Stress and Burnout in Postgraduate Physiotherapy Students: A Mixed Methods Observational Cohort Study

Background and Purpose: The impact of stress and burnout in students is an emerging topic. When students perceive that they are unable to cope with stressors, there is increased potential for burnout. To maximise students’ higher educational institution (HEI) outcomes, students must be able to effectively cope with stressful demands. Research suggests physiotherapy students, in particular, suffer from a high risk of stress and burnout, however limited research exists on postgraduate, pre-registration, physiotherapy students. The purpose of this study was to determine perceived stress, burnout and associated coping strategies across three time points in the �rst year of a post-graduate, pre-registration physiotherapy program. Subjects: All �rst year Doctor of Physiotherapy (DPHTY) students at Bond University 2019 were invited to participate. Methods: A mixed methods observational cohort design was implemented in one Australian HEI to determine stress, burnout and coping strategies across 3 time points. The 51-item self-administered questionnaire consisted of demographics, the Coping Self E�cacy (CSE) Scale and Maslach Burnout Inventory – General Survey for Students (MBI-GS (S)), and open-ended questions. Results: A response rate of 62% (n=38) was achieved. There were no differences in stress and burnout scores between sexes, nor differences in stress and burnout over time. Highest median CSE scores were seen at T1, with highest median MBI-GS (S) cynicism (CYN) scores at T2, exhaustion (EX) at T1 and T2, and professional e�cacy (PE) at T1 and T2. The greatest mean CSE changes were seen from T1-T2 and T1-T3, and PE greatest changes from T2-T3 and T1-T3. No strong correlation was found between stress and burnout. Curriculum coursework was a frequently reported stressor, along with clinical placement and transition periods. Coping strategies utilized by students were both positive and maladaptive. Positive strategies included sporting activities, baking, listening to music, and social connections, whereas maladaptive strategies included alcohol consumption, excessive eating and gaming. Conclusion: Student consistently identi�ed periods of stress and burnout,


Background
Stress is de ned as the dynamic interaction encompassing the physical, emotional, and psychological responses between the individual and their environment 25 .Not only is stress in uenced by higher educational demands within physiotherapy programs, but stress is also affected by other external factors including relationships, relocation, and nancial pressures 23 .Previous studies 2,13,23 of both undergraduate and postgraduate physiotherapy students have reported that the leading cause of stress in pre-registration physiotherapy students is academic stress, followed by social related stressors (e.g.spending time on extra-curricular activities, or time with friends and family).
When physiotherapy students perceive that they are unable to cope with stressful demands, the impacts of the stressors may manifest as burnout 25 .Burnout is considered to be a multifaceted behavioural syndrome often leading to negative responses for an individual when exposed for a prolonged period of time 26 .Burnout can affect an individual's physiological and psychopathological system causing anxiety, depression, interpersonal sensitivity, alcoholism, and other addictive disorders 26 .Previous research by Balogun et al. 5 found that emotional exhaustion and depersonalization scores in physiotherapy students were higher than reports for normative data within the majority of service professionals.Noting this potential risk of burnout in pre-registration physiotherapy programs, identifying whether students are capable of implementing coping strategies is of importance.
Individuals have differing perceptions of stress and as a consequence utilize different coping strategies 27 .Coping strategies can be de ned as the ability to adapt in response to a range of events that are perceived as stressful 28 .A study by Kohn, et al. 28 suggests that three general strategies exist in an attempt to cope with situations that are stressful; 1) problem-focused coping, which aims to remedy the threatening situation; 2) emotion-focused coping, which aims to manage the response; and 3) avoidance-focused coping, which involves attempts to remove the threatening situation.While differences exist between coping perceptions over time, along with an increased ability to positively respond to stressful situations, 3 Pierceall et al. 29 suggest the following as commonly successful coping mechanisms: talking to family and friends, leisure activities, and exercising.However, despite implementation of positive coping strategies, maladaptive coping strategies commonly arise, including alcohol abuse, drug abuse and smoking.
In the last decade, studies conducted globally have explored the relationship between physiotherapy coursework and perceptions of student stress and burnout  . Currnt research identi es challenges and imposing demands placed on physiotherapy students and the subsequent impacts both psychologically and emotionally that these demands have 2,3,6 .The impact of stress and burnout in physiotherapy students across the rst year of study, in particular, is of concern.It has been shown that the ability to cope with stress is an important factor affecting a student's success in an academic program 3 .Stress and burnout can furthermore affect students emotional wellbeing and can result in psychological morbidity.One study reported that among undergraduate physiotherapy students, the frequency of depression, anxiety and stress was 48%, 69% and 53% respectively 22 .Noting these concerns, there are differences in the structure of physiotherapy programs with some programs being conducted in an intensive fashion. For eample, the Doctor of Physiotherapy (DPHTY) program at Bond University in Australia, a post-graduate pre-registration physiotherapy program, comprises six semesters over two years (three trimesters per year), totaling 18 subjects and over 1200 clinical placement hours (50% of the program) 1 .How rst year physiotherapy students in an intensive, post-graduate, course perceive, and experience stress and their coping strategies may differ from those completing the degree over several years and / or completing their rst degree.The aims of this study were to identify the complexity of factors that in uence rst year Doctor of Physiotherapy (DPHTY) students' perceptions of stress, burnout and coping strategies with the intent of answering three research questions being: 1) Was there a difference in perceived stress and burnout over time?; 2) Did sex in uence the amount of stress and burnout experienced?; and 3) What were the coping mechanisms utilized by pre-registration DPHTY students?

Design
An observational cohort study design was used.The questionnaire was designed to establish students' perceptions of stress, burnout and coping strategies across three time points being 1) At the beginning of the program, 2) At the end of their rst semester of coursework and 3) At the end of the rst two placement blocks, 5 weeks respectively (cardiorespiratory and orthopaedics).The quantitative and qualitative components collectively addressed the three research questions.

Subjects
All 61 students in their rst year of a post-graduate pre-registration, insensitive DPHTY program conducted in Australia in 2019 were invited to participate.None of the DPHTY cohort were excluded from the study.Students were invited to participate 1-week prior to the rst time point and further invited to participate in the data collection at each successive time point, irrespective of participation in previous time points.

Instrumentation
A self-reported 51-item mixed methods questionnaire was designed, consisting of demographic questions, two validated questionnaires, the Coping Self-E cacy Scale (CSE) and the Maslach Burnout Inventory-General Survey for Students (MBI-GS (S), as well as open-ended questions.The CSE is a valid and reliable tool with a reported intra-class correlation coe cient of p < 0.001 and criterion validity of p < 0.001 31 .The CSE scale was incorporated to measure an individual's perceived ability to cope effectively with life challenges, and to assess changes in CSE scores 33 .The MBI-GS has also been proven to be a reliable and valid tool.There are no current reports on psychometric properties in the student version MBI-GS (S) hence the use of the general version MBI-GS reliability and validity scores 32 .The MBI-GS (S) was adapted and selected for inclusion in the questionnaire as it is recognized as the leading measure of burnout in students at college and university 34 .Additionally, open-ended questions allowed for qualitative responses to be gathered on; periods of stress encountered in the current semester, coping strategies that have been successful or unsuccessful during the current semester, further information not covered in previous questions, and three things the students wish they had known before starting the current semester and why.It was anticipated that the questionnaire would be completed within 15-20 minutes.

Data analysis
Descriptive statistics were used to summarise and present quantitative data.All quantitative data were assessed for normality using the Shapiro-Wilk test.Where a lack of normal distribution was found medians and ranges were reported [Table 1].A Fisher's Exact test was conducted to assess the signi cance of each variable, with a signi cance level of p < 0.05 [Table 1].A paired samples t-test was completed to compare the mean total scores of stress and burnout at opposing time points (T1vT2, T2vT3, T1vT3) [Table 2].A Mann Whitney U test was conducted to assess signi cance, with a p-value of ≤ 0.017 that accounts for multiplicity (0.05/3) [Table 2].A Pearson Correlation was then conducted to determine the relationship between stress and burnout across all time points [Table 3].Qualitative responses were subjected to a 5-step thematic analysis approach 30 with global themes and subthemes being identi ed and a priori themes integrated [Table 4].

Results
Of the 61 DPHTY rst year students invited to participate in the study, 38 (62%) participated across any of three time points.Of these respondents, 27 (71%) responded at T1, 30 (79%) responded at T2, and 20 (53%) responded at T3.The demographics of the student population are detailed in Table 1.
The median age of female participants was 23 (20-38) and for males was 26.5 (21-36) years, with strong evidence for signi cance between groups (p = 0.012) [Table 1].The percentage of those that had previously completed a Bachelor's degree was 87%, with the remaining 13% completing a Masters degree.The difference between groups in relation to their previous degree was not signi cant [Table 1].
Differences between sexes were observed across CSE scale and MBI-GS (S) subgroups, however these differences did not reach signi cance (Table 1).Highest median CSE scores for both males and females were seen at T1, and lowest scores at T3 (Table 1).The highest MBI-GS (S) CYN median scores were reported at T2, EX at T1 and T2, and PE at T1 and T2 (Table 1).CSE scores showed the greatest mean changes from T1-T2 and T1-T3, however these differences were not signi cant (Table 2).MBI-GS (S) mean scores identi ed that PE changes were greatest from T2-T3 and T1-T3, however were likewise not signi cant (Table 2).
No signi cant correlations were found between stress and burnout (Table 3).However, a strong, signi cant, and positive correlation was found between stress scores at CSE T2 and CSE T3 (r = 0.848, p < .05).Of the 51 total responses across time points for the MBI-GS (S) question "I feel depressed by my studies", 44 (86%) gave scores greater than zero, indicating that at some point during the time points, students have felt depressed by their studies.
Thematic analysis of the open-ended questions revealed common stress and burnout in uencers and common coping strategies [Table 4].Thematic analysis revealed seven global themes across the three time points including: curriculum coursework, clinical placement, transition periods, work-life balance, coping behaviors, nancial pressures, and course survival tips.
Theme 1: Curriculum Coursework The most frequent global theme causing stress as reported by students was curriculum coursework.The sub-theme 'academic functioning challenges' was evident throughout responses during T1 and T2.Students report not knowing where to focus or prioritize study, for example nding balancing study and study topics challenging.Another academic functioning challenge reported was a lack of accent training and language barriers, as students often study abroad and English may be their second language.Examination stress also appeared to be a prevalent sub-theme where participants described increased stress especially with completing three exams in three days [Table 4].
Theme 2: Clinical Placement In general, students described the 10-week clinical placement block as "enjoyable", with reports that a few days break between the clinical placement block may be bene cial.Due to these responses arising in T3, potentially, students were less focused and less stressed about clinical placement during the earlier aspect of the program.The majority of responses indicated that students were stressed about professional behaviours -receiving feedback, performance standards, self-directed learning and professional development (Table 4).

Theme 3: Transition Periods
Transitions to university life, clinical placement and relocating were discussed in T1 and T3.Participants reported di culty with being away from friends and family, and di culties with cohort cohesion.There are reports of transition doubt where students question whether they want to continue the program due to not currently enjoying the course.

Theme 4: Work-Life Balance
A global theme in the students' responses across all time points was the di culty nding the right balance between university life and having time for themselves.Students reported a lack of time management and guilt when doing activities other than study.Di culties maintaining relationships and having time to be involved in social activities were also reported (Table 4).

Theme 5: Coping Strategies
Both positive and maladaptive coping strategies were evident in written responses.Successful coping strategies commonly reported included social support coupled with study skills, exercise/recreational activities, and mindfulness and positive self-talk (Table 4).The open-ended responses further revealed that some students were seeking psychological intervention in order to cope.Students also reported maladaptive coping mechanisms including excessive alcohol consumption, excessive eating, and gaming.

Theme 6: Financial Pressures
Financial was reported across all three time points.Di culties were noted especially whilst on placement due to travel requirements and having to source accommodation (often resulting in paying multiple rent).With this, sourcing part-time work was reported to be di cult for students due to time pressures and course intensity (Table 4).

Theme 7: Course Survival Tips
Students consistently reported that they wish they had known more curriculum details and self-management techniques throughout all three time points.They wish they had known more information on content delivery along with a typical day as a Bond university student.Participants also reported that they needed to take time to themselves so to avoid burnout, with other reports stating that they wish they had known the best strategies for dealing with homesickness (Table 4).

Discussion
This study explored pre-registration Bond University DPTHY students' levels of perceived stress, burnout, and associated coping mechanisms.The rst research question focused on differences in perceived stress and burnout over time.The quantitative data from the CSE and MBI-GS (S) scores showed no signi cant changes at time points and between time points.These results are in contrast to previous research.A previous study reported by Van Veld et al. 3 , conducted in the United States, found changes in CSE scores over time in rst year DPHTY students.This difference between studies could be due to a variety of factors including timing of placement blocks, the curriculum coursework demands as well as the structure of the different programs.
Findings relating to the MBI-GS (S) are unique to this study, as it is the rst study completed on physiotherapy students to utilise this version of the MBI.Previous studies 4,5 have utilized the MBI, however an alternate version has meant the subscales differ from those within this study.Balogun et al. 4 completed a study in 1996 that determined that academic performance was not correlated with physiotherapy students' perceived levels of burnout.In another study, the same authors 5 found the emotional exhaustion and depersonalisation scores for physiotherapy students, were higher than the norms reported for the general population and most human services professionals.
Qualitative data suggests that changes in written responses in regards to the type of stressors across the time points could have been associated with transition periods.These di culties found within transition periods including; relocation adjustments, transition to academic life, transition to placement, and transition doubt, support the ndings of previous 18 studies conducted on students.This study determined that there was no strong correlation between stress and burnout.However, ndings indicate a strong correlation between stress scores at the start of the course (T1) and pre-placement (T2).These results could have been due to similarities in stress perceptions and coping at these time points.
A strong theme throughout the open responses was that curriculum coursework within the program and examinations caused heightened levels of stress.Students reported periods of stress with coursework and course load commitments, which is in line with previous research 3,12,14,18,23,24 conducted on undergraduate and pre-registration postgraduate students in several countries including Australia, USA, Israel and Sweden.Students frequently reported that their social life was lacking, along with time to undertake their hobbies due to workload and demands of the program.Students are required to undertake written examinations, seminar presentations, and practical examinations (OSCEs).Participants within the study reported feeling underprepared and anxious in the week/s leading up to assessments.A previous cross-sectional study 23 conducted in Australia and the United Kingdom found coursework stress to be the greatest source of stress for students.Similarly, Indian Bachelor of Physiotherapy students 18 reported that unpredictability of examinations and fear of failure were sources of stress, which align with responses generated from this study.
Placement related stressors have been frequently identi ed across time points 1 and 3. Student responses were commonly related to professionalism, with stress arising when not given immediate feedback from clinical educators and having to complete self-directed learning and professional development tasks.Additionally, nancial pressures arose as a theme throughout this study, and was ampli ed during the clinical placement block.Students often had to travel, therefore increasing accommodation costs, as well as nding di culty to attain or maintain part time positions.
Hampshire et al. 36 found that negative placement experiences have a signi cant impact with the potential for becoming the 'tipping point' for students.This study by Hampshire et al. 36 proposed a variety of suggestions for avoiding attrition, which include exible start and nish times, maximum travelling distances to placement, central feedback database, and student nancial support funds.Similarly, a Dutch study 10 on six undergraduate students conducted across three universities found placement stressors had an impact on the student's well-being.Some stressors included demanding supervisors, worrying about not being good enough, and worrying about meeting expectations.Potentially, students are being taught the appropriate clinical and academic skills but are not being taught appropriate professional skills.Students may bene t from skills in taking on feedback and understanding the importance of re ective practice.If expectations of clinical placements are clearly de ned prior, students may have reduced stress or better coping mechanisms.
The second research question focused on the in uence of sex in relation to stress and burnout throughout the rst year of the program.Whilst the current study did not identify sex to in uence stress or burnout, there were unique differences across all three time points in the rst year, and female students self-reported experiencing more stress.
The sex difference has previously been reported, with females experiencing more stress than males 20 .This crosssectional study completed on 231 undergraduate students in Pakistan reported that not only did women differ in their perception of stressors, but their reactions also differed, where they were more overtly reactive.It is explained this could be due to the gender role socialization of emotions, or that females are possibly more emotionally responsive.This cross-sectional study may have differing experiences of stress for females due to a variety of factors including the length of the study, the age of the participants, or the outcome measure utilised (Student Life Stress Inventory).
The third research question concentrated on coping mechanisms utilized by DPHTY students during the rst year of their program.
Qualitative themes from open-ended questions revealed a mix of maladaptive and positive coping strategies.Previously, a cross-sectional study reported 28 that three general strategies exist in an attempt to cope with stressful situations: problem-focused coping, emotion-focused coping, and avoidance-focused coping.Within our study students reported that they wish they had been made aware of and equipped with effective coping strategies to overcome such stressors from course demands.The theme, course survival tips, demonstrated that students felt unprepared for the course demands, and desired more self-management strategies when stressful periods arise.
The most common problem-focused coping strategy reported in the current study was exercise, with reports of it being a bene cial stress reliever across all three time-points.Whilst the use of exercise as a coping strategy is potentially not surprising for a physiotherapy cohort, such strategies should be promoted due to its proven stress-relieving bene ts 23,35 .For university students, opportunities to engage in sporting and social clubs often incur no additional costs, potentially promoting accessibility.This may be of bene t for HEIs; not only encouraging health and well-being, but also allowing for social interaction outside of class time.Students reported that maintaining social relationships within and outside of the program have been an effective emotion-focused coping strategy in managing stress.These ndings concur with previous studies 3,9 where maintaining relationships are important for coping.Being able to debrief and have open conversations appears to be imperative to the well-being of students.
Although the majority of students reportedly utilize positive coping strategies, there were also accounts of maladaptive coping strategies.The avoidance-focused coping strategies that have been identi ed as maladaptive include alcohol consumption, excessive eating, and gaming.Maladaptive coping strategies found by a cross-sectional American University study 29 included alcohol abuse, drug abuse, and smoking.They further recommended that universities provide ongoing research outlining stress, how to detect when an individual may be experiencing high levels of stress, and positive strategies to deal with such stressors.Perhaps in future, HEIs could increase wellness education and services such as advisement and counselling.Students may bene t from group discussion around health and wellbeing, and the challenging aspects around maladaptive coping strategies.This environment may elicit more students to speak when feeling stressed or burnt out.
The ndings from our study offer unique insights around the pressures and expectations of pre-registration physiotherapy students.Responses provide information to aid in the maintenance of student well-being, whilst ensuring production of quality health professionals, that may be of bene t to HEIs.It is important for physiotherapy programs to know the causes of stress and burnout in their students, and associated coping mechanisms utilised.
Findings from previous studies 36,37 in which students also report burden with travel for placement, nancial costs, in exible timetabling, and clinical placement stressors, demonstrate commonality with this research.It would be valuable to determine the tipping point for students undertaking pre-registration physiotherapy programs and trial targeted intervention strategies to mitigate potential stress and burnout.

Strengths And Limitations
To our knowledge, this is the rst study to explore both perceived stress and burnout in pre-registration DPHTY students.This study aims to serve as a foundation for future guidance and to inform HEIs program structure to optimize student welfare, academic ability, and support.This paper also allows for increased understanding of how an intensive course can impact the welfare of students.The use of previously validated and reliable tools coupled with open-ended questions allowed for a broad understanding of the complexity of being a student in an intensive entrylevel pre-registration program.Quantitative and qualitative data gathered has allowed for the research questions to be answered with a humanistic view.The use of two reliable and valid questionnaires (CSE and MBI-GS (S)), further enhances the strength of this study and allows for con dence in results generated.
The authors acknowledge methodological limitations identi ed as the students' lack of understanding of the true de nition of burnout.This was recognised as students reported feeling burnt out in the open-ended questions however did not meet the criteria according to the Maslach Burnout Inventory.This was discovered as a potential threat after the implementation of the survey.It is recommended that future studies provide a list of key de nitions prior to the delivery of the survey.Another methodological limitation included the length of time conducted, as well as a relatively small sample size.This study across three time points spanned two semesters and the results generated could have more impact if the spanned time included the entire physiotherapy program.

Conclusion
In summary, this study has presented a unique insight into experiences, attitudes and behaviours that pre-registration physiotherapy students possess in response to perceived stress, burnout, and coping strategies.This study has demonstrated that the DPTHY students reportedly experience varying levels of stress and burnout throughout their rst-year program.Students consistently exempli ed high levels of stress within the context of coursework and academic load.Although not signi cant, female students, generally, trended to reporting higher levels of perceived stress across all three time points.There were no differences between the sexes in regard to self-reported burnout.Whilst the relationship between stress and burnout was explored, no strong correlations were found.This study has also identi ed that physiotherapy students were implementing coping strategies, both positive and maladaptive and highlights the importance of continued research within postgraduate pre-registration physiotherapy programs to identify why students may be experiencing stress and burnout and to guide positive rather than maladaptive coping strategies.With further research, HEIs may implement frameworks to identify student stressors and burnout, adapt their program structure, and implement management strategies for students.Further programs to optimise student coping self-e cacy as well as developing tools for identi cation and management of stressors would be bene cial.Findings of this research provide valuable insights to inform curriculum design and optimize pre-placement support for DPHTY pre-registration physiotherapy.Ethics and gatekeeper approval were sought prior to commencement of the study from Bond University Research Ethics Committee (SG03019).A research assistant, independent to the Academic staff, recruited participants at each time point.Involvement in the project was voluntary and participants were invited to return the completed questionnaire to a locked survey box located on University Campus, within 1-week of distribution.Reminders were provided at each of the 3 time points to boost response rates.Surveys were entered into a purposely designed database and checked for accuracy by 2 members of the research team.

Abbreviations
Consent for publication was gained in accordance with ethical approval SG03019.

Table 1
Demographic information and descriptive data for student scores, CSE scale, MBI-GS (S) in relation to gender

Table 3
Pearson Correlation for Stress and Burnout over time points (as measured by CSE and MBI-GS (S) Key: CSE, Coping Self E cacy Scale; MBI-GS (S), Maslach Burnout Inventory -General Survey (Students); T1, time point 1 start of course; T2, time point 2 prior to clinical placement; T3, time point 3 immediately post placement; CYN, Cynicism subscale; EXH, Exhaustion subscale; PE, Professional E cacy subscale; AVG, average.* signi cant at p < 0.05

Table 4 :
Thematic Analysis Workload stress [leads to] feeling pressure/stress regarding amount of work to review and get done.""I feel there aren't enough hours in the day.We spend hours in class and then are expected to go home and study/do work.I feel stressed and T3"Having the placements before our holiday break was very helpful to solidify our learning.I loved the 10-week block of placements.I feel it will be nicer to have shorter blocks at class and then placements back to back, 10 and 10 is great.It's a very stressful course.""I feel it may be useful to have a few days break in between placements to have a good mental/physical break prior to starting the next block."2.2 Placement stress T3 "I felt extremely stress on my rst 5 weeks of my clinical placement.My educator hardly gave any immediate feedback and it made me very anxious as to knowing whether I was doing well or not.I got very unwell in my second block of my placement and I was physically/mentally exhausted making it di cult to perform to the best of my abilities.""Being on placement, coming home and preparing an in-service presentation and re ection -very overloaded at end each time.""Constantly thinking about how much I have to get done.Leads to anxiety attacks and poor sleep.""How little time off I would have.How much university would cut into my social life."4.2 Health impact and wellbeing "I've been burnt out from last semester, which made me ill with the u and I've had lingering u ever since leaving me extra upset about situations and it has been affecting my relationship and my strong mindset.""The travel to each of my placements was also very stressful as I was unable to afford extra accommodation in [X location] as I rent with my [name] on the [Y location].It was 2.5 hours each way every day" "Main periods of stress have been reassuring myself I can do what I want with this degree, that it's not a waste of time/money and it was the Key: a A priori themes from the Social and Academic Functioning (SAF) Scale, b A priori themes from the CSE scale