Relationship between pharmacy students’ resilience scores and their leadership,work experience and academic performance

Abstract

The goal is to examine if there is a relationship between students’ Resilience Scale for Adults (RSA) Scale scores, demographics, work experience, leadership style, personality types and academic performance. Three cohorts of third-year pharmacy (P3) students completed the RSA and demographic questions. Students’ academic performance, work experience, leadership preferences and demographics were compared. Over 850 students from three cohorts scored on five RSA dimensions – personal competence (4.10 ± 0.58), social competence (3.64 ± 0.75), family coherence (4.18 ± 0.73), social support (4.47 ± 0.59) and personal structure (3.93 ± 0.70) (5 = highest resilience). Social competence and personal structure scores were statistically significantly different from other dimensions. Students with greater work experience, preference for leadership and extroverted personality types had higher scores in social competence and personal structure. Based on this research, it is essential to foster leadership development and encourage work experience to support students in building relationships (social competence) and improving organizational skills (personal structure), since the lowest RSA scores were in these two domains.

Keywords

Resilience leadership work experience large classroom

Healthcare is a complex and stressful field that increasingly impacts resilience and psychological wellbeing (Beck et al., 1997; Lea et al., 2012; Marshall et al., 2008; Matheson et al., 2016; Nahrgang et al., 2011). Healthcare professionals must remain resilient and must be able to handle stress to provide appropriate care to their patients (Mospan and Olenik, 2018; Nahrgang et al., 2011; Schommer et al., 2020). Researchers have evaluated various healthcare professionals to identify ways of decreasing burnout and enhancing wellbeing and resilience (Action Collaborative on Clinician Well-Being and Resilience., n.d.; Cain, 2020; Marshall et al., 2008; Matheson et al., 2016; Mospan and Olenik, 2018; Payakachat et al., 2014; Schommer et al., 2020). Introducing coping mechanisms to students is essential in creating an effective and resilient practitioner.

The educational guidelines for pharmacy expect that pharmacy graduates have developed the skills necessary to be effective members of the healthcare team (Accreditation Council for Pharmacy Education, n.d.; CAPEoutcomes2013.pdf, n.d.). The 2013 educational outcomes published by the US Center for the Advancement of Pharmacy Education (CAPE) outline capabilities of practice-ready pharmacists, including “the ability to be self-aware and examine and reflect on personal knowledge, skills, abilities, beliefs, biases, motivation and emotions that could enhance or limit personal and professional growth” (CAPEoutcomes2013.pdf, n.d.). Additionally, the Accreditation Council for Pharmacy Education (ACPE) Standards 2016 include key elements of self-awareness and leadership (Accreditation Council for Pharmacy Education, n.d.).

The capacity to be successful and healthy regardless of challenges is extremely important. Adjusting to stress is essential for maintaining day-to-day functioning. For students, this means being able to attend class productively, study, complete projects, perform during internships and rotations and remain physically and emotionally healthy. Stress and the associated decreased quality of life have been well documented in the literature (Gupchup et al., 2004; Hirsch et al., 2009; Marshall et al., 2008; Schommer et al., 2020; Tempski et al., 2015). Resilience is a multifactorial concept, drawing from experiences from the past and ideas for the future. It is the ability to endure, conquer and recover from adversities without developing significant medical or psychological complications (Chow et al., 2018; Definition of RESILIENCE, n.d.; Matheson et al., 2016; Stoffel and Cain, 2018). Academic resilience is defined as an increased probability of academic success despite stressful events and situations (Cassidy, 2015; Chisholm-Burns et al., 2018).

Resilience has been discussed in the context of healthcare education (Chisholm-Burns et al., 2018; Gruenberg et al., 2019; Stoffel and Cain, 2018; Tempski et al., 2015; Walker et al., 2006) while also gaining interest in the work–life balance arena (Mospan and Olenik, 2018). In medical students there is pressure to perform, leading to high rates of burnout, psychological stress, anxiety and depression (Dyrbye et al., 2006; Hojat et al., 1999; Paro et al., 2010). Baccalaureate and postgraduate nursing programs report comparable levels of anxiety and stress (Beck et al., 1997; Chow et al., 2018; Kaur and Maheshwari, 2015). Similar data are emerging regarding stress and anxiety in pharmacy students (Gupchup et al., 2004; Hirsch et al., 2009; Marshall et al., 2008; Payakachat et al., 2014; Schommer et al., 2020). A study by Tempski et al. showed that Brazilian medical students with very low resilience had worse overall and professional quality of life, physical/psychological health and social relationship scores. They also had a lower perception of their educational environment (Tempski et al., 2015).

Low resilience can also negatively impact students’ work abilities (Hall et al., 2016), and may even have implications for patient health. Baldwin et al. observed Scottish medical students, comparing work conditions to perceptions of work performance: “feeling overwhelmed” was correlated with an increased number of mistakes (Baldwin et al., 1997). Difficulty in coping with stress, burnout and low resilience can lead to reductions in healthcare workers’ performance (Hall et al., 2016; Nahrgang et al., 2011). How to help students improve their ability to handle stress and be more resilient is less well studied.

Recently several pharmacy publications have evaluated resilience and its relationship to academic success and quality of life (Cain, 2020; Gruenberg et al., 2019; Hagemeier et al., 2020; Kaur et al., 2020; Stoffel and Cain, 2018). Some suggest that these attributes should be part of the admissions process for PharmD programs (Gruenberg et al., 2019; Hammond, 2017). Kaur et al. (2020) assessed the relationship of burnout to students’ perception of their academic ability and found that emotional exhaustion was connected to professional inefficacy and academic self-perception. Hagemeier et al. (2020) explored the relationship between first-year PharmD students’ wellbeing scores and grade point averages (GPAs) for the fall semester and found a positive correlation. Gruenberg et al. (2019) evaluated the link between grit, academic outcome and residency match rates, and did not find a significant relationship between grit and academic or professional achievement.

Due to the subjective nature of resilience, stress and success, it is difficult to measure accurately the impact these factors have on students’ lives. A number of scales have been designed to address this difficulty. For the purpose of our research, we focused on the Resilience Scale for Adults (RSA). RSA was originally authored by Friborg et al. (2003) and was evaluated by Windle et al. (2011). This validated tool covers five dimensions measuring healthy adjustment to life stressors: ‘personal competence’ (12 statements), ‘social competence’ (10 statements), ‘family coherence’ (7 statements), ‘social support’ (9 statements) and ‘personal structure’ (5 statements). The RSA scale was developed to help quantify and identify the protective factors important to adult resilience (Friborg et al., 2003, 2005).

Our project had multiple objectives. We wanted to evaluate the resilience of pharmacy students in a standardized manner using the RSA scale. Additionally, we were interested in ascertaining whether some demographic attributes, personality traits or leadership role preferences affected resilience and whether resilience was correlated with academic achievement.

Methods

Third-year pharmacy (P3) students enrolled in the required ‘Over-the-Counter Drugs/Self-Care’ course were invited to participate in this research. At the start of the fall semester, we collected student demographic data including gender, level of English proficiency, Myers-Briggs personality preferences/types, leadership role preference and pharmacy work experience. Based on their previous work experience and team-based school work (e.g., Capstone Project), students were invited to self-select their leadership role preference from “Leader/Prefer Leading”, “Balanced” and “Follower/Prefer Following”. Additionally, they self-selected their level of work experience from “A lot” (defined by students as more than 1 year or generally more than 16 h per week), “Some” (defined by students as less than 1 year or generally under 16 h per week) and “Little/none” (defined by students as limited to rotations or less than 6 months). The researchers collected data over 3 years to help inform enhancements to planned curriculum revision. Students completed a questionnaire from the RSA adapted from Friborg et al. from the University of Tromsø, Norway, utilizing a Likert scale to indicate strong disagreement (1) to strong agreement (5) on each item (Friborg et al., 2003). (The original RSA contained 43 items, but six were removed by Friborg et al.) The Likert scores for each dimension were added and divided by the number of questions to calculate the RSA dimension scores for each student. Scores closer to five indicate higher resilience. At the end of the semester, students’ academic performance data (via GPAs, quiz and exam score averages) were evaluated to ascertain relationships with the RSA dimension scores and demographics. Students’ GPAs were provided by the university’s Registrar. A GPA of 3.0 or higher (B or above) was chosen to indicate stronger academic performance over time consistent with a level of an Honor Roll.

The university’s Institutional Review Board approved this research and survey instrument. An email was sent to students with an informed consent form and a link to the survey. Clicking on the link implied consent and voluntary participation. Students received one bonus point on their final exam for participating in the study. The data included in the study are only from those students who consented to participate.

The Qualtrics® (Qualtrics, Provo, UT) (Qualtrics Software, Version XM, Copyright © 2020, n.d.) platform tabulated the responses and provided descriptive statistics. Unpaired t-tests or analysis of variance (ANOVA) with Tukey-Kramer multiple comparisons were used to evaluate significant differences in mean assessments between student responses to RSA, demographics, leadership role preference and work experience. All analyses were performed using NCSS 2007© (East Kaysville, UT). (NCSS Statistical Software, Version 2007. Copyright © 2020, NCSS,LLC, East Kaysville, Utah, n.d.) Results were considered statistically significant if the observed level of significance was p < .05.

Results

Over three years, 886 students enrolled in the course and 856 (97%) consented to participate in the study: 64.7% were female, and 83% were between the ages of 22 and 23. Students responded to each of the 37 statements in the RSA tool categorized under five different dimensions (Table 1). Specific statements are included in Table 1 to help the reader appreciate the components of each dimension. No statistically significant differences were noted between the resilience scores of all three cohorts (Years 1, 2 and 3) (Table 2), and therefore we are discussing the results of all students collectively as one group. Students scored statistically significantly lower in social competence and personal structure and higher in the other RSA dimensions (Table 2).

Table 1.

Resilience scores for adults’ questionnaire (percentage of n = 856 student responses to each question).

Resilience group/items	Level of agreement (% responses, n = 856)
Personal Competence	1	2	3	4	5	Av. score
I believe in my own abilities	1	2	15	42	40	4.19
Believing in myself helps me to overcome difficult times	1	5	16	33	46	4.17
I know that I succeed if I carry on	1	2	11	38	48	4.31
I know how to reach my goals	1	3	21	43	33	4.04
No matter what happens I always find a solution	1	5	25	40	30	3.94
My future feels promising	1	4	16	36	42	4.13
I know that I can solve my personal problems	1	3	16	40	40	4.15
I am pleased with myself	2	4	24	41	29	3.93
I have realistic plans for the future	2	3	12	36	47	4.24
I completely trust my judgements and decisions	1	4	25	45	25	3.90
Social competence
I am good at getting in touch with new people	4	18	30	27	20	3.39
I easily establish new friendships	4	15	31	29	20	3.46
It is easy for me to think of good conversational topics	8	17	35	27	13	3.21
It is easy for me to make other people laugh	4	11	34	30	21	3.51
I enjoy being with other people	3	8	29	37	24	3.70
I easily laugh	2	5	14	32	47	4.18
It is important for me to be flexible in social circumstances	1	3	22	42	34	4.05
Family coherence
There are strong bonds in my family	1	4	9	22	63	4.41
I enjoy being with my family	1	2	11	21	65	4.48
In our family we are loyal towards each other	1	2	8	22	67	4.53
In my family we enjoy finding common activities	3	9	21	28	39	3.91
Even at difficult times my family keeps a positive outlook on the future	2	4	16	28	51	4.21
In my family we have a common understanding of what’s important in life	2	5	12	26	55	4.28
There are few conflicts in my family	7	15	26	28	24	3.48
Social support
I have some close friends/family members who really care about me	1	0	4	15	81	4.75
I have some friends/family members who back me up	1	1	5	17	77	4.68
I always have someone who can help me when needed	1	3	7	19	70	4.55
I have some close friends/family members who are good at encouraging me	1	2	8	22	67	4.53
I am quickly notified if some family members get into a crisis	1	4	13	32	50	4.24
I can discuss personal matters with friends/family members	2	5	13	30	50	4.20
I have some close friends/family members who value my abilities	0	1	8	28	63	4.51
There are strong bonds between my friends	1	3	13	29	55	4.34
Personal structure
Rules and regular routines make my daily life easier	1	3	20	37	39	4.08
I keep up my daily routines even at difficult times	5	14	31	34	16	3.43
I prefer to plan my actions	1	4	19	38	39	4.09
I work best when I reach for a goal	0	1	14	36	48	4.30
I am good at organizing my time	3	8	28	31	29	3.74

Note: 1 = Strongly Disagree; 5 = Strongly Agree.

Source: Instrument adapted from Friborg et al. (2003).

Table 2.

RSA dimension scores between student cohorts (mean ± SD).

RSA dimensions	Year 1 (n = 270)	Year 2 (n = 301)	Year 3 (n = 285)	Total (n = 856)
Personal competence	4.11 ± 0.55	4.10 ± 0.60	4.09 ± 0.60	4.10 ± 0.58
Social competence	^*3.68 ± 0.70	^*3.56 ± 0.78	^*3.70 ± 0.76	^*3.64 ± 0.75
Family coherence	4.18 ± 0.74	4.17 ± 0.71	4.21 ± 0.74	4.18 ± 0.73
Social support	4.48 ± 0.60	4.44 ± 0.62	4.50 ± 0.56	4.47 ± 0.59
Personal structure	^*3.95 ± 0.61	^*3.92 ± 0.72	^*3.92 ± 0.76	^*3.93 ± 0.70

Note: *Mean score is significantly lower than that for personal competence, family coherence, social support and overall resilience within the same column, p < .05. Scores closest to 5 indicate higher resilience.

Since our long-term goal is to understand how to increase overall resilience, we specifically focused on characteristics and their correlation with social competence and personal structure, for which students scored lowest. Three characteristics (English language proficiency, over-the-counter drugs/self-care course quiz and exam average) showed no statistically significant differences in relationship with the scores in these two dimensions. In addition, three Myers-Briggs personality preferences (sensing/intuition, thinking/feeling and judging/perceiving) showed no statistically significant relationship to social competence and personal structure scores. Other characteristics (female gender, extrovert/introvert Myers-Briggs personality preferences, GPAs, work experience and leadership role preference) were associated with statistically significantly different scores in these two dimensions (Table 3).

Table 3.

Social competence and personal structure scores and gender, personality type, GPA, work experience and leadership style (mean ± SD).

	Social competence		Personal structure
Gender	Male (n = 301)	Female (n = 554)	Male (n = 301)	Female (n = 554)
Gender	3.62 ± 0.83	3.65 ± 0.71	3.86 ± 0.68^x	3.97 ± 0.71^x
Myers-Briggs personality type	Extrovert (n = 429)	Introvert (n = 427)	Extrovert (n = 429)	Introvert (n = 427)
Myers-Briggs personality type	4.06 ± 0.56^a	3.23 ± 0.69^a	4.01 ± 0.67^x	3.84 ± 0.72^x
GPA	3.0 or higher (n = 544)	Below 3.0 (n = 296)	3.0 or higher (n = 544)	Below 3.0 (n = 296)
GPA	3.61 ± 0.75^a	3.72 ± 0.74^a	3.99 ± 0.71^x	3.82 ± 0.66^x

	Social Competence			Personal structure
Work experience	A lot (n = 383)	Some (n = 229)	Little/none (n = 244)	A lot (n= 383)	Some (n = 229)	Little/none (n = 244)
Work experience	4.05 ± 0.69^a	3.69 ± 0.75^b	3.42 ± 0.74^a,b	4.05 ± 0.69^x	3.94 ± 0.67^y	3.72 ± 0.70^x,y
Leadership style	Leader/prefer leading (n = 204)	Balanced (n = 270)	Follower/prefer following (n = 382)	Leader/Prefer leading (n = 204)	Balanced (n = 270)	Follower/prefer following (n = 382)
Leadership style	4.01 ± 0.70^a,b	3.76 ± 0.69^a,c	3.36 ± 0.71^b,c	4.12 ± 0.68^x,y	3.92 ± 0.70^x	3.83 ± 0.69^y

Note: ^a,b,c,x,y values sharing a common superscript within a row are statistically significant, p < .05. Scores closest to 5 indicate higher resilience.

Female students had no difference in social competence scores, but had statistically significantly higher personal structure scores than males. Extroverted students had higher social competence and personal structure scores than introverts. Students with higher GPAs scored lower on social competence but higher on personal structure. Students with the least work experience (Little/None) scored lowest on social competence and personal structure. Those with a preference for leadership scored highest on social competence and personal structure (Table 3).

Discussion

The conversation about wellbeing has become commonplace in healthcare circles. Practitioners and students are recognizing that their success is dependent on their ability to handle change and to deal with stress and burnout(Brazeau, 2018; Mospan and Olenik, 2018; Schommer et al., 2020; Stoffel and Cain, 2018). Recently, researchers have begun to differentiate between general resilience (Friborg et al., 2003, 2005) and academic resilience (Chisholm-Burns et al., 2018). In this research we evaluated a number of traits, with some being more modifiable (e.g., work experience, leadership and GPA) than others (e.g. personality types and gender).

In our students, the three highest resilience scores were in ‘social support’, ‘family coherence’ and ‘personal competence’. The results suggest that higher resilience scores are derived from having strong support from family and friends and belief in one’s own abilities. Lower scores in ‘personal structure’ and ‘social competence’ suggest the need to develop organizational skills and learn to establish new friendships. Females scored slightly higher on social competence and statistically significantly higher on personal structure.

Our results suggest that extroverted students are more resilient than their introverted peers. It was not surprising to us that these students scored higher on social competence, but we are not fully able to explain why extroverted students scored higher on personal structure. Even though personality seems to be inherent to each individual, we know that it is possible to acquire new characteristics that are typically attributed to someone with the opposite personality type. Based on this research, students with extroverted tendencies will have greater social competence characteristics. Therefore, it may be helpful to share with introverted students how to communicate better with others to build supportive and meaningful relationships.

Students with higher GPAs appeared to have higher personal structure scores, which makes sense since they may be more organized and have better established rules and routines. We were surprised that the same group of students scored lower on the social competence scale than those with lower GPAs. We were unable to determine whether this group of students spent more time studying and had less time to socialize, and therefore had lower social competence scores.

Two areas that stood out were pharmacy work experience and leadership. In many professional programs, the intensity of academic study can prevent students from seeking work experience. Moreover, international students (about 20% of our students) are unable to work during their program. Since having little or no work experience appears to be associated with lower resilience scores, we believe that seeking employment or even shadowing should be encouraged whenever possible, even if only during the summer months.

In our opinion, compared to followers, leaders perceive that they have greater control of their circumstances. Making decisions helps leaders to feel more autonomous and therefore more resilient. We believe that leaders are made, not born; therefore more attention should be paid in academia to developing leaders and fostering leadership skills. Leadership styles can vary a great deal and are not dependent on personality, as is commonly believed by students. Research also suggests that a growth mindset contributes to resilience where effort and hard work increase skill and confidence (Duckworth, n.d.). Students should be encouraged to cultivate a growth mindset and explore leadership styles to find the best fit. Additionally, during turbulent times such as the recent global pandemic, leadership skills like enthusiasm and forward thinking can help facilitate wellbeing (Brazeau et al., 2020). Leadership development is a desired CAPE Outcome and is also noted in multiple areas of the ACPE 2016 Standards (Accreditation Council for Pharmacy Education, n.d.; CAPEoutcomes2013.pdf, n.d.).

The high percentage of international students in our program could be a confounding factor influencing lower social support and lower social competence scores due to their need to adjust to a different culture and being far from family and friends. Most of the literature on social skills and social competence evaluates youth and adolescents; little is available on college students. Our research confirms that students are struggling to maintain routines during difficult times (like examination weeks) and organizing their time. Some of the strategies that have been recommended in the literature to improve organizational skills and goal setting include training students on the use of continuing professional development, via either recorded or live sessions on SMART learning objectives (Tofade et al., 2012), encouraging additional co-curricular activities (Vos et al., 2018) and requiring reflective journal writing (Hughes et al., 2019) to foster goal setting and attainment. Our university is exploring the expansion of its co-curricular offerings as well as including content and opportunities for students to practice setting SMART goals earlier in the educational program. We are also exploring encouraging students to adopt healthy behaviors to enhance resilience, as supported by Cain (2020).

This research has some limitations. It was performed in one pharmacy school and the results may not be applicable to other schools. Due to the large sample size, in some areas where statistical significance was demonstrated the findings might not have a practical significance (for example, female versus male gender). Although a Myers-Briggs personality assessment was given, 16 different composite types were not evaluated. Only specific characteristics were analyzed. Leadership preferences were only self-selected; in future research better parameters for leadership preferences should be utilized. Students received one bonus point on one exam for participation. Responses to stress and coping mechanisms are multifaceted, based on maturity, experience, cultural norms and current circumstance. Even though we utilized a validated tool for general resilience, this measurement was taken at one point in time, and might not reflect the true multifactorial nature of resilience.

Conclusion

Preference to lead, greater work experience and extrovert personality traits seem to be associated with higher social competence and personal structure scores in pharmacy students. Based on this research, it is essential to foster leadership development and encourage work experience to support students in building relationships (social competence) and improving organizational skills (personal structure) since the lowest RSA scores were in these two domains.

Further research should focus on whether encouraging students to gain more work experience and develop leadership skills will ultimately decrease long-term burnout, enhance students’ overall resilience and wellbeing, develop confidence and advance the pharmacy profession.

Contribution to the literature

We looked at several variables, including leadership, work experience, personality type and academic performance, to determine whether any could potentially affect resilience. Our sample included 856 pharmacy students. Such a large number of students has not been captured in the published literature on resilience in pharmacy education. This research will assist in identifying areas for integration into pharmacy programs to help students develop stronger resilience.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Lana Dvorkin Camiel

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