Abstract
Objective. Health care students are at particular risk of stress and exposure to adverse events, negatively affecting well-being and performance and leading to increased attrition. Academic resilience has been identified as one factor helping mitigate such negative effects in students. Despite this, there is limited research exploring the topic in pharmacy education.
Methods. Using a cross-sectional survey design, students attending three schools of pharmacy in the United Kingdom (N=1161) completed psychometric measures of academic resilience and well-being. Comparative, correlational, and regression analyses were conducted, exploring the relationship between academic resilience and well-being.
Results. Academic resilience and well-being were significantly lower in pharmacy students compared to other student populations. Academic resilience was a positive correlate and predictor for well-being. Academic resilience was highest in first-year students, declined over subsequent years of study, and varied by pharmacy school and gender but not ethnicity.
Conclusion. Introducing and embedding strategies to enhance academic resilience in pharmacy education may improve well-being and performance and reduce attrition.
INTRODUCTION
Resilience is broadly defined as the process of adapting and coping when faced with adversity.1-4 Established through lived experience and education,5,6 resilience is a multifaceted set of protective factors7 involving thoughts, behaviors, and actions expressed as an individual’s responses to stress and adversity involving “bouncing back,” personal growth, and change.8,9 Resilience is a positive mental health and well-being indicator associated with academic performance and learning in studies involving student samples.10 Evidence suggests that conceptualizing and measuring resilience within specific domains or contexts offers greater assessment validity than applying a generalized, global construct measure.11 The term academic resilience is the context-specific form of resilience in educational contexts,3,4,12 reflecting students’ capacity to continue to achieve academically having faced challenges and adversity, including academic failure or setbacks, that threaten their progress.1 Higher levels of academic resilience are associated with students’ self-confidence, coping, forming positive and supportive relationships, managing negative emotions, positive mental well-being, improved academic performance, and reduced attrition.2,13-18
Habitual uncertainty, adverse events, emotional demands, and lack of supportive relationships are prevalent in health care practice.19,20 Positive adaptation, buoyancy, and avoidance of burnout are key to working in these challenging and stressful environments.4,21-24 Correlated with lower levels of emotional exhaustion and improved sense of personal accomplishment, resilience has been identified as a protective factor mitigating burnout in health care professionals25 and an important positive predictor in clinical training and professional practice.26-28 Health care students are exposed to both academic pressure and stressors in the clinical environment.29 Thus, recent evidence of low academic resilience in health care students and the suggestion that this may affect students’ ability to cope with the challenges of clinical placements30 present a significant concern for clinical education providers.
Despite evidence of a negative correlation between stress levels and performance and that of differences in gender and ethnicity in the reported stress levels of pharmacy students,31 and despite the growing interest in the topic,32 research focusing on academic resilience in pharmacy education is limited.4 One study conducted with US pharmacy students reported gender and year of study differences in academic resilience, but it found no age or ethnicity differences or relationship with academic performance at point of entry.33 However, to date, no study has investigated academic resilience in UK pharmacy students or explored factors or outcomes associated with academic resilience in this student population. Furthermore, few studies have focused explicitly on mental health and well-being in pharmacy education. This is despite increased emphasis on student mental health in professional standards for the accreditation of pharmacy schools, including the Accreditation Council for Pharmacy Education Standards 2016,31,34 and growing (but conflicting) evidence regarding the impact of student demographics, including gender, ethnicity, degree choice, route of entry, and pharmacy school on mental health, well-being, and resilience.13,35,36
Given evidence suggesting the potential for greater exposure to adversity and limited research in the area, the present study explored the relationship between academic resilience and well-being and the influence of student demographics in UK pharmacy students. The aim was to inform interventions and measures focused on enhancing academic resilience and improving student well-being and attainment in pharmacy education. Based on extant literature, we anticipated finding a positive correlation between academic resilience and well-being, and we anticipated seeing differences according to student demographics and pharmacy school.
METHODS
The study used a cross-sectional survey design with undergraduate Master of Pharmacy (MPharm) students from three UK pharmacy schools, school A, B, and C. The MPharm, involving four years of academic study followed by a one-year training placement, is the UK undergraduate master’s degree leading to registration as a pharmacist, equivalent in nature to the Doctor of Pharmacy (PharmD). Students typically enroll at age 18. Schools representing different geographical locations in the United Kingdom were selected on the basis of having similar course structures, cohort sizes, and entry requirements. While the schools are all accredited by the regulator, the General Pharmaceutical Council, there are notable differences between the schools’ outcomes as measured by performance in the end point qualifying examination. School C has a lower pass rate than schools A and B, which, we hypothesized, might lead to demonstrable differences in academic resilience and well-being, as these factors have been associated with academic attainment.
Following institutional review board approval, surveys were distributed in registered classes for students from all years apart from the final year at school C, who were invited via email to complete the survey online, as they were undertaking an independent research project or off-campus placement with no scheduled on-campus classes. In total, 1,586 students were invited to complete the survey. Participants were not compensated or rewarded, and consent was implied by completion of the survey. The survey comprised validated psychometric measures of academic resilience with the Academic Resilience Scale (ARS-30),11 well-being with the Warwick-Edinburgh Mental Wellbeing Scale (WEMWBS),37 and questions capturing demographic and situational data, including gender, ethnicity, year of study, school, and questions related to possible academic setbacks or adversities encountered, including whether the student was attending their first-choice university, whether pharmacy was their first choice for undergraduate study, and how their university place was secured.
The ARS-3011 is a 30-item measure of student responses to academic adversity. Items are measured on a five-point Likert scale. Summing responses gives an overall academic resilience score with a theoretical range of 30-150. Higher scores indicate greater academic resilience. The ARS-30 comprises three subscales, perseverance (eg, “I would work harder”), reflecting and adaptive help seeking (eg, “I would try to think about my strengths and weakness to help me work better”), and negative affect and emotional response (eg, “I would feel like everything was ruined and was going wrong”), with theoretical ranges of 14-70, 9-45, and 7-35, respectively. While the ARS-30 was adapted for use with US pharmacy students in one study,33 the original measure was selected for the present study to be more consistent with research in the wider field of academic resilience, enabling comparison with other student populations and providing valuable insight in the context of exploring resilience and well-being in pharmacy education. Published data based on a normative sample of nonpharmacy undergraduate university students showed a mean (SD) ARS-30 total score of 115.6 (14.8).11
The WEMWBS37 is a 14-item scale measuring feeling and functional aspects of mental well-being, including positive affect (eg, “I’ve been feeling optimistic about the future”), satisfying interpersonal relationships (eg, “I’ve been feeling interested in other people”), and positive functioning (eg, “I’ve been feeling useful”) in general populations, including university students.37 Items are scored along a five-point scale from “none of the time” to “all of the time.” Summing scores provides an overall well-being score with a theoretical range of 14-70, where higher scores indicate greater positive mental well-being. According to available population data, the mean (SD) WEMWBS score is 50.7 (8.32).38
Following reliability analysis (Cronbach alpha) of the ARS-30 and WEMWBS, comparative analyses were conducted using independent and one-sample t tests (sample means with population norms, gender, first-choice course, and first-choice university), and analysis of variance (ANOVA) with Tukey post hoc comparisons (ethnicity, school, and year of study). Effect size was calculated using Cohen d for independent t test results and eta-squared (η2) for ANOVA results.39,40 Pearson correlation and regression were used to explore the relationship between academic resilience and mental well-being. Findings were considered significant at a p ≤ .05.
RESULTS
Of the 1586 students invited, 1161 students responded, representing a 73% response rate and reduced risk of sampling bias. The highest and lowest response rate was recorded for first-year (84%) and fourth-year students (48%), respectively, and for school A (79%) and school C (62%), respectively, with the low response (24%) from fourth-year students in school C potentially explaining its low overall response rate (Table 1). The majority of respondents were female (72%), and the largest ethnic group represented overall was White (38%), followed by Asian (34%). The UK application process allows students to select one first (firm) and one second (insurance) choice university/course place offer. Students failing to meet entry requirements for their firm or insurance offer must seek an alternative offer through the “clearing” process. The majority of respondents had secured their MPharm place through firm or insurance choices (57%), were attending their first-choice university (78%), and had chosen pharmacy as their first-choice course (76%) (Table 2).
Response Rate by School and Year of Study of Pharmacy Students Who Participated in a Large-scale Multicenter UK Study of Academic Resilience
Demographics of Pharmacy Students Who Participated in a Large-scale Multicenter UK Study of Academic Resilience by School of Pharmacy (N=1161)a
Reliability analysis estimating internal consistency supported the reliability of the ARS-30 in the present study, α=.89 (overall scale), α=.83 (perseverance subscale), α=.79 (reflecting and adaptive help seeking subscale), and α=.79 (negative affect and emotional response subscale). A value of α≥.07 is routinely cited in the literature as acceptable. The WEMWBS also demonstrated acceptable internal consistency reliability, α=.90.
One sample t test comparisons with published norms for the ARS-30 and WEMWBS11,37,38 (Table 3) demonstrated that pharmacy students had significantly lower academic resilience (mean=108.4 vs.115.6, t(1079)=17.1, p<.001, large effect size d=13.85), well-being (mean=46.4 vs. 50.7, t(1118)=16.98, p<.001, large effect size d=8.57), and scored lower on all academic resilience subscales (perseverance mean=55.7 vs. 59.2, t(1114)=16.87, p<.001, large effect size d=6.94; reflection and help seeking mean=33.3 vs. 35.41, t(1138)=13.37, p<.001, large effect size d=5.34; negative affect and emotional response mean=19.4 vs. 21.0, t(1134)=11.26, p<.001, large effect size d=4.92) than comparable student populations.
Mean Academic Resilience and Well-being Scores of Pharmacy Students Who Participated in a Large-scale Multicenter UK Study of Academic Resilienceby
Correlational analysis revealed a significant medium positive correlation between overall academic resilience and well-being (r(1047)=0.47, p<.001). The ARS-30 subscales also showed medium positive correlations with well-being (perseverance r(1079)=0.37, p<.001; reflection and help seeking r(1101)=0.3; negative affect and emotional response p<.001, r(1095)=0.46, p<.001). Regression analysis demonstrated that academic resilience was a significant predictor for well-being (b=.3, t(1047)=17.34, p<.001), explaining 22% of variance in well-being scores (R2=.22, F(1, 1047)=300.51, p<.001). Multiple regression exploring ARS-30 subscales as predictors for well-being showed that the model was significant (R2=.26, F(3, 1045)=123.66, p<.001), explaining 26% of variance, with all subscales identified as significant predictors for well-being (perseverance b=.19, t(1045)=3.92, p<.001; reflecting and help seeking b=.19, t(1045)=3.3, p<.001; negative affect and emotional response b=.643, t(1045)=12.6, p<.001).
Table 4 presents mean academic resilience scores for each of the demographic data sets. Male students had higher mean scores, indicating greater resilience, than female students for overall academic resilience, perseverance, and negative affect and emotional response, but a lower mean score for reflecting and adaptive help seeking. However, only differences in negative affect and emotional response (t(1116)=5.33, p<.001, small to moderate effect size d=0.35) and reflecting and adaptive help seeking (t(1121)=−2.31, p<.05, small effect size d=0.15) subscales reached significance.
Overall Academic Resilience and Academic Resilience Subscale scores by Demographics for Pharmacy Students Who Participated in a Large-scale Multicenter UK Study of Academic Resilienceby
Comparisons according to ethnic group suggested White students had the lowest mean overall academic resilience score and Black students had the highest. However, differences in overall academic resilience between ethnic groups did not reach significance (F(4, 1067)=1.05, p>.05). While separate ANOVAs suggested a significant effect of ethnic group for the reflecting and adaptive help seeking subscale (F(4, 1126)=3.01, p<.01, small effect size η2=0.01), post hoc pairwise comparisons were not significant (p>.05).
The ANOVAs confirmed a significant small to moderate effect of year of study for overall academic resilience (F(3, 1067)=16.89, p<.001, effect size η2=0.05), and for the three subscales, perseverance (F(3, 1111)=15.59, p<.001, effect size η2=0.04), reflecting and help seeking (F(3, 1135)=13.90, p<.001, effect size η2=0.04), and negative affect and emotional response (F(3, 1131)=14.83, p<.001, effect size η2=0.04). First-year students reported significantly higher overall academic resilience (p<.01) and subscale scores than all other years (p<.05), with the exception of fourth-year students, where differences in perseverance did not reach significance (p>.05). Third-year students scored significantly lower for negative affect and emotional response (indicating lower resilience) than all other years (p<.05), while second-year students scored significantly lower on reflecting and help seeking and perseverance than third- and fourth-year students, respectively (p<.01).
Overall academic resilience (F(2, 1077)=3.68, p<.05, small effect size η2=0.01) and perseverance (F(2, 1112)=10.66, p<.01, small effect size η2=0.02) varied significantly according to pharmacy school; school C scored significantly lower on overall academic resilience than school A (p<.05) and significantly lower on perseverance than both schools A and B (p<.001).
Small differences in academic resilience according to how students secured their place on the course and whether students did or did not attend their first-choice university or first-choice course were not significant (p>.05), with the exception of perseverance scores, which were significantly higher for students attending their first-choice university (t(1104)=2.14, p<.05, small effect size d=0.15).
DISCUSSION
As the first study investigating academic resilience in UK pharmacy students, the principal aim was to explore the relationship between academic resilience and well-being and identify demographic and situational factors explaining variations in academic resilience and well-being. Consistent with previous literature reporting poor well-being in health care students,14,41 pharmacy students reported significantly lower academic resilience and mental well-being2 compared with normative data from comparable student populations, highlighting the need to introduce measures addressing poor student well-being as a priority for pharmacy education. Critically, in a field where correlates and predictors of resilient outcomes such as well-being are “uniformly modest,”42 the study found a significant positive relationship between academic resilience and well-being and identified academic resilience as a significant predictor of well-being. Findings are similar to previous studies reporting an association between higher academic resilience and improved well-being and academic outcomes in health care students,14,26,41,43,44 suggesting that cultivating academic resilience in pharmacy education will benefit pharmacy student well-being and academic outcomes.
Interest in student resilience in higher education continues to grow,32 with emerging evidence regarding interventions to enhance academic resilience.45 Positive relationships, self-confidence, productive failure, and emotion regulation are common features of these interventions, but developing and targeting interventions based on evidence and insight into particular student populations is likely to lead to improved outcomes.45 Thus, findings from the present study indicating that gender, year of study, pharmacy school, and attending first-choice pharmacy school all influence academic resilience provide valuable insight to help inform and tailor academic resilience interventions in pharmacy education according to environmental, organizational, and cohort-specific contexts, as suggested by Brewer and colleagues.32 Despite a trend toward male students exhibiting greater overall academic resilience, significant differences were only identified for negative affect and emotional response, for which male students exhibited greater resilience, and reflecting and adaptive help seeking, for which female students exhibited greater resilience. Male students are, therefore, likely to benefit from training in reflection and identifying and using support, whereas female students might find interventions focusing on emotion regulation strategies more valuable.
Other studies have conceptualized resilience as a dynamic process and charted fluctuations over time, reporting that “organizational newcomers” are more resilient, explained in terms of less pronounced emotional exhaustion.46 This is supported by findings here of a trend toward declining academic resilience from the first to the fourth year, with first-year students reporting significantly higher academic resilience than all other years and third-year students reporting significantly lower emotional academic resilience. The second-year students’ lower scores on perseverance and reflecting and help seeking may be indicative of increasing academic, social, and developmental demands, as these students are facing further transitional challenges.47 Similar gender and year of study differences have been reported in US pharmacy students.33 While higher education typically directs support toward first-year students, easing their transition,32 greater emphasis on tailored interventions targeted at second-, third-, and fourth-year students appears equally justified to maintain and enhance resilience and improve well-being.
Additionally, for students not attending their first-choice pharmacy school, academic self-efficacy could have been negatively affected by their having failed to achieve their expected academic entry grades; lower academic self-efficacy could also help explain the lower academic resilience reported for these students.2,11 These students might find particular value in resilience training emphasizing productive failure, safe-to-fail, and self-efficacy. Furthermore, school C, which has an established profile of lower end point pass-rates than the two other schools in the study, reported lower academic resilience than the other two schools. This may represent evidence of an association between resilience and academic attainment, further emphasizing the value of identifying low academic resilience in pharmacy students and introducing measures to address this and mitigate its impact on academic attainment and professional qualification. In line with previous research, no differences in academic resilience according to ethnicity were found.33,43,48
Further insight could be gained by adopting a longitudinal design with multiple data points, including measures of academic performance and other educational outcomes such as progression and retention/attrition, and considering age and socioeconomic background. Such a study would have provided information on the nature of the temporal trajectory of academic resilience and increased the scope of the study. Finally, the lowest response rate was recorded in fourth-year students in school C, the only year group to be invited to complete the study online, suggesting that in-person completion may lead to higher response rates. In general, future research in the area, and in pharmacy education in particular, should focus on evaluating interventions in terms of increased academic resilience and student well-being and collect outcome data, including retention, academic attainment and professional qualification, to evaluate the measurable impact of increased academic resilience and well-being.
CONCLUSION
The lower levels of academic resilience and mental well-being reported by pharmacy students, along with the predictive relationship between academic resilience and well-being identified in the study, provide evidence of the need for interventions that cultivate and enhance academic resilience with the aim of improving well-being and overall education and professional outcomes in pharmacy education. Current accreditation standards, which focus on the well-being of patients and not pharmacy students or professionals, need reviewing and may need broadening. In the meantime, pharmacy schools should consider implementing program-based interventions designed to address low academic resilience and poor mental well-being.49 Analysis of demographic data presented a nuanced temporal and situational resilience trajectory, providing the basis to better tailor and target interventions to the needs of pharmacy students, thus improving the effectiveness of interventions. The study also provides further evidence supporting the reliability and validity of the ARS-30 as a measure of academic resilience in pharmacy students so that it can, as is suggested, be used to evaluate resilience and well-being interventions, a much-needed avenue for future research and practice in pharmacy education. As the largest study of academic resilience among pharmacy students and the first of its kind within the United Kingdom, this study provides an important and valuable addition to the limited literature, with the potential to impact pharmacy education, and education more generally, at an international level.
- Received December 15, 2021.
- Accepted March 21, 2022.
- © 2023 American Association of Colleges of Pharmacy
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