1. Background
Medical education is a stressful period for medical students worldwide, often associated with high job burnout, anxiety, and depression, which may adversely affect their quality of professional life (1). The WHO defines quality of life as an individual's perceived physical, social, and mental well-being, influenced by their culture, value systems, personal goals, hopes, and expectations (2). The quality of professional life provides insight into how individuals interact with their environment, achieve their aspirations, and experience feelings of "being," "belonging," and "becoming" (3).
Engaging in effective self-care is an approach to reducing stress and promoting well-being during medical education (4). Psychological self-care involves specific actions taken by individuals and organizations to improve health, reduce stress, and maintain optimal mental and emotional states (5). Self-care encompasses the ability of individuals, families, and communities to enhance health, prevent disease, maintain health, and manage disease and disability with or without the support of healthcare providers (6). Resilience, which is positively correlated with the quality of professional life, is a personality trait closely linked to mental health (7).
Resilience is crucial in the medical students' stressful work environment (8). It aids students in withstanding difficult situations without harm and potentially growing in personality from such experiences (9). Although resilience may not directly correlate with medical students' academic performance (10), it is positively associated with their well-being. Previous studies have shown that resilience correlates with lower levels of psychological distress (10), higher life satisfaction (11, 12), improved quality of life (11), fewer anxiety symptoms (12), and greater mental well-being (13, 14) among medical students.
Psychological distress is an emotional suffering state associated with environmental stressors and demands that are challenging to manage in daily life (13). Studies indicate that medical students encounter numerous stressors throughout their academic programs that require adequate flexibility for healthy adaptation (14). Due to varying cultural contexts in different cities and countries, students in Asian countries often experience increased psychological pressure from families and teachers concerning academic and career progress (15).
2. Objectives
Given the limited research on the professional life of medical interns and the role of self-care in enhancing the quality of professional life among medical students, this study aims to explore the quality of professional life in medical students and its relationship with self-care, resilience, anxiety, and depression. The study seeks to answer several questions: (1) What is the status of professional life and self-care among medical clerks and interns? (2) How do demographic factors, psychological self-care, resilience, and anxiety or depression influence the quality of professional life in medical students? (3) Can demographic characteristics, psychological self-care, and resilience predict anxiety and depression among students?
3. Methods
This descriptive-analytical study was conducted with medical clerks and interns at Babol University of Medical Sciences (Babol, Iran) from May to September 2022. The study was approved by the ethics committee of Babol University of Medical Sciences (IR.MUBABOL.HRI.REC 1401.035) and adhered to the Declaration of Helsinki. Participants' names were not recorded to ensure confidentiality. All participants were informed about the study details and signed written consent forms at the start of the study.
Census sampling was used in this study, with all 350 medical trainees at Babol University Medical School invited to participate. The inclusion criteria specified that participants must be medical students at Babol University of Medical Sciences who had not taken academic leave in the past year nor transferred to another university to complete academic courses. Exclusion criteria included medical clerks and interns who left the university during the past year or chose not to participate in the study. Additionally, participants who did not fully complete the questionnaires were excluded. A medical student and member of the research team (second author) explained the study's purpose, inclusion and exclusion criteria, and the questionnaire completion method through text and voice messages in two WhatsApp groups containing all medical clerks and interns. Links to the online questionnaires were shared in these groups, and volunteers anonymously completed and submitted them. Out of 350 medical clerks and interns, 49 chose not to participate, 21 did not meet the inclusion criteria, and 10 did not fully complete the questionnaire. Ultimately, 270 students qualified and were included in the study.
3.1. Quality of Professional Life Questionnaire
This questionnaire, designed by Stamm, contains 30 questions and is divided into three subsets: Compassion fatigue, compassion satisfaction, and psychological burnout. Scores of 22 or lower indicate low compassion fatigue and burnout; scores of 23 to 41 suggest a medium level of both; scores of 42 or higher denote high levels of compassion fatigue and burnout (16). This study used the Persian version of the revised Quality of Professional Life Questionnaire. The intra-class reliability of the scale was 0.96, and its reliability based on internal consistency (Cronbach's alpha) was 0.73. The content validity ratio (CVR) for the entire tool was 0.7, and for individual items, it ranged from 0.5 to 1. The content validity index (CVI) was 0.91 (17).
3.2. Connor-Davidson Resilience Scale
This scale comprises 10 questions delineating five dimensions: Personal competency, confidence in individual instincts, tolerance of negative emotions, positive acceptance of change and secure relationships, and control and spiritual effects. The resilience scores range from 10 to 40 (18). The Persian version of Connor-Davidson Resilience Scale (CD-RISC 10) is a validated scale, exhibiting a Cronbach’s alpha coefficient of 0.89 and an ICC coefficient of 0.90. Additionally, the CVR is 0.8, and the Content Validity Index (CVI) is 0.89 (19).
3.3. Psychological Self-care Questionnaire
Yunibhand (1999) developed this questionnaire, comprising 46 questions across seven sub-components: Self-awareness, effective communication, time management, problem-solving, development and maintenance of support systems, religious activities, and physical self-care. The total score ranges from 46 to 184. We utilized the Persian version of this tool, reporting a Cronbach’s alpha of 0.7 for the 46‐item questionnaire. The CVR is 0.82, and the CVI is 0.85 (20).
3.4. Hospital Anxiety Depression Scale (HADS)
This instrument consists of 14 questions, assessing anxiety and depression separately (21). Responses are rated on a 4-point Likert scale. Hossein Kaviani et al. confirmed the validity and reliability of the Persian versions of both the first and second versions of the questionnaire. Their findings demonstrated the validity and reliability of all measures and subscales among depressed and anxious Iranian patients. The reliability coefficients, as measured by Cronbach's alpha, were 0.81 and 0.78 for the anxiety and depression subscales, respectively (22).
3.5. Data Analysis
The data underwent statistical analysis using SPSS version 23. Descriptive analysis included mean±standard deviation for quantitative data and percentage frequency for qualitative data. Furthermore, t-tests, chi-square tests, and multiple linear regressions were employed to investigate the relationships of interest. The significance level was set at 0.05.
4. Results
A total of 270 medical students from Babol University of Medical Sciences participated in this study, which examined their mental resilience, self-care practices, quality of professional life, and psychological distress. The participants had an average age of 24.63 ± 2.61 years (ranging from 21 to 41 years), with a majority being female, living at home, and single. Table 1 presents demographic information alongside mean scores for professional life, resilience, psychological self-care, depression, and anxiety.
Table 1.Demographic Information Along with the Mean Scores of the Questionnaires a
| Parameter b | Values |
|---|---|
| Sex | |
| Female | 123 (45.6) |
| Male | 147 (54.4) |
| Residential status | |
| Dormitory | 78 (28.9) |
| House | 192 (71.1) |
| Marital status | |
| Married | 55 (20.4) |
| Single | 215 (79.6) |
| Quality of professional life | |
| Compassion fatigue | 17.43 ± 7.87 |
| Compassion satisfaction | 34.52 ± 8.13 |
| Psychological burnout | 15.34 ± 4.10 |
| Resilience | 24.12 ± 5.28 |
| Psychological self-care | 127.47 ± 17.97 |
| Anxiety | 7.24 ± 3.76 |
| Depression | 7.84 ± 3.50 |
a Values are expressed as mean ± SD or No. (%).
b Range of psychological self-care scores: 46 - 184; Resilience: 10 - 40; compassion satisfaction: 17 - 50, psychological burnout: 7 - 24; compassion fatigue: 10 - 36; quality of professional life: 50 - 97; anxiety: 0 - 21; and depression: 0 - 21.
According to the findings, the quality of professional life among medical students was deemed desirable, as indicated by their low levels of compassion fatigue (mean of 17.43 ± 7.87 out of 36) and psychological burnout (mean of 15.34 ± 4.10 out of 24), along with a moderate level of compassion satisfaction (mean of 34.52 ± 8.13 out of 50). Additionally, their mean scores for depression (7.84 ± 3.50 out of 21) and anxiety (7.24 ± 3.76 out of 21) were low. Psychological self-care among students surpassed the average (127.47 ± 17.97 out of 180), while their resilience against stress was relatively low (24.12 ± 5.28 out of 38).
Subsequently, the correlation between resilience and psychological self-care questionnaires with other measures was examined. Apart from a lack of significant correlation between resilience and compassion fatigue, significant correlations were observed in other instances. Specifically, a positive correlation existed between the self-care and resilience questionnaires with compassion satisfaction and quality of professional life, while negative correlations were observed in other cases, as illustrated in Table 2.
Table 2.The Correlation Between Psychological Self-care and Resilience with Other Questionnaires
| Variables | Pearson Correlation | P-Value a |
|---|---|---|
| Self-care-compassion satisfaction | 0.890 | < 0.001 |
| Self-care-psychological burnout | -0.539 | < 0.001 |
| Self-care-compassion fatigue | -0.234 | < 0.001 |
| Self-care-anxiety | -0.288 | < 0.001 |
| Self-care-depression | -0.356 | < 0.001 |
| Self-care-psychological distress | -0.347 | < 0.001 |
| Self-care-quality of professional life | 0.207 | 0.001 |
| Resilience-compassion satisfaction | 0.675 | < 0.001 |
| Resilience-psychological burnout | -0.620 | < 0.001 |
| Resilience-compassion fatigue | -0.107 | 0.078 |
| Resilience-anxiety | -0.190 | 0.002 |
| Resilience-depression | -0.323 | < 0.001 |
| Resilience-psychological distress | -0.275 | < 0.001 |
| Resilience-quality of professional life | 0.314 | < 0.001 |
a The Pearson correlation test was used.
Table 3 compared the means of psychological self-care, quality of professional life, and anxiety/depression between men and women. No differences were found between male and female students in terms of the mean total psychological self-care and quality of professional life (P > 0.05). However, the mean scores for anxiety and depression symptoms were significantly higher in women compared to men (P < 0.05).
Table 3.Comparison of Means (SD) of Psychological Self-care, Quality of Professional Life, and Anxiety/Depression between Men and Women
| Variables | Students' Gender | P-Value a | |
|---|---|---|---|
| Female | Male | ||
| Psychological self-care | 127.72 ± 17.84 | 127.16 ± 18.20 | 0.679 |
| Resilience | 24.22 ± 5.47 | 24.00 ± 5.08 | 0.758 |
| Compassion satisfaction | 34.69 ± 8.09 | 34.32 ± 8.22 | 0.648 |
| Psychological burnout | 15.27 ± 4.03 | 15.43 ± 4.19 | 0.662 |
| Compassion fatigue | 18.05 ± 8.27 | 16.68 ± 7.34 | 0.336 |
| Quality of professional life | 69.01 ± 10.89 | 66.43 ± 9.15 | 0.348 |
| Anxiety | 7.76 ± 3.89 | 6.62 ± 3.52 | 0.016 |
| Depression | 8.16 ± 3.64 | 7.46 ± 3.30 | 0.016 |
| Psychological distress | 15.91 ± 7.11 | 14.08 ± 6.08 | 0.114 |
at-test was used.
Finally, factors associated with the quality of professional life and psychological distress questionnaires were investigated (Table 4). Regression analysis was employed, with age, gender, psychological self-care, and resilience as independent variables. The dependent variables initially included quality of professional life and then psychological distress. According to Table 4, only psychological self-care was associated with the quality of professional life (β = 0.318) among medical students. Additionally, age (P < 0.001, β = 0.299), female gender (P = 0.013, β = -0.136), and psychological self-care (P < 0.001, β = -0.327) were significant factors for anxiety and depression among medical students.
Table 4.The Factors Associated with Quality of Professional Life and Anxiety/Depression in Multiple Linear Regression
| Variables and Predictors | Beta a | P-Value |
|---|---|---|
| Quality of professional life | ||
| Female sex | -0.072 | 0.215 |
| Age | 0.092 | 0.117 |
| Psychological self-care | 0.318 | < 0.001 |
| Resilience | -0.023 | 0.773 |
| Anxiety/depression | ||
| Female sex | -0.136 | 0.013 |
| Age | 0.299 | < 0.001 |
| Psychological self-care | -0.327 | < 0.001 |
| Resilience | -0.077 | 0.307 |
a Standardized coefficients.
5. Discussion
The research findings suggest that the quality of professional life among medical students was satisfactory. Furthermore, medical clerks and interns exhibited low levels of compassion fatigue and job burnout, while their compassion satisfaction scores fell within a moderate range. A study conducted in Brazil compared the quality of life of 206 medical students with that of 199 young individuals in the general population. Researchers observed that medical students reported a lower quality of life, particularly in the psychological and social domains, with one-fourth of them experiencing diminished quality of life in terms of physical and environmental health (15). Another study by Seifi et al. examined students at Birjand University of Medical Sciences, revealing a mean quality of professional life of 51.5 and a mean resilience score of 66.8. Their sample exhibited a poorer quality of professional life compared to the students in our study, although they demonstrated a superior resilience status. Notably, their study encompassed students across various clinical, physiopathological, and basic science stages, whereas our study solely focused on clinical students (23).
In our study, medical clerks and interns exhibited above-average psychological self-care scores, which likely positively influenced their careers. Neglecting self-care puts individuals at risk of adopting maladaptive coping strategies that could compromise their professional performance standards (24). Robat Sarpooshi et al. explored the correlation between the health literacy levels of 400 diabetic patients and their self-care behaviors, finding that those with higher education levels tended to have higher self-care scores (25).
According to our study, the mean levels of depression and anxiety were low among students, and they demonstrated resilience against stress. In contrast, a study investigating stress, anxiety, and depression prevalence and related factors among medical students at Fayoum University in Egypt reported high prevalence rates for these mental health issues (26). These disparities may stem from cultural variations, differences in healthcare and medical education systems, variations in study populations, and discrepancies in study tools. Our study also revealed low levels of resilience to stress among students, aligning with findings from Rahimi et al., which highlighted high stress levels among medical students and inadequate coping mechanisms and psychological resilience among physicians and medical students (27). If resilience is considered an inherent aspect of one's personality upon entry into medical school, then medical schools should prioritize admitting candidates equipped with the psychological resources to navigate the challenges inherent in medical education.
In this study, self-care and female gender emerged as negative predictors, while age was identified as a positive predictor of psychological distress among medical clerks and interns. A similar study involving 139 male and female Australian students in 2015 yielded comparable results, showing that higher levels of self-care correlated with lower levels of distress (28). Significant gender differences in distress levels among medical students were also evident in our study, with female gender serving as a negative predictor of psychological distress. This finding was consistent with the results of a study by Fawzy and Hamed among Egyptian medical students, where psychological distress was significantly associated with female gender (29).
Moreover, our study confirmed that psychological self-care positively predicted the quality of professional life among medical clerks and interns. Lin et al. also noted that environmental stressors could adversely impact the quality of professional life for interns (9). While their findings aligned with ours, they observed that self-care alone could not entirely moderate the quality of professional life in students. In contrast, our study found that psychological self-care could predict the quality of professional life. This distinction might be attributed to the clinical level status of the students in our study, where the significance of self-care is heightened. In contrast, Lin's study included students from the first to the fifth years of medical school. Additionally, a similar study by Miguel et al. in 2021 utilized regression analysis to explore the predictive effect of certain questionnaires. They found that self-care could predict psychological distress in medical students, with this effect persisting over the long term (up to 5 years) (30).
While this study has strengths, such as the inclusion of students from various sectors, it also possesses weaknesses. The students' status and the sector in which they completed the questionnaires may have influenced the study results; for instance, students in major sectors might have experienced less anxiety and stress compared to those in simpler or minor sectors. Future research should consider incorporating non-clinical years of the medical curriculum, such as the physiopathology or basic sciences course, which typically occurs in the first six months of education. Additionally, it would be beneficial to examine the duration of students' attendance at different educational levels. Furthermore, it is advisable to administer questionnaires that account for the significant impact of main departments, such as pediatrics, internal medicine, and surgery, on the mental well-being of students.
The results of the present study hold significant clinical implications. Considering the positive impact of psychological self-care and resilience on enhancing the quality of professional life and alleviating psychological distress among clerks and interns, strategies such as incorporating psychological self-care training during internships could be employed to enhance professional quality of life and mitigate psychological distress in medical students. Thus, the findings underscore the importance for clinical education planners for medical students to prioritize the promotion of psychological self-care and resilience among clerks and interns in hospital settings.
5.1. Conclusions
Psychological self-care emerges as a crucial factor in predicting the quality of professional life and reducing anxiety and depression among medical clerks and interns. Additionally, the results indicate that self-care and female gender serve as negative predictors, while age acts as a positive predictor of psychological distress among these medical professionals.
