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BMC Medical Education

Journal Abbreviation: BMC MED EDUC Journal ISSN: 1472-6920

About BMC Medical Education

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BMC Medical Education

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• Medicine (miscellaneous)

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The set of journals have been ranked according to their SJR and divided into four equal groups, four quartiles. Q1 (green) comprises the quarter of the journals with the highest values, Q2 (yellow) the second highest values, Q3 (orange) the third highest values and Q4 (red) the lowest values.

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BMC Medicine

Research: Prevalence of diabetic cardiomyopathy

An analysis of electronic health records suggests diabetic cardiomyopathy affects a significant proportion of patients with type 2 diabetes (T2D), suggesting that routine echocardiography should be better utilized in the management of T2D patients.

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Qualitative themes on the implementation and benefits of an intervention to allow families access to funds for healthy foods were derived for use in improving the schemes further rollout.

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BMC Medicine  is recruiting new Editorial Board Members. To increase our engagement with the Editorial Board and community at large, we are recruiting Editorial Board Members to be part of a collaborative editorial model whereby Editorial Board Members assess manuscripts in their area of expertise alongside the in-house Editorial team. To apply, click here .

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BMC Medicine is the flagship medical journal of the BMC series. An open access, transparent peer-reviewed general medical journal, BMC Medicine publishes outstanding and influential research in all areas of clinical practice, translational medicine, medical and health advances, public health, global health, policy, and general topics of interest to the biomedical and sociomedical professional communities. We also publish stimulating debates and reviews as well as unique forum articles and concise tutorials. 

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2022 Citation Impact 9.3 - 2-year Impact Factor 10.4 - 5-year Impact Factor 3.011 - SNIP (Source Normalized Impact per Paper) 3.447 - SJR (SCImago Journal Rank)

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Volume 20, issue 1, December 2020

499 articles in this issue

The impact of death and dying on the personhood of medical students: a systematic scoping review

Authors (first, second and last of 20).

• Chong Yao Ho
• Cheryl Shumin Kow
• Lalit Kumar Radha Krishna
• Content type: Research article
• Open Access
• Published: 28 December 2020
• Article: 516
• Curriculum development

Impact of simulation-based teamwork training on COVID-19 distress in healthcare professionals

Authors (first, second and last of 8).

• Anna Beneria
• Mireia Arnedo
• Jordi Bañeras Rius
• Published: 21 December 2020
• Article: 515
• Career choice, professional education and development

Viva la VOSCE?

Authors (first, second and last of 6).

• J. G. Boyle
• I. Colquhoun
• Content type: Correspondence
• Published: 18 December 2020
• Article: 514
• Assessment and evaluation of admissions, knowledge, skills and attitudes

Correction to: Distance learning in clinical medical education amid COVID-19 pandemic in Jordan: current situation, challenges, and perspectives

• Mahmoud Al-Balas
• Hasan Ibrahim Al-Balas
• Bayan Al-Balas
• Content type: Correction
• Published: 16 December 2020
• Article: 513

Video-based, student tutor- versus faculty staff-led ultrasound course for medical students – a prospective randomized study

• Christine Eimer
• Max Duschek
• Gunnar Elke
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• Approaches to teaching and learning

Characteristics of dental note taking: a material based themed analysis of Swedish dental students

Authors (first, second and last of 4).

• Viveca Lindberg
• Sofia Louca Jounger
• Nikolaos Christidis
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Mixed reality for teaching catheter placement to medical students: a randomized single-blinded, prospective trial

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Vertical integration in medical education: the broader perspective

• Marjo Wijnen-Meijer
• Sjoukje van den Broek
• Olle ten Cate
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• Published: 14 December 2020
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Vaccination perception and coverage among healthcare students in France in 2019

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How does cognitive function measured by the reaction time and critical flicker fusion frequency correlate with the academic performance of students?

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• Tianjiao Du
• Published: 11 December 2020
• Article: 505

Peer assessment of professionalism in undergraduate medical education

• Vernon R. Curran
• Nicholas A. Fairbridge
• Diana Deacon
• Article: 504

Medical students’ self-reported gender discrimination and sexual harassment over time

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• Sofia Kühner
• Anna Rask-Andersen
• Published: 10 December 2020
• Article: 503

Preparing lifelong learners for delivering pharmaceutical care in an ever-changing world: a study of pharmacy students

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Doctors in Chinese public hospitals: demonstration of their professional identities

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Effects on applying micro-film case-based learning model in pediatrics education

• Published: 09 December 2020
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Developing an interprofessional transition course to improve team-based HIV care for sub-Saharan Africa

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Simulation training for emergency skills: effects on ICU fellows’ performance and supervision levels

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Collaborative knotworking – transforming clinical teaching practice through faculty development

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Temporal changes in emotional intelligence (EI) among medical undergraduates: a 5-year follow up study

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Advising special population emergency medicine residency applicants: a survey of emergency medicine advisors and residency program leadership

• Alexis E. Pelletier-Bui
• Caitlin Schrepel
• Emily Hillman
• Published: 07 December 2020
• Article: 495

Peer mentoring experience on becoming a good doctor: student perspectives

• Mohd Syameer Firdaus Mohd Shafiaai
• Amudha Kadirvelu
• Narendra Pamidi
• Article: 494

An interpretive phenomenological analysis of formative feedback in anesthesia training: the residents’ perspective

• Krista C. Ritchie
• Ronald B. George
• Article: 493

Team-based learning replaces problem-based learning at a large medical school

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• Jane Bleasel
• Article: 492

Simulated patient and role play methodologies for communication skills and empathy training of undergraduate medical students

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• Cristina Bagacean
• Ianis Cousin
• Christian Berthou
• Published: 04 December 2020
• Article: 491

How much is needed? Patient exposure and curricular education on medical students’ LGBT cultural competency

• Dustin Z. Nowaskie
• Anuj U. Patel
• Article: 490

Impact of a web-based module on trainees’ ability to interpret neonatal cranial ultrasound

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• Sean McAleer
• Published: 03 December 2020
• Article: 489

Effectiveness of blended learning versus lectures alone on ECG analysis and interpretation by medical students

• Charle André Viljoen
• Rob Scott Millar
• Vanessa Celeste Burch
• Article: 488

Active learning of medical students in Taiwan: a realist evaluation

• Chien-Da Huang
• Hsu-Min Tseng
• Liang-Shiou Ou
• Article: 487

A best-worst scaling survey of medical students’ perspective on implementing shared decision-making in China

• Richard Huan XU
• Lingming ZHOU
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• Article: 486

Factors influencing specialty choice and the effect of recall bias on findings from Irish medical graduates: a cross-sectional, longitudinal study

• Frances M. Cronin
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• Article: 485

Residents’ identification of learning moments and subsequent reflection: impact of peers, supervisors, and patients

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• Karen D. Könings
• Article: 484

Google analytics of a pilot study to characterize the visitor website statistics and implicate for enrollment strategies in Medical University

• Szu-Chieh Chen
• Thomas Chang-Yao Tsao
• Yafang Tsai
• Published: 01 December 2020
• Article: 483

Evaluation of blended medical education from lecturers’ and students’ viewpoint: a qualitative study in a developing country

• Mohamad Jebraeily
• Habibollah Pirnejad
• Zahra Niazkhani
• Published: 30 November 2020
• Article: 482

Visual arts in the clinical clerkship: a pilot cluster-randomized, controlled trial

Authors (first, second and last of 11).

• Garth W. Strohbehn
• Stephanie J. K. Hoffman
• Joel D. Howell
• Article: 481

Preferred teaching styles of medical faculty: an international multi-center study

• Nihar Ranjan Dash
• Salman Yousuf Guraya
• Wail Nuri Osman Mukhtar
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Pursue today and assess tomorrow - how students’ subjective perceptions influence their preference for self- and peer assessments

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• Stefan Lettner
• Anita Holzinger
• Published: 27 November 2020
• Article: 479

Correction to: Examining aptitude and barriers to evidence-based medicine among trainees at an ACGME-I accredited program

• Mai A. Mahmoud
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• Published: 26 November 2020
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Correction to: A comparative study of dementia knowledge, attitudes and care approach among Chinese nursing and medical students

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• Article: 477

Effectiveness of simulation-based interprofessional education for medical and nursing students in South Korea: a pre-post survey

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Education of pharmacists in Ghana: evolving curriculum, context and practice in the journey from dispensing certificate to doctor of pharmacy certificate

• Augustina Koduah
• Irene Kretchy
• Mahama Duwiejua
• Article: 475

The evaluation of stomatology English education in China based on ‘Guanghua cup’ international clinical skill exhibition activity

• Yangjingwen Liu
• Zhengmei Lin
• Article: 474

Effectiveness of clinical scenario dramas to teach doctor-patient relationship and communication skills

• Yinan Jiang
• Article: 473

Do we need special pedagogy in medical schools? – Attitudes of teachers and students in Hungary: a cross-sectional study

• Zsuzsanna Varga
• Zsuzsanna Pótó
• Zsuzsanna Füzesi
• Article: 472

Physiotherapy students can be educated to portray realistic patient roles in simulation: a pragmatic observational study

• Shane A. Pritchard
• Jennifer L. Keating
• Felicity C. Blackstock
• Article: 471

Students’ understanding of social determinants of health in a community-based curriculum: a general inductive approach for qualitative data analysis

• Sachiko Ozone
• Junji Haruta
• Tetsuhiro Maeno
• Published: 25 November 2020
• Article: 470

The effect of 3D-printed plastic teeth on scores in a tooth morphology course in a Chinese university

• Article: 469

The training needs for gender-sensitive care in a pediatric rehabilitation hospital: a qualitative study

• Sally Lindsay
• Kendall Kolne
• Article: 468

Using interviews and observations in clinical practice to enhance authenticity in virtual patients for interprofessional education

• Desiree Wiegleb Edström
• Niklas Karlsson
• Samuel Edelbring
• Article: 467

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• Open access
• Published: 27 May 2024

Associations between medical students’ stress, academic burnout and moral courage efficacy

• Galit Neufeld-Kroszynski   ORCID: orcid.org/0000-0001-9093-1308 1   na1 ,
• Keren Michael   ORCID: orcid.org/0000-0003-2662-6362 2   na1 &
• Orit Karnieli-Miller   ORCID: orcid.org/0000-0002-5790-0697 1  

BMC Psychology volume  12 , Article number:  296 ( 2024 ) Cite this article

52 Accesses

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Medical students, especially during the clinical years, are often exposed to breaches of safety and professionalism. These contradict personal and professional values exposing them to moral distress and to the dilemma of whether and how to act. Acting requires moral courage, i.e., overcoming fear to maintain one’s core values and professional obligations. It includes speaking up and “doing the right thing” despite stressors and risks (e.g., humiliation). Acting morally courageously is difficult, and ways to enhance it are needed. Though moral courage efficacy, i.e., individuals’ belief in their capability to act morally, might play a significant role, there is little empirical research on the factors contributing to students’ moral courage efficacy. Therefore, this study examined the associations between perceived stress, academic burnout, and moral courage efficacy.

A cross-sectional study among 239 medical students who completed self-reported questionnaires measuring perceived stress, academic burnout (‘exhaustion,’ ‘cynicism,’ ‘reduced professional efficacy’), and moral courage efficacy (toward others’ actions and toward self-actions). Data analysis via Pearson’s correlations, regression-based PROCESS macro, and independent t -tests for group differences.

The burnout dimension of ‘reduced professional efficacy’ mediated the association between perceived stress and moral courage efficacy toward others’ actions. The burnout dimensions ‘exhaustion’ and ‘reduced professional efficacy’ mediated the association between perceived stress and moral courage efficacy toward self-actions.

Conclusions

The results emphasize the importance of promoting medical students’ well-being—in terms of stress and burnout—to enhance their moral courage efficacy. Medical education interventions should focus on improving medical students’ professional efficacy since it affects both their moral courage efficacy toward others and their self-actions. This can help create a safer and more appropriate medical culture.

Peer Review reports

Introduction

In medical school, and especially during clinical years, medical students (MS) are often exposed to physicians’ inappropriate behaviors and various breaches of professionalism or safety [ 1 , 2 , 3 ]. These can include lack of respect or sensitivity toward patients and other healthcare staff, deliberate lies and deceptions, breaching confidentiality, inadequate hand hygiene, or breach of a sterile field [ 4 , 5 ]. Furthermore, MS find themselves performing and/or participating in these inappropriate behaviors. For example, a study found that 80% of 3 rd– 4th year MS reported having done something they believed was unethical or having misled a patient [ 6 ]. Another study showed that 47.1–61.3% of females and 48.8–56.6% of male MS reported violating a patient’s dignity, participating in safety breaches, or examining/performing a procedure on a patient without valid consent, following a clinical teacher’s request, as a learning exercise [ 5 ]. These behaviors contradict professional values and MS’ own personal and moral values, exposing them to a dilemma in which they must choose if and how to act.

Taking action requires moral courage, i.e., taking an active stand or acting in the face of wrongdoing or moral injustice jeopardizing mental well-being [ 7 , 8 , 9 , 10 ]. Moral courage includes speaking up and “doing the right thing” despite risks, such as shame, retaliation, threat to reputation, or even loss of employment [ 8 ]. Moral courage is expressed in two main situations: when addressing others’ wrongdoing (e.g., identifying and disclosing a past/present medical error by colleagues/physicians); or when admitting one’s own wrongdoing (e.g., disclosing an error or lack of knowledge) [ 11 ].

Due to its “calling out” nature, acting on moral courage is difficult. A hierarchy and unsafe learning environment inhibits the ability for assertive expression of concern [ 12 , 13 , 14 ]. This leads to concerning findings indicating that only 38% of MS reported that they would approach someone performing an unsafe behavior [ 12 ], and about half claimed that they would report an error they had observed [ 15 ].

Various reasons were suggested to explain why MS, interns, residents, or nurses, hesitate to act in a morally courageous way, including difficulty questioning the decisions or actions of those with more authority [ 12 ], and fear of negative social consequences, such as being disgraced, excluded, attacked, punished, or poorly evaluated [ 13 ]. Other reasons were the wish to fit into the team [ 6 ] and being a young professional experiencing “lack of knowledge” or “unfamiliarity” with clinical subtleties [ 16 ].

Nevertheless, failing to act on moral courage might lead to negative consequences, including moral distress [ 17 ]. Moral distress is a psychological disequilibrium that occurs when knowing the ethically right course of action but not acting upon it [ 18 ]. Moral distress is a known phenomenon among MS [ 19 ], e.g., 90% of MS at a New York City medical school reported moral distress when carrying for older patients [ 20 ]. MS’ moral distress was associated with thoughts of dropping out of medical school, choosing a nonclinical specialty, and increased burnout [ 20 ].

These consequences of moral distress and challenges to acting in a morally courageous way require further exploration of MS’ moral courage in general and their moral courage efficacy specifically. Bandura coined the term self-efficacy, focused on one’s perception of how well s/he can execute the action required to deal successfully with future situations and to achieve desired outcomes [ 21 ]. Self-efficacy plays a significant role in human behavior since individuals are more likely to engage in activities they believe they can handle [ 21 ]. Therefore, self-efficacy regarding a particular skill is a major motivating factor in the acquisition, development, and application of that skill [ 22 ]. For example, individuals’ perception regarding their ability to deal positively with ethical issues [ 23 ], their beliefs that they can handle effectively what is required to achieve moral performance [ 24 ], and to practically act as moral agents [ 25 ], can become a key psychological determinant of moral motivation and action [ 26 ]. Due to self-efficacy’s importance there is a need to learn about moral courage efficacy, i.e., individuals’ belief in their ability to exhibit moral courage through sharing their concerns regarding others and their own wrongdoing. Moral courage efficacy was suggested as important to moral courage in the field of business [ 27 ], but not empirically explored in medicine. Thus, there is no known prevalence of moral courage efficacy toward others and toward one’s own wrongdoing in medicine in general and for MS in particular. Furthermore, the potential contributing factors to moral courage efficacy, such as stress and burnout, require further exploration.

The associations between stress, burnout, and moral courage efficacy

Stress occurs when people view environmental demands as exceeding their ability to cope with them [ 28 ]. MS experience high levels of stress during their studies [ 29 ], due to excessive workload, time management difficulties, work–life balance conflicts, health concerns, and financial worries [ 30 ]. Studies show that high levels of stress were associated with decreased empathy [ 31 ], increased academic burnout, academic dishonesty, poor academic performance [ 32 ], and thoughts about dropping out of medical school [ 33 ]. As stress may impact one’s perceived efficacy [ 34 ], this study examined whether stress can inhibit individuals’ moral courage efficacy to address others’ and their own wrongdoing.

An aspect related to a poor mental state that may mediate the association between stress and MS’ moral courage efficacy is burnout. Burnout includes emotional exhaustion, cynicism toward one’s occupation value, and doubting performance ability [ 35 ]. Burnout is usually work-related and is common in the helping professions [ 60 ]. For students, this concept relates to academic burnout [ 36 ], which includes exhaustion due to study demands, a cynical and detached attitude to studying, and low/reduced professional efficacy, i.e. feeling incompetent as learners [ 37 ].

Burnout has various negative implications for MS’ well-being and professional development. Burnout is associated with psychiatric disorders and thoughts of dropping out of medical school [ 33 ]. Furthermore, MS’ burnout is associated with increased involvement in unprofessional behavior, eroding professional development, diminishing qualities such as honesty, integrity, altruism, and self-regulation [ 38 ], reducing empathy [ 31 , 39 ] and unwillingness to provide care for the medically underserved [ 40 ]. Thus, burnout may also impact MS’ views on their responsibility and perceived ability to promote high-quality care and advocate for patients [ 41 ], possibly leading them to feel reluctant and incapable to act with moral courage [ 42 ]. Earlier studies exploring stress and its various outcomes, found that burnout, and specifically exhaustion, can become a crucial mediator for various harmful outcomes [ 43 ]. Although stress is impactful to creating discomfort, the decision and ability to intervene requires one’s own drive and power. When one is feeling stress, leading to burnout their depleted energy reserves and diminished sense of professional worth likely undermine their perceived power (due to exhaustion) or will (due to cynicism) to uphold professional ethical standards and intervene to advocate for patient care in challenging circumstances, such as the need to speak up in front of authority members. Furthermore, burnout may facilitate a cognitive distancing from professional values and responsibilities, allowing for moral disengagement and reducing the likelihood of morally courageous actions. This mediation role requires further exploration.

This study examined associations between perceived stress, academic burnout, and moral courage efficacy. In addition to the mere associations among the variables, it will be examined whether there is a mediation effect (perceived stress → academic burnout → moral courage efficacy) to gain more insight into possible mechanisms of the development of moral courage efficacy and of protective factors. Understanding these mechanisms has educational benefit for guiding interventions to enhance MS’ moral courage efficacy.

H1: Perceived stress and academic burnout dimensions will be negatively associated with moral courage efficacy dimensions.

H2: Perceived stress will be positively associated with academic burnout dimensions.

H3: Academic burnout dimensions will mediate the association between perceived stress and moral courage efficacy dimensions.

Materials and methods

Sample and procedure.

A quantitative cross-sectional study among 239 MS. Most participants were female (60%), aged 29 or less (90%), and unmarried (75%). About two thirds (64.3%) were at the pre-clinical stage of medical school and about a third (35.7%) at the clinical stage. In December 2019, the research team approached MS through email and social media to participate in the study and complete an online questionnaire. This was a part of a national study focused on MS’ burnout [ 44 ]. The 239 participants were recruited by a convenience sampling. Data were collected online through Qualtrics platform, via anonymous self-reported questionnaires. The University Ethics Committee approved the study, and all participants signed an informed consent form.

Moral courage efficacy —This 8-item instrument, developed for this study, is based on the literature on moral courage, professionalism, and speaking-up, including qualitative and quantitative studies [ 7 , 13 , 45 , 46 , 47 ], and discussions with MS and medical educators. The main developing team included a Ph.D. medical educator expert in communication in healthcare and professionalism; an M.D. psychiatrist expert in decision making, professionalism, and philosophy; a Ph.D. graduate who analyzed MS’ narratives focused on moral dilemmas and moral courage during professionalism breaches; and a Ph.D. candidate focused on assertiveness in medicine [ 14 ]. This allowed the identification of different types of situations MS face that may require moral courage.

As guided by instructions for measuring self-efficacy, which encourage using specific statements that relate to the specific situation and skill required [ 48 ], the instrument measures MS’ perception of their own ability, i.e., self-efficacy, to act based on their moral beliefs when exposed to safety and professionalism breaches or challenges. Due to our qualitative findings indicating that students change their interpretation of the problematic event based on their decision to act in a morally courageous way and that some are exposed to specific professionalism violations while others are not when designing the questionnaire, we decided to make the cases not explicit to specific types of professionalism breaches – e.g., not focused on talking above a patient’s head [ 1 ], but rather general the type of behavior e.g., “behaves immorally”. This decreases the personal interpretation if one behavior is acceptable by this individual; and also decreases the possibility of not answering the question if the individual student has never seen that specific behavior. Furthermore, to avoid “gray areas” in moral issues, we wrote the statements in a manner where there is no doubt whether there is a moral problem (“problematic situation”) [ 47 ], and thus the focus was only on one’s feeling of being capable of speaking up about their concern, i.e., act in a moral courage efficacy (see Table  1 ).

The instrument’s initial development consisted of 14 items addressing various populations, including senior MDs. The 14-item tool included questions regarding the willingness to recommend a second opinion or to convey one’s medical mistake to patients and their families. These actions are less relevant to MS. Thus, we extracted the questionnaire to a parsimonious instrument of 8 items.

The 8 items were divided into two dimensions: others and the self. This division is supported by the literature on moral courage that distinguishes between courage regarding others- vs. self-behavior. Hence, the questionnaire was designed to assess one’s perceived ability to act/speak up in these two dimensions: (a) situations of moral courage efficacy relating to others’ behavior (e.g., “ capable of telling a senior physician if I have detected a mistake s/he might have made ”); (b) situations of moral courage efficacy relating to self (e.g., “ capable of disclosing my mistakes to a senior physician ”). This two-dimension division is important and was absent in former measurements of moral courage. It was also replicated in another study we conducted among MS [ 49 ]. Furthermore, factor analysis with Oblimin rotation supported this two-factor structure (Table  1 ). All items had a high factor loading on the relevant factor (it should be mentioned that item 4 was loaded 0.59 on the relevant factor and 0.32 on the non-relevant factor).

All items are rated on a 5-point Likert scale (0 = to a small extent; 4 = to a very great extent) and are calculated by averaging the answers on the dimension, with higher scores representing higher moral courage efficacy. Internal reliability was α = 0.80 for the “others” dimension and α = 0.84 for the “self” dimension.

Perceived stress —This single-item questionnaire (“How would you rate the level of stress you’ve been experiencing in the last few days?” ) evaluates MS’ perceived stress currently in their life on an 11-point Likert scale (0 = no stress; 10 = extreme stress), with higher scores representing higher perceived stress. It is based on a similar question evaluating MS’ perceived emotional stress [ 29 ]. Even though a multi-item measure might be more stable, previous studies indicated that using a single item is a practical, reliable alternative, with high construct validity in the context of felt/perceived stress, self-esteem, health status, etc [ 43 , 50 , 51 ].

Academic burnout —This 15-item instrument is a translated version [ 44 ] of the MBI-SS (MBI–Student Survey) [ 37 ], a common instrument used to measure burnout in the academic context, e.g. MS [ 52 , 53 ]. It measures students’ feelings of burnout regarding their studies on three dimensions: (a) ‘exhaustion’ (5 items; e.g., “ Studying or attending a class is a real strain for me ”), (b) ‘cynicism’ (4 items; e.g., “ I doubt the significance of my studies ”), (c) lack of personal academic efficacy (‘reduced professional efficacy’) (6 items; “ I feel [un]stimulated when I achieve my study goals ”). Each item is rated on a 7-point Likert scale (0 = never; 6 = always) and is calculated by summing the answers on the dimension (after re-coding all professional efficacy items), with higher scores representing more frequent feelings of burnout. Internal reliability was α = 0.80 for ‘exhaustion’, α = 0.80 for ‘cynicism’, and α = 0.84 for ‘reduced professional efficacy’.

Statistical analyses

IBM-SPSS (version 25) was used to analyze the data. Pearson’s correlations examined all possible bivariate associations between the study variables. PROCESS macro examined the mediation effects (via model#4). The significance of the mediation effects was examined by calculating 5,000 samples to estimate the 95% percentile bootstrap confidence intervals (CIs) of indirect effects of the predictor on the outcome through the mediator [ 54 ]. T -tests for independent samples examined differences between the study variables in the pre-clinic and clinic stages. The defined significance level was set generally to 5% ( p  < 0.05).

This study focused on understanding moral courage efficacy, i.e., MS’ perceived ability to speak up and act while exposed to others’ and their own wrongdoing. The sample’s frequencies demonstrate that only 10% of the MS reported that their moral courage efficacy toward the others was “very high to high,” and 54% reported this toward the self. Mean scores demonstrate that regarding the others, MS showed relatively low/moderate levels of moral courage and higher levels regarding the self. As for the variables tested to be associated with moral courage efficacy, MS showed relatively high perceived stress and low-to-moderate academic burnout (see Table  2 for the variables’ psychometric characteristics).

Table  2 also shows the correlations among the study variables. According to Cohen’s (1988) [ 55 ] interpretation of the strength in bivariate associations (Pearson correlation), the effect size is low when r value varies around 0.1, medium when it is around 0.3, and large when it is more than 0.5. Hence, regarding the associations between the two dimensions of moral courage efficacy: we found a moderate positive correlation between the efficacy toward others and the efficacy toward the self. Regarding the associations among the three academic burnout dimensions: we found a strong positive correlation between ‘exhaustion’ and ‘cynicism,’ a weak positive correlation between ‘exhaustion’ and ‘reduced professional efficacy,’ and a moderate positive correlation between ‘cynicism,’ and ‘reduced professional efficacy.’

As for the associations concerning H1, Table  2 indicates that one academic burnout dimension, i.e., ‘reduced professional efficacy,’ had a weak negative correlation with moral courage efficacy toward the others, thus high burnout was associated with lower perceived moral courage efficacy toward others. Additionally, perceived stress and all three burnout dimensions had weak negative correlations with moral courage efficacy toward the self—partially supporting H1.

As for the associations concerning H2, Table  2 indicates that perceived stress had a strong positive correlation with ‘exhaustion,’ a moderate positive correlation with ‘cynicism,’ and a weak positive correlation with ‘reduced professional efficacy’—supporting H2.

Based on these correlations, we conducted regression-based models to examine the unique and complex relationships among the study variable, including their various dimensions, while focusing on the examination of whether academic burnout mediates the association between perceived stress and moral courage efficacy (see Tables  3 and 4 ; and Figs.  1 and 2 ).

A model presenting the association between perceived stress and moral courage efficacy toward others, mediated by academic burnout. Note full arrows contain significant β coefficient values (fractured arrows mean nonsignificance

Focusing on moral courage efficacy toward others

Table  3  and Fig.  1 indicate that perceived stress was positively associated with all three academic burnout dimensions: ‘exhaustion’ (path a 1 ), ‘cynicism’ (path a 2 ), and ‘reduced professional efficacy’ (path a 3 ). These paths support H2. In turn, ‘reduced professional efficacy’ was negatively associated with moral courage efficacy toward the others (path b 3 ), supporting H1. The CIs of the indirect effect (paths a 3 b 3 ) did not contain zero; therefore, perceived stress had a significant indirect effect on moral courage efficacy toward the others, through the burnout dimension ‘reduced professional efficacy.’ This path supports H3.

A model presenting the association between perceived stress and moral courage efficacy towards self, mediated by academic burnout. Note full arrows contain significant β coefficient values (fractured arrows mean non-significance

Focusing on moral courage efficacy toward the self

Table  4  and Fig.  2 also indicate that perceived stress was positively associated with all three academic burnout dimensions: ‘exhaustion’ (path a 4 ), ‘cynicism’ (path a 5 ), and ‘reduced professional efficacy’ (path a 6 ). These paths support H2. In turn, ‘exhaustion’ and ‘reduced professional efficacy’ were negatively associated with moral courage efficacy toward the self (paths b 4 , b 6 respectively). These paths support H1 The CIs of the indirect effects (paths a 4 b 4 , a 6 b 6 ) did not contain zero; therefore, perceived stress had a significant indirect effect on moral courage efficacy toward the self, through the burnout dimensions ‘exhaustion’ and ‘reduced professional efficacy.’ These paths support H3. It should be noted that in this analysis, the initially significant association between perceived stress and moral courage efficacy toward the self (path c 2, representing H1) became insignificant in the existence of academic burnout dimensions (path c’ 2 ). These results demonstrate complete mediation and also support H3.

In addition to examining the complex relationships between stress, academic burnout, and moral courage efficacy among MS, we tested the differences between MS in the pre-clinical and clinical school stages in all study variables. The results indicate non-significant differences in moral courage efficacy. However, medical-school-stage differences were found in stress [t(197.4)=-4.36, p  < 0.001] and in one academic burnout dimension [t(233)=-2.40, p  < 0.01]. In that way, MS at the clinical stage reported higher levels of perceived stress ( M  = 7.32; SD  = 2.17) and exhaustion ( M  = 19.67; SD  = 6.58) than MS in the pre-clinical stage ( M  = 5.94; SD  = 2.59 and M  = 17.48; SD  = 6.78, respectively).

This study examined the associations between perceived stress, academic burnout, and moral courage efficacy to understand MS’ perceived ability to speak up and act while exposed to others’ and their own wrongdoing. The findings show that one dimension of burnout, that of ‘reduced professional efficacy,’ mediated the associations between perceived stress and moral courage efficacy toward both others and self. ‘Exhaustion’ mediated the association between perceived stress and moral courage efficacy only toward the self.

Before discussing the meanings of the associations, this study was an opportunity to explore moral courage efficacy occurrence. The findings indicated fairly low/moderate mean scores of perceived ability to speak up and act while confronted with others’ wrongdoing and moderate/high scores of perceived ability while confronted with one’s own wrongdoing. This implies that students do not feel capable enough to share their concerns regarding others’ possible errors and feel more able, but still not enough, to share their own flaws and needs for guidance. These findings require attention, from both patient safety and learning perspectives.

Regarding patient safety, feeling unable to act while confronted with others or self- wrongdoing means that some errors may occur and not be addressed. This is in line with former findings that showed that less than 50% of MS would actually approach someone performing an unsafe behavior [ 12 ], or report an error they had observed [ 15 ]. These numbers are likely to improve in postgraduates as studies showed that between 64 and 79% of interns and residents reported they would likely speak up to an attending when exposed to a safety threat [ 56 , 57 ].

Regarding learning, our MS’ scores must improve for various reasons. First, moderate scores may indicate a psychologically unsafe learning environment, which prevents or discourages sharing uncertainties, especially about others’ behavior, and creates difficulty for students to share their own concerns, limitations, mistakes, and hesitations when feeling incapable or unqualified for a task [ 58 ]. Second, limited sharing of errors may be problematic because by not disclosing their error, students miss the chance to learn from it; [ 59 ] they lose the opportunity for reflective guidance to explore what worked well, what did not, and how to improve [ 59 , 60 ]. Third, if they do not discuss others’ errors or their own, they may deny themselves the necessary support to learn the all-important skills of how to deal with the emotional turmoil and challenges of errors, and how to share the error with a patient or family member [ 61 ]. Furthermore, if MS feel incapable of sharing their concern about a senior’s possible mistake, they miss other learning opportunities—e.g., the senior’s reasoning and clinical judgment may show that a mistake was not made. In this case, the student would miss being shown why they were wrong and what they did do well. Thus, identifying what can enhance moral courage efficacy and practice is needed. The fact that there are no significant differences between pre-clinical and clinical years students in their perceived ability to apply moral courage, may indicate that there is a cultural barrier in perceiving the idea of sharing weakness or of revealing others’ mistakes as unacceptable. Thus, the socialization, in the medical school environment, both in pre-clinical and clinical years, perhaps lacks the encouragement to speak up and provision of safe space.

This study examined the associations between perceived stress, academic burnout, and moral courage efficacy among MS. The findings indicate that, like earlier studies, stress is not directly connected to speaking up [ 62 ] or moral courage. It rather contributes to it indirectly, through the impact of burnout. Beyond the well-established role of stress in explaining burnout [ 63 , 64 ], we identified a negative consequence of burnout—hindering moral courage efficacy. This may help explain the path in which previous studies found burnout to impair MS’ quality of life, how it leads to dropout, and to more medical errors [ 65 ]. When individuals experience the burnout dimension of ‘reduced professional efficacy,’ they may feel less confident and fit, leading them to feel more disempowered to take the risk (required in courage) and share their concerns and hesitations about others’ mistakes and their own challenges. This fits earlier studies indicating that being a young professional experiencing “lack of knowledge” or “unfamiliarity” with clinical subtleties is a barrier to moral courage [ 11 ]. This may have various negative implications, of limited moral courage efficacy, as seen here, as well as paying less attention and not fully addressing their learning needs, leading to a vicious cycle of “feeding” the misfit feeling, potentially increasing their moral distress. Furthermore, those who feel they know less and, therefore, need more support to fill the gap in knowledge and skills, are less inclined to ask for help.

Beside the negative associations between ‘reduced professional efficacy’ and both dimensions of moral courage efficacy (toward others and the self), another dimension of academic burnout—‘exhaustion’—was negatively associated with moral courage efficacy toward the self. This is worrying because when learners are exhausted, their attention is reduced and they are at greater risk of error, as proven in an earlier study [ 65 ]. The current study adds to this information another worry, showing that MS are less willing to share their hesitations about themselves or the mistakes they already made, thus perhaps not preventing the error or fixing it. MS might create an unspoken contract with senior physicians about not exposing each other’s mistakes, with various possible negative implications. Some MS’ tendency to defend physicians’ mistakes was identified elsewhere [ 66 ].

The findings concerning medical-school-stage differences demonstrated that MS in the clinical stage had higher perceived stress and exhaustion levels than MS in the pre-clinical stage. These results support previous studies indicating stress, academic burnout, and more challenging characteristics among more senior students, including a decline in ideals, altruistic attitudes, and empathy during medical school studies; or more exhaustion, cynicism, and higher levels of detached emotions and depression through the years of medical school [ 67 , 68 , 69 ]. These higher levels of stress and exhaustion, can be explained by the senior students’ exposure to the rounds in the hospitals, which requires ongoing learning, more pressure, and a sense of overload in their academic life.

Limitations and future studies

Despite the importance of the findings, the study has several limitations. First, the participants were from one university, and recruited via convenience sampling, including only MS who voluntarily completed the questionnaires, undermining generalizability. To address this limitation, future research should aim to include a more diverse and representative sample of medical students from multiple universities and geographical regions. This would enhance the external validity and applicability of the findings across different educational and cultural contexts. Second, future studies are recommended to follow up on medical students’ stress, academic burnout, and moral courage efficacy over time. Exploring the development of professional efficacy and the barriers to exposing one’s and others’ weaknesses and flaws within the medical environment can help improve the medical culture into a safer space. Third, an intriguing avenue for future research is the exploration of the construct of ‘moral courage efficacy’ within different cohorts of healthcare students throughout their undergraduate and postgraduate years to learn about their moral courage efficacy development as well as and to verify the association between the findings from this newly developed scale and actual moral courage behavior. Additionally, experimental designs, such as interventions to reduce stress and burnout among medical students, could be employed to observe the impact on moral courage efficacy.

Conclusions and implications

This study is a first step in understanding moral courage efficacy and what contributes to it. The study emphasizes the importance of promoting MS’ well-being—in terms of stress and burnout—to enhance their moral courage efficacy. The findings show that the ‘reduced professional efficacy’ mediated the association between perceived stress and moral courage efficacy, toward both the others and self. This has potential implications for safety, learning, and well-being. To encourage MS to develop moral courage efficacy that will potentially increase their morally courageous behavior, we must find ways to reduce their stress and burnout levels. As the learning and work environments are a major cause of burnout [ 38 ], it would be helpful to focus on creating safe spaces where they can share others- and self-related concerns [ 70 ]. The first step is a learning environment promoting students’ overall health and well-being [ 71 ]. Useful additions are processes that support MS while dealing with education- and training-related stresses, improving their academic-professional efficacy, and constructively helping them handle challenging situations through empathic feedback [ 70 ]. This can lead them to a stronger belief in their ability to share safety and professionalism issues, thus enhancing their learning and patient care.

Data availability

No datasets were generated or analysed during the current study.

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Acknowledgements

The authors wish to thank Dr. Lior Rozental in helping in recruiting students to the study. This study was done as part of Orit Karnieli-Miller’s Endowed chair of the Dr. Sol Amsterdam, Dr. David P. Schumann in Medical Education, Tel Aviv University. This study is written in the blessed memory of Oshrit Bar-El, devoted to enhancing Moral Courage.

The manuscript was partially supported by a grant by the by the Israel Science Foundation (grant no. 1599/21).

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Galit Neufeld-Kroszynski and Keren Michael contributed equally to this work.

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Department of Medical Education, Faculty of Medical & Health Sciences, Tel Aviv University, Tel Aviv, 69778, Israel

Galit Neufeld-Kroszynski & Orit Karnieli-Miller

Department of Human Services, Max Stern Yezreel Valley College, Yezreel Valley, Israel

Keren Michael

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GNK: conception and design, interpretation of data, drafting and revision of the manuscript, and final approval of the version to be published; KM: analysis and interpretation of data, drafting and revision of the manuscript, and final approval of the version to be published; OKM: conception and design, interpretation of data, drafting and revision of the manuscript, and final approval of the version to be published.

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Correspondence to Orit Karnieli-Miller .

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Study findings were presented at the Academy for Professionalism in Healthcare Conference, June 2nd, 2022, virtual; and the 7th International Conference on Public Health, August 8th, 2021, virtual.

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Neufeld-Kroszynski, G., Michael, K. & Karnieli-Miller, O. Associations between medical students’ stress, academic burnout and moral courage efficacy. BMC Psychol 12 , 296 (2024). https://doi.org/10.1186/s40359-024-01787-6

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Perceptions of attitudes toward statistics among medical undergraduates: insights from a regional medical college in China

• Yupeng Guo 1 ,
• Shengzhong Rong 1 ,
• Jing Dong 1 ,
• Yingying Niu 1 &
• Hongjun Guan 1  

BMC Medical Education volume  24 , Article number:  579 ( 2024 ) Cite this article

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Among Chinese medical students, medical statistics is often perceived as a formidable subject. While existing research has explored the attitudes of Chinese postgraduate medical students towards statistics and its impact on academic performance, there is a scarcity of studies examining the attitudes of Chinese medical undergraduates on this subject. This study endeavors to scrutinize the attitudes of Chinese medical undergraduates towards statistics, assessing their ramifications on learning achievements, and delving into the influence of demographic factors.

1266 medical undergraduates participated in this study, completing a questionnaire that included SATS-36 and additional queries. Furthermore, an examination was administered at the end of the medical statistics course. The analysis encompassed the SATS score and exam scores, examining both the overall participant population and specific demographic subgroups.

Undergraduate medical students generally exhibit a favorable disposition towards statistics concerning Affect, Cognitive Competence, and Value components, yet harbor less favorable sentiments regarding the Difficulty component of SATS-36, aligning with previous research findings. In comparison to their postgraduate counterparts, undergraduates display heightened enthusiasm for medical statistics. However, they demonstrate a lower cognitive capacity in statistics and tend to underestimate both the value and difficulty of learning statistics. Despite these disparities, undergraduate medical students express a genuine interest in statistics and exhibit a strong dedication to mastering the subject. It is noteworthy that students’ attitudes toward statistics may be influenced by their major and gender. Additionally, there exists a statistically significant positive correlation between learning achievement and the Affect, Cognitive Competence, Value, Interest, and Effort components of the SATS-36, while a negative correlation is observed with the Difficulty component.

Educators should carefully consider the influence of attitudes toward statistics, especially the variations observed among majors and genders when formulating strategies and curricula to enhance medical statistics education.

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Introduction

Medical statistics is a crucial branch of statistics that encompasses various aspects of medical and biological research, including experiment and trial design, data collection, analysis, and representation. Around the World, medical students are required to take medical statistics courses to acquire the necessary skills and abilities in statistics. These skills play a pivotal role in the professional development of medical practitioners [ 1 , 2 , 3 ]. Over the past few decades, with the emergence of Evidence-based medicine (EBM), the knowledge and skills in medical statistics have become increasingly important for future doctors [ 2 ].

Considering the importance of medical statistics, numerous studies have revealed that medical students generally view the subject as challenging and experience anxiety when learning about it. Compared to other disciplines in medical training, the majority of students state that the medical statistics course is more challenging. Researchers have attributed this phenomenon to the mathematical properties of statistics, but numerous studies have shown that students’ attitudes toward statistics are important when it comes to learning statistics. Students generally recognize the value and usefulness of statistics, but they also find it difficult to learn. Positive attitudes are positively correlated with course achievement [ 4 , 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 ], and additional factors such as demographics [ 13 ], educational backgrounds [ 14 ], and mathematical foundations [ 4 ] may also have an impact on students’ attitudes toward statistics.

In China, medical statistics is a mandatory subject for both undergraduate and postgraduate medical students. A study by Zhang et al. [ 4 ] investigated the attitudes of medical postgraduates toward medical statistics using the Survey of Attitudes Toward Statistics (SATS) [ 15 ]. The findings revealed that Chinese medical students generally held positive attitudes toward statistics, although they perceived medical statistics as a challenging subject. Despite positive correlations between course achievement and attitudes towards medical statistics, students’ attitudes experienced negative changes after completing a statistics course. It’s noteworthy that Zhang et al.‘s study focused on postgraduates in an elite medical college, which is nationally renowned for its academic excellence, leaving a gap in understanding the attitudes of undergraduate medical students in regional medical colleges, which represents the non-renowned and ordinary majority. Compared with the students in elite medical colleges, these medical undergraduates enrolled in regional medical colleges generally demonstrate lower scores in the National College Entrance Examination (the Gaokao), suggesting they may have different capabilities and habits in learning science and technology, so it is necessary and meaningful to find out what attitude they hold towards medical statistics and whether their attitude is different from Zhang et al.‘s results. To address this gap, we conducted a cross-sectional survey in a typical medical college in northeastern China, examining the attitudes of undergraduate medical students towards medical statistics and exploring influencing factors, as well as the association between attitudes and course achievement. The results could contribute to alleviating undergraduates’ anxiety about learning medical statistics and have implications for curriculum design and delivery methods in the class.

Participants

The investigation took place at Mudanjiang Medical University, a regional medical institution situated in Heilongjiang Province, China, in April 2023. The study targeted undergraduate students enrolled in clinical medicine, dentistry, radiology, or nursing majors, specifically those in their second or third academic years. Notably, Chinese students pursuing clinical medicine, dentistry, and radiology undergo a five-year medical training program, culminating in the attainment of a medical bachelor’s degree. Conversely, nursing majors follow a four-year medical training program, leading to the award of a nursing bachelor’s degree. Due to the students with medical degrees and the students with nursing degrees having different characteristics and career prospects, to facilitate result interpretation, we categorized participants into medical undergraduates and nursing undergraduates. Medical statistics was a mandatory course for all the participants of our study, they were mandated to undertake the same medical statistics course. The curriculum of this course encompasses various topics such as descriptive statistics, probability distribution of random variables (normal distribution, t distribution, F distribution, and Chi-square distribution), confidence intervals for mean, hypothesis testing (t-test, analysis of variance, Chi-square test), nonparametric statistics, linear correlation and regression, logistics regression, general experimental design, and the application of SPSS software. Prior to their involvement, participants were thoroughly briefed on the study’s objectives and procedures, and their informed consent was obtained through signed approval documents. Although Chinese law does not mandate ethical approval for this type of study, ethical approval for this study was granted by the School of Public Health of Mudanjiang Medical University.

Instruments

We employed the SATS-36 scale, developed by Schau [ 15 ], to assess students’ attitudes toward medical statistics. The initial version of SATS, termed SATS-28, comprised 28 7-point Likert-type scale items designed to measure four attitude components: Affect (6 items, reflecting students’ emotions regarding statistics), Cognitive Competence (6 items, gauging students’ attitudes toward their intellectual knowledge and skills applied to statistics), Value (9 items, assessing students’ perspectives on the usefulness, relevance, and worth of statistics in personal and professional contexts), and Difficulty (7 items, capturing students’ perceptions of the difficulty of statistics as a subject). Subsequently, Schau [ 16 ] introduced 8 additional items to measure two more attitude components: Interest (4 items, evaluating students’ interest in statistics) and Effort (4 items, quantifying the effort students invest in learning statistics), resulting in the formation of SATS-36. Each item was scored on a scale where higher scores indicated more positive attitudes (1 = “strongly disagree,” 4 = “neither disagree nor agree,” 7 = “strongly agree”). The component scores were computed as the mean of the item scores constituting the respective components. In instances where items featured negative wording, scores were reversed in accordance with the SATS-36 guidelines (e.g., 1 replaced by 7). The SATS-36 scale demonstrated favorable internal consistency. Schau [ 16 ] and other researchers [ 6 , 7 , 17 ]consistently reported high Cronbach’s alpha coefficient values for the six attitude components of SATS-36: Affect (0.80 to 0.89), Cognitive Competence (0.77 to 0.88), Value (0.74 to 0.90), Difficulty (0.64 to 0.81), Interest (0.85 to 0.88), and Effort (0.67 to 0.85), meaning the scale has good internal consistency and validity as a measurement instrument. Additionally, many studies have confirmed that SATS-36 is a cross-cultural tool that has been previously validated in different languages [ 18 , 6 , 8 , 12 ]. In this study, we translated the scale into a Chinese version. Before the formal survey, we invited 20 students to test whether our Chinese version was clear, understandable, and acceptable. The result of the test showed that our Chinese version had good face validity.

Investigation process

The survey utilized the Tencent questionnaire web system for data collection. Participants were instructed to complete an SATS-36 questionnaire and additional inquiries at the beginning of the course. The course was completed in 8–10 weeks. One week after the course’s end, a standard course examination was administered by the college administration to evaluate the participants’ academic performance. All the participants had to take this course examination. This closed-book standard examination was designed by the teachers of lessons and based on quantitative criteria, grading out of 100 points and comprised 40 single-choice questions (40 items, 1 point each), 10 fill-in-the-blank questions (10 blanks, 1 point each), 10 definition questions (5 items, 2 points each), and 40 points of calculation questions (4–5 items, encompassing tasks such as calculating confidence intervals and hypothesis testing). In accordance with Chinese academic norms and the college administration, students would receive academic credits upon scoring above 60 points. Since all the questions of the examination were developed according to the content of the course, examination scores could be used to evaluate the participants’ academic performance. To investigate the influence of students’ attitudes on course achievements, the SATS-36 scores would be subjected to analysis alongside the examination scores. Furthermore, demographic information, such as age, gender, and major, would be considered in the analysis.

Statistical analysis

All statistical analyses were performed using R version 4.2.3. The demographic characteristics of participants were summarized using counts and frequencies across categories. Descriptive statistics, including mean, median, and standard deviation (SD), were employed to characterize SATS and examination scores for both the overall sample and various subgroups. Given the non-normal distribution of most SATS and examination scores, statistical comparisons among demographic factors were conducted using Wilcoxon tests. Spearman correlation coefficients were computed to investigate associations between SATS scores and examination scores, both overall and within demographic subgroups. All statistical tests were two-tailed, and significance was established at P-value ≤ 0.05.

Participants’ demographics

The survey garnered responses from 1266 participants, with an average age of 20.65 years (Median = 21, SD = 0.92, range 18–25). Females constituted 66.1% of the participants, aligning with the typical gender distribution in Chinese medical colleges. The distribution of participants across majors appeared rational, mirroring the real-world scenario. Detailed demographic characteristics are presented in Table  1 .

SATS scores and course achievement

The Cronbach’s α coefficient for our study was 0.71, indicating a high level of consistency in our results. Table  2 provides an overview of the mean, median, and standard deviation (SD) values for both SATS scores and examination scores. Our findings revealed predominantly positive sentiments among students regarding medical statistics, with a mean score of 4.55 for the Affect component. Participants expressed confidence in their intellectual abilities and skills to grasp medical statistics, as evidenced by a mean score of 4.63 on the Cognitive Competence Component. Recognizing the value of medical statistics in their future careers, students recorded a mean score of 5.27 on the Value component, and they demonstrated an interest in the subject with a mean score of 4.88 on the Interest component. Notably, participants displayed a strong willingness to exert additional effort in learning medical statistics, as reflected in a mean score of 6.07 on the Effort component. Simultaneously, students acknowledged the inherent difficulty of medical statistics learning, as indicated by a mean score of 3.49 on the Difficulty component. The mean examination score for participants stood at 72.98, aligning with the typical performance levels observed in other subjects across Chinese medical colleges, underscoring commendable learning achievements among students.

SATS scores and course achievement within participant subgroups

Initially, we conducted an analysis of SATS scores and exam performance across female and male student cohorts. Our examination revealed variations among the six SATS components, specifically in the components of Value, Difficulty, and Effort (Table  3 ). Additionally, disparities were observed in the overall examination scores. In comparison to their male counterparts, female students expressed a greater belief in the importance of statistics knowledge for their future careers. Notably, on the Effort component, female students indicated a willingness to exert more effort in medical statistics learning compared to male students. However, they also acknowledged the perceived difficulty of medical statistics more than their male counterparts did. In terms of academic achievement, female students outperformed their male counterparts, achieving a higher mean score.

Subsequently, we categorized the participants into two groups based on age, those < 21 years old and those > = 21 years. A comparison of SATS scores and examination scores between these age groups was conducted. The analysis revealed no notable variance in SATS scores between the two age groups, except for a slight discrepancy in the examination scores (Table  4 ). Nevertheless, given the marginal nature of the examination score difference, we deemed it lacking in practical significance.

Finally, an examination of SATS scores and examination scores between medical undergraduates and nursing undergraduates was conducted. The analysis revealed that medical undergraduates achieved higher scores in the Affect, Cognitive Competence, and Value components compared to their nursing counterparts. Additionally, medical undergraduates outperformed nursing undergraduates in the overall examination scores (Table  5 ).

The correlation between SATS scores and the course achievement

Displayed in Table  6 are Spearman’s correlation coefficients illustrating the association between SATS scores and examination scores. Our analysis indicates a positive correlation between examination scores and the Affect, Cognitive Competence, Value, Interest, and Effort components, while a negative correlation is observed with the Difficulty component for all participants. Notably, this correlation pattern remains largely consistent across subgroups defined by gender, age, and major.

In this investigation, we explored the attitudes of medical undergraduate students toward medical statistics at a regional medical college in China. Employing SATS-36 scales, a survey was administered at the commencement of the medical statistics course. Results revealed that medical undergraduates generally harbor positive attitudes towards statistics in terms of Affect, Cognitive Competence, and Value components, while expressing negative sentiments regarding the Difficulty component of SATS-36. These findings align with those reported by previous studies [ 4 , 8 , 9 , 12 , 19 ]. Specifically, compared with Zhang et al.’s report for Chinese medical postgraduates [ 4 ], our findings suggested undergraduates exhibited a heightened affinity for medical statistics compared to postgraduates (mean of 4.55 in this study compared to 4.50). However, undergraduates demonstrated lower cognitive proficiency in learning than postgraduates (mean of 4.63 in this study compared to 4.79). Regarding the Value component, undergraduates perceived medical statistics as less valuable than postgraduates (mean of 5.27 in this study compared to 5.45). The Difficulty component, reflecting students’ perceptions of the subject’s difficulty, indicated that undergraduates perceived medical statistics as less challenging than postgraduates (mean of 3.49 in this study compared to 2.92).

We posit that compared to postgraduates, undergraduates may not fully recognize the value of statistics for their learning goals. The distinction arises from the fact that undergraduates primarily aim to pass examinations, while postgraduates must apply medical statistics for research purposes. Furthermore, as postgraduates have prior exposure to medical statistics courses during their undergraduate period, undergraduates’ relative lack of learning experiences contributes to their limited knowledge and disregard for the difficulty in learning statistics. Conversely, it could be attributed to undergraduates’ curiosity at the commencement of the course that they hold more positive feelings toward medical statistics due to their lack of prior experience. Notably, Zhang et al. did not report on Interest and Effort components. In our study, we obtained a mean of 4.88 on the Interest component, indicating students’ interest in statistics, and a mean of 6.07 on the Effort component, the highest score across all subscales, suggesting students’ willingness to invest significant effort in statistics learning despite acknowledging its difficulty.

To delve deeper into how demographic factors influence attitudes toward medical statistics and learning achievements, we scrutinized the impact of participants’ gender, age, and major. Beginning with gender, notable differences emerged in the Value, Difficulty, and Effort components. Specifically, female students exhibited a greater appreciation for statistics than their male counterparts (mean of 5.34 for females compared to 5.15 for males, p  < 0.05). Interestingly, while females acknowledged the statistical course’s increased difficulty compared to males (mean of 3.47 for females compared to 3.54 for males, p  < 0.05), they demonstrated a greater willingness to exert effort in their learning endeavors (mean of 6.15 for females compared to 5.91 for males, p  < 0.05). These findings align partially with the studies conducted by Cindy van Es & Michelle M. Weaver [ 13 ], Hannigan A et al. [ 7 ], and Milic NM et al. [ 9 ]. The intriguing revelation was that female students achieved higher mean examination scores than their male counterparts (mean of 74.67 for females compared to 69.70 for males, p  < 0.05). This observation aligns with broader education studies highlighting females’ tendency to attain higher academic achievements [ 20 , 21 ]. Considering the previously mentioned attitudes of female students, we posit that their heightened recognition of the value and difficulty of statistics leads to increased attention and, subsequently, superior examination performance.

Examining age groups (< 21 vs. >=21), no differences were identified in the SATS components, consistent with the findings of Milic NM [ 9 ]. However, several studies suggest that older students typically hold negative attitudes toward statistics [ 4 , 6 , 7 , 11 ]. Although a significant learning achievement difference was noted between age groups, the magnitude was deemed too small to hold practical significance.

Turning to the influence of majors on students’ attitudes. Participants of our study belonged to clinical medicine, dentistry, radiology, and nursing majors. Simplifying the analysis, we categorized them into medical undergraduates and nursing undergraduates. The results demonstrated medical undergraduates tended to score higher on Affect, Cognitive Competence, and Value components, achieving better course achievement compared to their nursing counterparts. In China, where the National College Entrance Examination is pivotal, nursing programs typically require lower scores than medical programs. Additionally, nursing undergraduates harbor distinct career perspectives from medical undergraduates, influencing their attitudes toward statistics and contributing to the significant learning achievement disparity observed between the two groups.

We discovered a positive correlation between course achievement and the Affect, Cognitive Competence, Value, Interest, and Effort components, while observing a negative correlation with the Difficulty component across all participant groups and subgroups. These outcomes generally align with earlier research findings, as indicated by various previous studies [ 22 , 4 , 6 , 8 , 9 , 19 ]. Notably, our results specifically resonate with the findings of Nja CO et al. [ 19 ]. concerning the Difficulty component. In summary, our analysis confirmed that students exhibiting a positive attitude are inclined to achieve better learning outcomes. However, since our study was a cross-sectional survey, we couldn’t figure out whether there was a causality yet.

To summarize the previous discussion, our study found that compared with postgraduates, medical undergraduates have their characteristics on the attitude towards statistics, which manifested more positive affect but less Cognitive Competence, Value, and Difficulty components, besides confirmed gender and major factors are associated with students’ attitude towards statistics, as well as the students exhibiting a positive attitude are inclined to achieve better learning outcomes. Several studies have revealed that early learning experiences have a significant impact on the attitudes toward current statistics courses [ 4 , 7 ]. Our study, along with Zhang et al. ‘s, can serve as a comparison between undergraduates and postgraduates to illustrate this conclusion. This also suggests that to improve medical postgraduates’ attitudes towards statistics, course content should be designed well during the undergraduate stage, specially making it different from the postgraduate stage, and more attention should be paid to the associated factors influencing attitude. Methods could be adding more examples of real research in accordance with students’ majors, avoiding too much mathematical theory, reducing teaching standards of calculating ability, early application of statistics analysis software, or introducing innovative pedagogical strategies. These methods require further research.

It is worth noting that our study participants were enrolled in a regional medical college in China. With a total of 304 medical colleges in the country and an estimated 120 thousand new students entering Chinese medical colleges annually, the majority typically enroll in regional medical colleges akin to the institution where our investigation was conducted. This underscores the significance of our study in contributing to the advancement of medical statistics education in China. Our findings suggest that, despite China’s strong tradition of mathematics education and students undergoing rigorous mathematical training from their primary school years, the experience of anxiety and frustration during the learning of medical statistics in college is not uncommon, which implies that teaching methods proven effective in other countries can be applied in the Chinese context.

Our study has several limitations. Firstly, it was conducted in a single medical college, and while participants hailed from diverse regions across China, the inherent biases stemming from their backgrounds could not be entirely mitigated. Secondly, the survey was administered through a web app. Although we made efforts to filter out dubious responses completed hastily, we cannot guarantee the absence of arbitrary replies from impatient participants. Thirdly, while our results affirm the effectiveness of SATS for undergraduates in China, indicating a positive correlation with medical statistics learning achievements, we did not delve into the impact of students’ backgrounds, particularly their mathematical education, which has been shown in numerous studies to influence statistics learning outcomes [ 4 , 6 , 7 , 9 , 23 ]. In subsequent investigations, we intend to explore how factors such as education, geographical location, and cultural influences contribute to medical statistics course achievement among Chinese undergraduates, aiming to uncover the key determinants in this context.

The findings of this study align broadly with previous research, highlighting the difference between undergraduates’ and postgraduates’ attitudes toward medical statistics, and the influence of students’ genders and majors on their attitudes toward medical statistics. Additionally, the study reinforces the notion that students’ positive attitudes are associated with better learning outcomes. Consequently, educators should prioritize understanding the impact of attitudes, particularly considering variations related to genders and majors, when devising strategies and curricula to enhance medical statistics education for medical undergraduates.

Data availability

The data of this study are available from the corresponding author upon reasonable request.

Abbreviations

Survey of Attitudes Toward Statistics

Evidence-Based Medicine

Standard Deviation

A free software environment for statistical computing and graphics

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Acknowledgements

The authors would like to thank Dr. Candace Schau for her SATS-36 scale.

The study was funded by grants-in-aids from Heilongjiang Province Higher Education Teaching Reform Research Project (SJGY20210912, SJGZ20220154), Mudanjiang Medical University Education and Teaching Reform Project (JY2015030, MYPY20170010). The funding bodies played no role in the design of the study and collection, analysis, and interpretation of data and in writing the manuscript.

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Department of Epidemiology and Medical Statistics, School of Public Health of Mudanjiang Medical University, Tongxiang Road, Aimin District, Mudanjiang City, Heilongjiang Province, 157011, China

Yupeng Guo, Shengzhong Rong, Jing Dong, Tao Ji, Yingying Niu & Hongjun Guan

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YG and HG designed and conducted the study. SR, JD, TJ and YN collected the data. YG and SR conducted the statistics analysis. All authors contributed to the writing of the paper. All authors read and approved the final manuscript.

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Correspondence to Hongjun Guan .

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The study was approved by the School of Public Health of Mudanjiang Medical University (LL‑2023SPHMMU, 2023-2-28). Written informed consent forms were obtained from the subjects that participated in this study. All methods were carried out in accordance with relevant guidelines and regulations.

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Guo, Y., Rong, S., Dong, J. et al. Perceptions of attitudes toward statistics among medical undergraduates: insights from a regional medical college in China. BMC Med Educ 24 , 579 (2024). https://doi.org/10.1186/s12909-024-05600-1

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Received : 04 January 2024

Accepted : 23 May 2024

Published : 27 May 2024

DOI : https://doi.org/10.1186/s12909-024-05600-1

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