current legislation and policies.

Eight themes emerged:

Coding of Data from the Interview Transcriptions:

Figure 3 Coding of Data from the Interview Transcriptions

Table 1 Table of preference for Coping Strategies

The Happy Bag Strategy emerged as the most popular coping strategy.

The ten questions in the Questionnaire (see Appendix 1 ) were given at week 1 and repeated on week 8. As the course progressed, the responses became more detailed. These answers advocated more student involvement and the promotion of humanistic type learning. Campbell, McNamara and Gilroy (2006) highlight that as well as gathering information, questionnaires can also be instrumental in educating – ‘ opening respondents’ eyes to particular ways of looking’ (p.146). All the students at some stage felt that their minds had been opened and their opinions had changed. The question that seemed most difficult to answer was “W hat makes you happy?” Three students could not identify anything that made them happy or a happy event in their life. All of the other responses included relationships or money, which again was concerning if this was not at the student’s disposal. For Question 2: “ What makes you sad?” again all of the students felt that relationship difficulties with family and friends were significant, and two out of nine highlighted inappropriate behaviour of others. As can be seen from the examples given, all students’ personal difficulties were very individualised and different. Questions 4 - ( When you are angry, how do you react?) and 5 ( Have you ever hurt yourself? If yes, how and why?) - required detail about what students did when they were angry, and four of the nine had Self-harmed in the past. It was rewarding to see that after the 8 week project these answers changed dramatically.

Question 9 asked about difficult situations and the following responses are summarised: relationship difficulties, drinking, pregnancies, family issues, money difficulties and not belonging. It was also interesting that Question 10, the second time it was asked, in week 8: “ What activities make you happy?” had five responses: using my Happy Bag and listening to my “ Happy Music ”; new ones were also added such as walking my dog, speaking to friends and eating chocolate.

I felt that these responses advanced the need to highlight Emotional Intelligences and Health and Wellbeing within our department. 

I composed field notes every week of my Observations ( Appendix 3 ). I found that a class who would normally tease and mock each other became defensive of each other if they spoke about personal issues. I saw this as a sign of their growing maturity and ability to express themselves openly, and to accept difference and humanistic learning. This highlights how educators can help facilitate self-actualisation. I did not realise the extent that some members supported others, until I observed more closely.  As the weeks progressed there was a lot less mocking and teasing as they developed a greater empathy and positive regard for each other. The students learned their behaviour had consequences, so they modified their reactions and how they responded to each other.

This information helped me to meet the three objectives for my research: To support students who Self-harm, to identify coping strategies for students to deal with difficult situations, and to document the effectiveness of the chosen coping strategies. Objective 4, the development of inclusive practice for students who have difficulties coping, was achieved by successfully creating awareness-raising and support courses for staff. The information also answered the Research Questions:  (1) All students felt that coping strategies were effective. (2) The Happy Bag and Music coping strategy was experienced as the most effective. The Chain Analysis and the Safety Plan were not perceived as as effective as the Happy Bag. Arguably, they are more cognitive than practical and may be more effective for students who do not have learning difficulties. Further research would be required to examine this. (3) The strategies helped by allowing learners to express themselves, learn from their behaviour and modify their behaviour, and empower themselves to change how they responded to difficult situations. Only two of the four Self-harming students reported Self-harm, but to a lesser degree. The others reported that were continuing to use the strategies. Those who did not Self-harm reported using these techniques more to help them to cope with their emotional outbursts.

The four main recommendations from this research:

  • Self-harm has to be spoken about and addressed so that students become aware that as the behaviour is learned, it can be unlearned.
  • Staff should be supported to use specific coping strategies to support students who Self-harm and be given the confidence to speak to students who disclose that they Self-harm.
  • Educational facilitators need to be doing more to provide a safe environment to fully comply with the Curriculum for Excellence’s four Capacities to enable all young people to become: Confident Individuals, Successful Students, Responsible Citizens and Effective Contributors.
  • Further research is required into the Chain Analysis and the Safety Plan to establish if students with more cognitive ability utilised them as much as the Happy Bag strategy.

Reflections and Conclusions:

Coping strategies are an effective method to help learners deal with difficult situations. If research, planning, involvement and collaboration of both students and staff are undertaken, it reduces the fear and risk of failure inherent in Self-harm. This study sits at the interface between health and education, as I required the information and expertise of health professionals to understand the issues with Self-harm and how to address the problem. Furthermore, my skills as a teacher and my pedagogical understanding of learning theories enabled me to work with young people in the classroom setting to help them learn to understand their behaviour. Although this practitioner research set out to support learners who Self-harm, it actually had a knock-on effect by involving the rest of the staff group in supporting learners with communication difficulties. Coping strategies have some limitations (some students will require a lot more support) but they can be beneficial in helping students to reflect on their emotions and behaviours and enable them to develop their own individual coping. Teaching professionals have the potential to teach students how to cope with challenges, and to enable them to respond and know they have choice and control over how they react to situations in life.

Questionnaire:

  • What makes you happy?
  • What makes you sad?
  • What do you do when you feel you cannot cope with difficult situations?
  • When you are angry, how do you react?
  • Have you ever hurt yourself?  If yes, how and why?
  • When you are happy, how do you react?
  • Would you like to learn more about how to deal with situations that are difficult?
  • Is there someone you can talk to when things get difficult?
  • What would you consider a difficult situation?
  • What activities make you happy?

Observational Prompt Tool:

For classroom observations to assist with filed notes each week:

  • What strategies do they like best?
  • Who initiates the conversation?
  • What is the non-verbal evidence?
  • Who asks the question/ who gives feedback?
  • Is peer support provided / Is it constructive?

My Observation Notes: Edited Synopsis of Field notes.

 I introduced the initial questionnaire. I was amazed at how difficult all of them found the question about what makes them happy so difficult to answer. Students found expressing what made them sad a lot easier to write. 2 learners said to each other, out of earshot, that they cannot remember a time when they were ever very happy.

I was surprised as how willing they were to show not only me but the class the contents of their bags. If students were not sure three of them hunched their shoulders. It was great to hear that all of them had used their bags already, however, all of them had difficulties coping with situations within the space of one week.

Learner 7 had used her bag a lot and felt that it had helped her relationship with her boyfriend as she was not fighting as much as she calmed down by looking at her bag or listening to music instead. Four of the 8 learners reflected that they had been stressed and 2 had shouted at family and the other two at friends. They said that they would use the Happy Bags, listen to music or look at their lists on the safety plan if as Learner 4 put it “Me head didnae feel right and I was about to get cross”.

Learner 1 appeared to be in bad form and snapped at others a bit during the class. I asked him if he was alright and he said “yeah”.

Learner 1 remained more subdued and again snapped at a few of the group which is very much out of character for him. I asked to speak to him outside the door as he looked very upset. He disclosed on his Learning Journal that his father had walked out on his mother and he had not seen him since and was afraid he never would see him again. He also disclosed that he was uncertain about his sexuality and had used his “Happy Bag”.

Learner 8 said that her Mum asked her “what has come over you, we are not arguing and shouting at each other as much recently?” She told her Mum that she was using her “Happy Bag” and Music if she was angry. Her Mum replied “I wish you discovered this ages ago!” Learner 7 wrote in her Journal that she had phoned her Dad and was meeting him that evening in prison. She told her Dad about the project and that she used his bag when she was sad and missing him and it made him “feel better”.

Learner 3 said that she had not Self-harmed for the last 7 weeks and really found listening to music helped. Learners 5, 7 and 8 who also Self-harm all stated that they did not Self-harm as much as they had. Learner 5 said “I feel more in control now” and Learner 7 responded “Things are not getting to me as much”. He also said “people were not calling me names anymore and I can be myself”. The rest of the group who do not Self-harm said that they think more now when they get cross or angry. I noticed even in the class that they had become more supportive of each other and more considerate of each other’s’ feelings.

Two students said that they felt they got on better as a group. I noticed that they were not arguing as much and were much more willing to listen to each other. Learner 4 wrote: “I cannot change others but now I can change myself”. All learners could now write what they could do when they were sad as opposed to “don’t know” or “not sure” or one response previously had been “drink” from Learner 4. Learner 5 who had shown me her arm at the beginning and made me consider Self-harm as a topic came and showed me her arms. She had no fresh cuts and her previous cuts were almost healed.

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Self-harm, Coping Strategies, Inclusive Education, Mental Health and Education

Published in Volume 21 Vulnerable Learners , 01 October 2014

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Stress and Coping Strategies among Nursing Students in Clinical Practice during COVID-19

Hanadi y hamadi.

1 Brooks College of Health, University of North Florida, Jacksonville, FL 32224, USA

Nazik M. A. Zakari

2 College of Applied Sciences, Al Maarefa University, Riyadh 11597, Saudi Arabia; as.ude.tscm@irakazn (N.M.A.Z.); as.dem.cmfk@imanlanf (F.N.A.N.); as.ude.tscm@adimsj (J.A.S.S.)

Ebtesam Jibreel

Faisal n. al nami, jamel a. s. smida, hedi h. ben haddad.

3 Department of Finance and Investment, College of Economics and Administrative Sciences, Imam Mohammad Ibn Saud Islamic University, Riyadh 13318, Saudi Arabia; as.ude.umami@daddahlahh

Associated Data

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

Stress is common among nursing students and it has been exacerbated during the COVID-19 pandemic. This study examined nursing students’ stress levels and their coping strategies in clinical practice before and during the COVID-19 pandemic. A repeated-measures study design was used to examine the relationship between nursing students’ stress levels and coping strategies before and during the pandemic. Confirmatory factor analyses were conducted to validate the survey and a student T-test was used to compare the level of stress and coping strategies among 131 nursing students. The STROBE checklist was used. During COVID-19, there was a reliable and accurate relationship between stress and coping strategies. Furthermore, both stress and coping strategy scores were lower before COVID-19 and higher during COVID-19. Nursing students are struggling to achieve a healthy stress-coping strategy during the pandemic. There is a need for the introduction of stress management programs to help foster healthy coping skills. Students are important resources for our health system and society and will continue to be vital long term. It is now up to both nursing educators and health administrators to identify and implement the needed improvements in training and safety measures because they are essential for the health of the patient as well as future pandemics.

1. Introduction

Nursing is a practice-based profession, in the sense that the performance of nursing students depends largely on their clinical practicum; therefore, the quality of clinical training practice is crucial to the nursing education and profession. Furthermore, nursing students’ opinions regarding the quality of clinical training practices need to be strongly taken into consideration because of the demanding nature of the occupation. Nursing students are exposed to many sources of stress during clinical training and must handle stressful situations accordingly. Stressful situations can vary, including working with and handling breakout infections, where students assume an integral role in infection control measures and come into direct contact with infectious microorganisms. Becoming aware of and understanding students’ clinical practice stressors and coping strategies during clinical training in different situations provides educators with valuable information to maximize their students’ learning opportunities [ 1 ].

During a(n) pandemic/endemic, nursing students find themselves under additional stress factors such as the fear of being infected and infecting their close family members [ 2 ]. Two studies during the SARS (2003) and MERS outbreaks (2016) found that nursing students perceived themselves to be at a higher risk of infection and were reluctant to work in healthcare facilities due to inadequate safety and disease control measures [ 3 , 4 ]. Increased stress levels during the 2003 MERS outbreak in South Korea were negatively linked with nursing students’ intention to provide care to patients during future emerging infectious diseases [ 5 ].

Nursing students and staff are situated on the frontlines to combat infectious diseases and provide care and support to patients. They play a crucial role in providing effective infection control measures and ensuring the de-escalation of the spread of infectious microorganisms. Therefore, along with other medical staff and healthcare workers, nursing students and staff rushed to aid patients suffering from the most recent, fast-emerging, and rapidly spreading virus COVID-19 [ 6 ].

The COVID-19 pandemic spread to hospitals and nurses, putting them under enormous pressure in terms of workload and healthcare duties [ 7 ]. As a result, the lives and health of nurses and nursing students on the frontline, who are actively fighting the virus and are under great risk of contracting the disease, face dangerous repercussions [ 8 ]. COVID-19 studies and findings provide further evidence in regard to the anxiety experienced by nursing students and their response to treating this global pandemic [ 9 ].

Due to its extremely infectious and hazardous features, and the drastic lack of medication and treatment for the virus, COVID-19 has resulted in increased stress levels for nursing students and staff, which has consequently affected their coping strategies [ 8 ]. Therefore, understanding the relationship between stress levels and coping strategies of nursing students is critical. In non-pandemic times, the findings in Khater, Akhu-Zaheya [ 10 ], and Hamaideh [ 11 ] suggested that the most common coping behavior utilized by nursing students was problem-solving, followed by staying optimistic and transference.

It is essential to evaluate the quality of the clinical practices and identify stressors that arise from different clinical settings according to nursing students’ perspectives. Therefore, this study aimed to examine nursing students’ stress levels and their coping strategies in clinical practice before and during the COVID-19 pandemic.

Theoretical Framework

Stress has different definitions related to formulated theoretical models. It can be defined either as a stimulus, a response, or a combination of the two [ 12 , 13 ]. The definition of stress as a response was discovered by Selye (1976), who defines stress as the non-specific response of the body to any kind of demand [ 14 , 15 ]. On the other hand, Holmes and Rahes define stress as a stimulus without consideration to any response [ 16 ], stating that stress is: “an independent variable stimulus or load produced in an organism, creating discomfort, in such a way that whether tolerance limits are surpassed, stress becomes insufferable, appearing then psychological and physical problems”.

The definition that is most relevant to and can be appropriately adopted in this study to explain the reality of nursing student’s stress during clinical practice is Lazarus and Folkman’s theoretical framework. Based on Lazarus’ theory regarding the difficulty in differentiating between response and stimulus as the definition of stress, he conceptualizes an apparent stress definition that can reconcile differences between the separate theories of stress as a response or stress as a stimulus. He defines stress as “A particular relationship between the person and the environment that is appraised by the person as taxing and/or exceeding his or her resources and endangering his or her well-being” [ 17 ]. This is because it describes stress as a transactional relationship between the person and their surrounding environment [ 17 ]. Stress is not a singular facet, but rather arises due to influencing factors that affect the individual and, in turn, impact their response in such situations. For example, one of these stressful situations can occur during students’ clinical practice once the students face a new environment and establish new relationships with staff nurses, patients, and an instructor and/or supervisor [ 18 ]. A study found that the most stressful clinical settings identified by the study were the intensive care unit followed by the emergency room, then the surgical units, while the area that was considered the least stressful was the medical units [ 19 ]. Therefore, this study uses this working definition of stress to examine nursing students’ stress levels and their coping strategies in clinical practice before and during the COVID-19 pandemic.

2. Materials and Methods

2.1. setting.

The study was conducted in the nursing department at a private University to evaluate and compare the students’ perspectives of clinical practice stressors and the coping strategies used to respond to these stressors before the COVID-19 pandemic and during the first wave of the COVID-19 pandemic. The findings from this study will be utilized to improve the learning and the educational process in their current situation, reflecting on the level of the students who will graduate from nursing school in the future.

2.2. Design and Sample

A repeated-measures study design was used. The sample nursing students were all undergraduate academic nursing students studying at a private University who are participating in clinical training. Students not in clinical training were excluded from the study.

2.3. Data Collection Tool

This survey was developed using two previously validated surveys, the Perceived Stress Scale (PSS) and the Coping Behavior Inventory (CBI) survey. The PSS was developed by Sheu and Lin [ 20 ] and measures both the types of stressful events and the degree of stressors within clinical practices. This survey also included three demographic questions: The gender of the participant, their clinical training area, and their academic year of study. The PSS consists of 29 items (See Table 1 ) on a 5-point Likert scale (from 0 to 4) that are grouped into 6 stress/stressor categories. Those groups are stress from taking care of patients; teachers, and nursing personnel; assignments and workload; peers and daily life; the clinical environment; and lack of professional knowledge and skills.

The Perceived Stress Scale (PSS) and Coping Behavior Inventory (CBI) questions.

A score of 2.67 and higher was indicative of a high level of stress, a score between 1.34 and 2.66 was indicative of a moderate level of stress, and a score of less than 1.34 indicated a low level of stress [ 21 ]. The instrument’s reliability showed Cronbach’s alpha values of 0.86 and 0.89 [ 20 , 22 ] and a content validity index of 0.94 [ 22 ].

The CBI survey was first developed by Sheu and Lin [ 20 ] and measures the coping methods nursing students are more likely to utilize and their perceived effectiveness. The CBI survey consists of 19 items (See Table 1 ) all on a 5-point Likert Scale (from 0 to 4) that are grouped into 4 categories: Avoidance, Transference, Problem-solving, and Stay optimistic. A score of 2.67 and higher was indicative of a high level of coping strategies, a score between 1.34 and 2.66 was indicative of a moderate level of coping strategies, and a score of less than 1.34 indicated a low level of coping strategies. The instrument’s reliability showed a Cronbach’s alpha coefficient ranging from 0.76 to 0.80 [ 20 , 22 ].

2.4. Data Collection Procedure

Prior to data collection, the study protocol was approved by the Institutional Review Board (IRB) of the university. A researcher approached all eligible nursing students at the end of in-person lectures and explained to them the purpose of the study. They were informed that participation in this study is voluntary, and they could withdraw from it at any time. A refusal to participate would not affect their learning process and academic results. Students who were interested in the study were asked to sign a paper or digital consent form, fill in the questionnaire, and immediately return it to the researcher. Other eligible students who did not have in-person lectures were sent the survey via a Google Form to invite them to participate and complete the survey. The survey was sent out to a total of 180 students. Nursing students completed the survey on paper and online between 1 January 2019, and 2 February 2019, for the period before COVID-19 and 30 September 2020, and 30 October 2020, for the period during COVID-19.

2.5. Participants

Overall, 75 students were enrolled in clinical practice before and during COVID-19. One hundred and thirty-one nursing student responses were provided, resulting in about an 82% response rate before and during COVID-19. Out of the responses, 99 (75.6%) identified as female and 32 (24.4%) identified as male (See Table 2 ). The majority (60.3%) of the nursing students were in the Medical-Surgical clinical training area. In addition, 36 (27.5%) nursing students were in Level 5 (first year of clinical practice) of their academic year, and 32 (24.4%) were in Level 10 (last year of clinical practice also known as internship year) of their academic year. Nursing students in Level 5 participate in up to 2 clinical practice courses while Level 9 and 10 nursing students are in full clinical practice internships. The higher the level, the higher the clinical practice competency needed and the higher the necessary complexity. Only surveys that were fully completed were calculated in our response rate, therefore we had no missing data within the response for our analysis.

Nursing student demographic characteristics, n = 131.

2.6. Ethical Considerations

Before using the PSS and CBI tools, the researcher obtained permission from the original authors. The data collection tool contained a cover page that explained the aim of the study. All principles of ethics were adhered during the study. Therefore, anonymity and confidentiality of each individual’s data were also assured during the data collection stage. Participation in the survey was entirely optional and was at the discretion of each receiving the survey.

2.7. Statistical Analysis

The nursing student sample in this study was used to test the reliability and validity of the combined survey using confirmatory factor analysis. To analyze the results of the survey, means and standard deviations were utilized to examine the level of stress and coping strategies subscales and total scores. The Student T-test was used to compare the subscales and mean scores for the level of stress and coping strategies before and during the COVID-19 pandemic. We also used the Kolmogorov–Smirnov test to check the cumulative distributions of our two samples. All analyses were conducted in Stata 16, and significance was determined at p < 0.05.

The results from the comprehensive confirmatory factor analysis based on the varimax rotation factors of the entire sample results, the sample results before COVID-19, and the sample results after COVID-19 can be viewed in Table 2 . Although not shown, the covariance between stress and coping strategies was positive and significant for all the sample (covariance = 0.4; p < 0.001), both the sample results before (covariance = 0.28; p < 0.001) and after (covariance = 0.58; p < 0.001) COVID-19. When examining the entire sample responses factor loading show in Table 3 , all factor loadings were above 0.40 [ 23 ].

Unstandardized estimated for all-sample, before and after COVID-19.

Notes: LR test is the Wheaton et al. (1977) relative/normed chi-square (χ 2 /df), mc is the correlation between the dependent variable and its prediction, and mc 2 = mc^2 is the Bentler-Raykov squared multiple correlation coefficient.

The overall average score of stress before COVID-19 was 1.32 (low stress) and 1.95 (moderate stress) during COVID-19 (See Table 4 ). Across all six stress categories, the average stress score was lower before COVID-19 than during COVID-19. The largest change was found in the stress category “lack of professional knowledge and skills” where the average stress score before COVID-19 was 0.95 (low stress) and 1.78 (moderate stress) during COVID-19 with a 0.83 change. The smallest change was found in the stress category “the environment” from an average stress level of 1.16 (low stress) before COVID-19 and 1.70 (moderate stress) during COVID-19. The overall average score of coping strategies before COVID-19 was 1.84 (moderate coping) and 2.17 (moderate coping) during COVID-19. Across all four coping strategies categories, the average coping strategies score is lower before COVID-19 than during COVID-19. The largest change was found in the coping strategy category “Transference” where the average coping strategy score before COVID-19 was 1.87 (moderate) and 12.41 (moderate) during COVID-19 with a 0.54 change. The smallest change was found in the coping strategy category “stay optimistic” from an average coping strategy level of 2.06 (low) before COVID-19 and 2.15 (moderate) during COVID-19.

Means and std. deviation and T-test for subscales items of stress experienced by nursing students and coping strategies in their clinical practice before and during the COVID-19 pandemic.

* p -value for Chi-squared test < 0.05.

The results from the T-tests (See Table 4 ) show that there are statistically significant differences in both average stress scores and average coping strategies before and during COVID-19 across the majority of the categories. This statistical difference shows that both stress and coping strategy scores were lower before COVID-19 and higher during COVID-19. However, there was no statistically significant difference in the coping strategy category “Problem-solving” and “Stay optimistic” with a before-COVID-19 average coping strategy score of 2.09 and 2.06, and during scores of 2.32 and 2.15, respectively.

4. Discussion

Through the development of this survey, we have built upon previous research indicating the importance of understanding nursing students’ well-being through examining their stress levels and coping strategies. We have developed and tested a measurement scale that is reliable and accurately measures all identified in the Perceived Stress Scale (PSS) and the Coping Behavior Inventory (CBI) survey individually. However, our findings show that when the study is conducted on nurses in Saudi Arabia, there is not a strong reliable relationship between perceived stress and coping strategies (loading factor 0.4 and less) for the entire sample and the before COVID-19 sample. However, interestingly during COVID-19, there was a reliable and accurate relationship between stress and the use of coping strategies. A recent 2020 article regarding students’ coping strategies during the COVID-19 pandemic found that approximately 35% of students experienced some level of anxiety and used four types of coping strategies: Seeking social support, avoidance/acceptance, mental disengagement, and humanitarian [ 24 ].

The current study aimed to analyze the impact of the COVID-19 pandemic on nursing students’ stress levels and coping strategies. Through the combination of these two surveys, were have built upon previous research indicating the importance of stress and coping strategies among nursing students during unprecedented times. We have utilized a measurement scale that reliably and accurately measures stress and coping strategies before and during the COVID-19 pandemic. These findings can help inform nursing curricula developers on how to incorporate the needed skills and resources to prepare nurses for future infectious outbreaks. This is important as the Saudi Vision 2030 framework, released in 2017, has set a path to increase nurse graduates over the next 10 years and enhance the health delivery system to be community-focused. To meet this goal, Saudi Arabia has committed to increasing the nursing workforce by graduating and hiring 10,000 new nurses annually [ 25 ].

While multiple studies have reported on the psychological well-being of healthcare workers during COVID-19 [ 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 ], our study is one of the first to examine the influence of the pandemic by controlling for before the pandemic in nursing students in Saudi Arabia. Data collection occurred during the first wave of the pandemic in the country. The results of this study reflect an increased level of stress and coping strategies among nursing students during the continuing COVID-19 pandemic than before the pandemic. We found that, overall, across all subscales of stress there was a significant increase in stress relating to taking care of patients, teachers and nursing staff, assignments and workload, peers and daily life, lack of professional knowledge and skills, and the environment. These stressors can be attributed to multiple factors such as the unpreparedness to care for COVID-19 patients, increases in safety protocols in the clinical setting and decreases in safety personal protective equipment, relying heavily on simulation for training, and added assignments in an online learning environment to keep up with skill development. The stressful learning environment hinders student success. The completion of clinical practice and a precursor to licensure adds even more added pressure on students to complete an excessive workload to meet the non-direct care hours required [ 34 ].

According to previous research, even in normal circumstances, nursing students experience stress and must utilize several coping strategies to reduce both stress and anxiety. A study conducted in Bahrain found that almost all nursing students experience moderate to severe levels of stress while in their clinical practice [ 35 ]. Furthermore, another study found that over 99% of nursing students reported the level of perceived stress moderate or high. Several studies have revealed that the cause of clinical stress can be attributed to fear and uncertainty of unknown events, fear of medical errors, working with unfamiliar equipment, and gaps between theory and practice [ 36 ]. The additional increase in the level of stress among nursing students due to COVID-19 can have both internal and external consequences [ 37 ]. It can cause students to perform poorly and may lead to a withdraw from the program as self-doubt sets in, changes in mental and physical health, and can eventually affect the quality of care provided to patients. Several studies have shown that due to the demand and utilization of personal protective equipment across the globe, many direct care workers such as nurses and nursing students lacked the proper protective equipment, which increased their vulnerability to contracting COVID-19 [ 38 , 39 ]. As a result, many nurses have lost their lives to COVID-19, while others continue to fight against the deadly virus. Consequently, nurses perceive an increased risk of catching COVID-19 [ 40 ], which has increased turnover intentions [ 41 ]. However, a study conducted in China during the COVID-19 pandemic found that only 3% of their sample believed clinical nursing work to be “too dangerous to engage in” and have an increased intention of leaving the nursing profession [ 42 ].

The COVID-19 pandemic is currently the biggest threat to the lives and health of nurses and nursing students and has been shown to impact their emotional response and coping strategies. Our study shows that nursing students’ use of Avoidance and Transference as coping strategies and overall coping strategies increased during the COVID-19 pandemic in comparison to before the pandemic. However, our study did not identify a statistical difference between nursing students’ use of problem-solving or staying optimistic as coping strategies. This is in contradiction to a recent study that found that nursing students were more willing to use coping strategies that focused on problem-solving [ 8 ]. Our study findings can be explained by examining Gan and Liu's [ 43 ] study, which found that undergraduate students who regarded stressful events as controllable were more likely to apply problem-focused coping strategies; however, since COVID-related events were uncontrollable during the study period, students might have relied on emotion-focused coping strategies such as Avoidance and Transference, which contradict some priory studies [ 44 , 45 ]. A study conducted before the pandemic found that the most common coping behavior used by nursing students was transference, followed by staying optimistic and problem-solving, while the least used was Avoidance [ 46 ]. These findings are important for both nursing schools and hospitals, where they must focus on providing psychological support to nurses as well as training them in all available coping strategies to improve their ability to manage their emotions and effective coping tools to improve the lives of the nursing student, their families, and ultimately their patients.

Limitations

The study focused on nursing students in Saudi Arabia from a single private university. Due to the correlational nature of our study, no causal conclusions can be made; however, our findings may lead to a greater understanding of stress and coping strategies of nursing students involved in the COVID-19 pandemic. Hence, the findings should not be generalized to the overall student population.

5. Conclusions

The psychological impact of the pandemic on nursing students should not be ignored. The well-being of these students is affected by high levels of stress and emotional-based coping strategies. To alleviate the degree of impact, guidelines and strategies should be adopted into current nursing curricula even before the student is in clinical practice. Prioritizing research and policy effort on mental health, stress, and coping strategies of students needs to occur to equip future nursing students with the tools needed to be successful in the field of nursing. However, future research needs to replicate this study on a greater scale across multiple universities across multiple countries. Moreover, using in-depth data collection strategies, such as qualitative interviews or focus groups, in future research would significantly help explain the rationales behind why students adopted one coping strategies over another.

Relevance to Clinical Practice

Our study highlights that there was a strong, reliable, and accurate relationship between stress and the use of coping strategies during the COVID-19 pandemic compared to before. We anticipate that this relationship will only continue. Students are important resources for our health system and society and will continue to be vital long term. It is now up to both nursing educators and health administrators to identify and implement the needed improvements in training and safety measures because they are essential for the health of the patient, but also future pandemics.

Acknowledgments

The authors would like to thank Almaarefa University for its financial support of this research. The authors would also like to thank the University of North Florida, and all the participants in who took part of the study.

Author Contributions

Study design: H.Y.H., E.J., N.M.A.Z., and J.A.S.S.; data collection and analysis: F.N.A.N. and H.H.B.H.; manuscript writing: H.Y.H., E.J., N.M.A.Z., F.N.A.N., H.H.B.H., and J.A.S.S.; agrees to be accountable for all aspects of work: H.Y.H., E.J., N.M.A.Z., F.N.A.N., H.H.B.H., and J.A.S.S. All authors have read and agreed to the published version of the manuscript.

This research received no external funding.

Institutional Review Board Statement

The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Institutional Review Board (or Ethics Committee) of AlMaarefa University (protocol code 07-20062021 and 21 June 2019).

Informed Consent Statement

Informed consent was obtained from all subjects involved in the study.

Data Availability Statement

Conflicts of interest.

The authors declare no conflict of interest.

Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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    A study by the University of Aberdeen, Scotland, showed that students who self-harmed found coping strategies to be an effective way of dealing with their emotions and behaviors [71]. Among ...

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  5. Health anxiety, perceived stress, and coping styles in the shadow of

    Background In the case of people who carry an increased number of anxiety traits and maladaptive coping strategies, psychosocial stressors may further increase the level of perceived stress they experience. In our research study, we aimed to examine the levels of perceived stress and health anxiety as well as coping styles among university students amid the COVID-19 pandemic. Methods A cross ...

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    Introduction: Coping strategies and adaptation skills are key features in successfully adjusting to university challenges. Coping skills are an essential part of the Psychological immune system, which leads to successful adaptation. Due to COVID-19 most universities have changed their face-to-face teaching for online education.

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  8. Mental Health and Coping Strategies in Undergraduate Students During

    Abstract. Since the outbreak of the COVID-19 pandemic by the World Health Organization in early 2020, different research has been designed to understand how mental health can be impacted by the pandemic. This study has focused on possible coping strategies developed by the university population in response to social distancing.

  9. Frontiers

    Existing research suggests that numerous aspects of the modern academic career are stressful and trigger emotional responses, with evidence further showing job-related stress and emotions to impact well-being and productivity of post-secondary faculty (i.e., university or college research and teaching staff). The current paper provides a comprehensive and descriptive review of the empirical ...

  10. University students' strategies of coping with stress during the

    The COVID-19 pandemic has changed the functioning of universities worldwide. In Poland, the transfer to online teaching was announced without prior warning, which radically changed students' daily functioning. This situation clearly showed the students' helplessness and difficulties with coping with this new, stressful situation, highlighted in many previous studies. A sudden and far ...

  11. A Study on Stress Level and Coping Strategies among Undergraduate Students

    The purpose of the study was to study the relationship between stress and coping strategies among university students. Eighty- six university students participated in the study. A quantitative ...

  12. Coping the Academic Stress: The Way the Students Dealing with Stress

    This qualitative research uses a case study approach to comprehend in detail the students' coping mechanism towards academic stress. There are 8 participants in total, recruited through purposive ...

  13. Perceived academic stress, causes, and coping strategies

    Discussion. The current research focused on undergraduate university students' psychological well-being during the global COVID-19 pandemic, and accessed the prevalence and various variables contributing to academic stress, as well as exploring coping strategies used by students.

  14. Emotional intelligence and its relationship with stress coping style

    Individuals with weak emotional intelligence face several difficulties in managing stress-related issues. This fact is endorsed from different studies which suggest a strong association between stress and emotional intelligence (Sharma and Kumar, 2016).An uncontrolled stress is often associated with physical and mental disorders that ultimately lead to psychological issues including conflicts ...

  15. Assessment of academic stress and its coping mechanisms ...

    Academic stress is the most common mental state that medical students experience during their training period. To assess academic stress, to find out its determinants, to assess other sources of stress and to explore the various coping styles against academic stress adopted by students. Methods: It was a cross sectional study done among medical students from first to fourth year. Standard self ...

  16. How medical students cope with stress: a cross-sectional look at

    Stress and coping in medical school. Medical students deal with many types of stressors in medical school: intense academic demands and workloads, challenging curricular aspects and learning environments, personal life events, and psychological pressures that are difficult to cope with [19,20,21,22].In fact, in a recent study concerning medical student resilience and the roles of coping styles ...

  17. Stress and Coping Patterns of University Students

    Abstract and Figures. Stress is a common experience for university students. Elevated stress with limited healthy coping capabilities may result in students turning to external resources such as ...

  18. Coping strategies of healthcare professional students for stress

    Results . Twenty-two studies were included in this review, using a wide range of survey instruments including the Brief Coping Orientation to Problems Experienced (Brief COPE) Inventory and the Coping Behaviour Inventory Common coping strategies utilised by healthcare students include problem-focused strategies such as planning, problem-solving and active coping.

  19. Emotional intelligence and its relationship with stress coping style

    Abstract. This study investigated the relationship between emotional intelligence and stress coping style in a group of 265 students, using Goleman's Theory of Emotional Intelligence. Findings indicated highest mean value of emotional intelligence for motivation and empathy. Majority students showed active problem and emotional coping ...

  20. Coping Strategies of students of High School and College for Anxiety

    This study examines three different coping strategies-problem solving, seeking social behaviour and avoidance adopted by high school and college students, during the pandemic. The study tries to understand the types of coping strategies adopted by students to deal with the stressful situation and how they use 'coping with hope' as a coping ...

  21. Coping Strategies for Students

    To support students who Self-harm. To identify coping strategies for students to deal with difficult situations. To document how effective these coping strategies were. To use objectives 1, 2 and 3 to develop inclusive practice for students who have difficulties coping, by educating other staff members.

  22. Stress and Coping Strategies among Nursing Students in Clinical

    Nursing students completed the survey on paper and online between 1 January 2019, and 2 February 2019, for the period before COVID-19 and 30 September 2020, and 30 October 2020, for the period during COVID-19. ... Prioritizing research and policy effort on mental health, stress, and coping strategies of students needs to occur to equip future ...

  23. A study to explore the coping strategies for the anxiety & perceived

    A study to explore the coping strategies for the anxiety & perceived stress among the nursing students during clinical training at Jaipur, Rajasthan. @article{2024AST, title={A study to explore the coping strategies for the anxiety \& perceived stress among the nursing students during clinical training at Jaipur, Rajasthan.}, author={}, journal ...

  24. Students' Struggles Ang Their Coping Mechanisms in The New Normal

    The study by Calo et al. (2021) revealed that one of the coping mechanisms of students in distance learning is taking breaks wherein they are doing enjoyable activities to energize their minds and ...