Measuring stress in podiatric students in Spain: psychometric validation and adaptation of the KEZKAK questionnaire

Introduction

Stress is a non-specific response of the organism to various stimuli. It is an adaptive, emergency process, and essential to survival (Román Collazo & Carlos Alberto Hernández Rodríguez, 2011). It is the generating agent of emotions and not an emotion in itself. It consists of a relationship between the individual and the environment, providing a perception of the extent to which environmental demands constitute a danger to well-being, and of whether the personal resources available are sufficient to meet these demands(Castillo Pimienta, Chacón de la Cruz & Díaz-Véliz, 2016).

In general, stress is positive at low levels, which predispose us to act against the demands presented by the environment. However, when it is moderate or extreme, stress demands greater attention, because the reactions it provokes in our ways of thinking and feeling may lead us to respond inappropriately (Alsulami et al., 2018; Marquina Luján & Pineda Palomino, 2019).

The clinical practicum is an element of vital importance in the curriculum of Health Sciences students, giving them the opportunity to perform techniques, acquire knowledge, develop skills and learn attitudes, within a clinical health environment that was previously unfamiliar and which is sometimes not as welcoming as they expect. Preparation and training prior to the student’s departure from academia to the real world is one of the great challenges of teaching, but not one to be addressed solely by the graduate student; undergraduates, too, must complete their theoretical-practical training in real environments. The presence of stress in university students is a reality. In healthcare programmes in which internships are carried out with patients in clinical situations and real environments, the stress inherent to the situation is aggravated by the psychological tension faced (Losa-Iglesias et al., 2019).

Studies have shown that, in general, health sciences students are exposed to higher levels of stress than are other students and the population in general. This stress is associated with the requirement to carry out clinical practices with real patients and in authentic clinical settings. However, most previous research in this field has focused on students of medicine and nursing (Castillo Pimienta, Chacón de la Cruz & Díaz-Véliz, 2016; Duarte et al., 2017; Losa-Iglesias et al., 2019). According to Rodrigues et al. (2016), the stress factors reported by nursing students concern feelings of insecurity, powerlessness, fear of the unknown and academic overload (Rotenstein et al., 2016). Similarly, podiatry students may experience stress in carrying out their clinical practices, where they are exposed to continuous stressors, such as fear of not doing well, doubting how to act, fear of cutting themselves or the patient with the scalpel, etc. In view of the real, stress-generating clinical scenarios faced, students must learn self-control. To help them do so, our aim is to calibrate the emotions and stress provoked in these situations.

In this line of stress measurement, a recent study evaluated the reliability and repeatability of findings obtained by the Stress Assessment in Nursing Students (ASNS) scale, modified for podiatry students, concluding that this instrument presented good psychometric properties (Palomo-López et al., 2020).

In this respect, too, the KEZKAK questionnaire was developed by Zuripia to identify stressors experienced by nursing students in their practicum (Zupiria Gorostidi et al., 2003). This questionnaire is a validated measurement instrument, for use in Spanish and Basque, that addresses the main stressful situations encountered by nursing students in their practicum, by means of direct questions in this respect.

In another investigation, the KEZKAK and other questionnaires were considered as the basis for an integrative evaluation of general self-efficacy, perceived competence, resilience and stress among nursing students, thus facilitating training in professional competencies, in line with the European guidelines of higher education. The authors suggested it would be interesting to follow up this research with comparative studies, considering different clinical contexts (Orkaizagirre-Gómara et al., 2020).

Accordingly, the aims of the present study are to develop a linguistic-cultural adaptation of KEZKAK for Spanish university students of podiatry, to be employed for measuring stressors during their practicum, to validate this adaptation and to evaluate its psychometric properties.

Materials & Methods

Results

A total of 223 students were initially recruited to this study. After application of the inclusion and exclusion criteria, 205 third and fourth-year students from the universities concerned finally completed the questionnaires and were included in the analysis. Of these students, 33.5% were male and 66.5% female, with an average age of 23.05 (SD 5.37) years. Only 22.3% were economically active, and their work activity was not related to health care (Table 1).

Construct validity

Factor analysis was conducted by application of the Kaiser–Meyer-Olkin and Bartlett tests. The adapted questionnaire was found to have five factorial structures (Fig. 1). According to total variance analysis, the Podiatry version of KEZKAK accounted for 61.185% of total variance.

Discussion

The aim of this study was to develop a cultural-linguistic adaptation of the KEZKAK questionnaire to be completed by Spanish university students of podiatry, as a means of measuring stressors during their practicum. We then evaluated this questionnaire and its psychometric properties. The results obtained show that the instrument tested is valid and reliable for this target population.

The study population were all volunteers and homogeneous in terms of age, although by sex there was a predominance of female students (66.5%), presumably due to their greater interest in university studies related to the health sciences (García-Díaz et al., 2020). This gender imbalance is present in undergraduate nursing programmes worldwide, and has been reported in many national and international studies (Boostel et al., 2018). The linguistic and cultural adaptation was performed with little difficulty following Beaton’s recommendations (Beaton et al., 2000).

Five of the initial items were unrelated to the context of podiatry students (such as item 18, “Seeing a patient die”) and so were excluded from the questionnaire. After filtering the items, the instrument finally obtained consisted of a self-administered questionnaire with 33 items, 5 factors, internal consistency, test re-test reliability, item-total and inter-item correlation and convergent validity to the STAI.

The Podiatry questionnaire presented five factors, in contrast to the nine of the original version, However, factorial analysis of the former showed that these five factors accounted for 61.185% of the total variance, a very similar level to that of the original, which had nine factors (64.4% of the total variance). These findings support the assumption of construct validity and show that the adapted questionnaire can safely be used to assess the presence and impact of stressors during the practicum of podiatry students. The first factor (17.22%) was composed of items related to feelings of powerlessness in the relationship with the patient. The second (32.99%) concerned the student’s perceived lack of professional skills. The third (44.51%) was related to emotional involvement and uncertainty, the fourth (55.96%) to relationships with tutors and peers, and the fifth (61.18%), to the student’s ability to relate to patients when they were given bad news or were suffering.

The difference in factorial structure between the adapted questionnaire and the original version may have arisen from inherent differences in the two branches of university studies (Nursing vs. Podiatry). Although both correspond to the field of health sciences, they differ regarding the clinical practices required and the relationship and degree of involvement with the patient during daily practice (Castello et al., 2019; Sánchez-García et al., 2019; Christensen et al., 2020). In this respect, it should be noted that the Portuguese version of KEZKAK, for Nursing students, only contains 31 items, divided into eight stressors (Barroso et al., 2008) of which the factors “Powerlessness and uncertainty”, “Not controlling the relationship with the patient” and “The patient seeks an intimate relationship” were combined into a single factor in the podiatric version of the questionnaire. The factors “Contact with suffering” and “Malaise from relationship with the patient” were also combined.

Strong internal consistency was observed in our questionnaire, as reflected in the Cronbach’s alpha score of 0.95, which is in line with the original and Portuguese-language versions (α = 0.95 and α = 0.935, respectively). No floor or ceiling effects were observed. The Podiatry version of KEZKAK presented convergent validity, with weak correlation for the STAI, which is in line with the original version and indicates that this questionnaire is capable of identifying stressors encountered during the practicum of podiatry students. In other words, it does not measure the degree of stress experienced by the student, but identifies potentially stressful situations (Alzayyat & Al-Gamal, 2014). The previous experiences of each student could affect the perception of stressors as a threat, either generating negative emotions such as fear, anxiety or anger, or causing stress to be viewed as a challenge to be coped with and/or overcome. From an educational standpoint, this instrument can help planners and students cope with stress-inducing situations and identify possible solutions.

In the field of podiatry, the only measurement instrument comparable with ours is the Spanish-language version of the ASNS instrument for podiatric students. However, this is used to mediate stress factors, not the situations that may provoke stress, such as clinical practices with real patients during the practicum. The ASNS instrument presents good reliability (α = 0.883), but falls short of the excellent internal consistency we obtained (α = 0.95). The ASNS instrument consists of 30 items and six domains, in contrast to the Spanish-language version of KEZKAK, adapted for podiatric students, which consists of five factors and explains 61.185% of the total variance. No factor analysis was performed in the ASNS adaptation, and so the number of domains might have been modified. Neither was the respondent population fully identified (i.e., whether the students were currently in the first, second, third, …year of their course), and so it is unclear the extent to which these students had previously had contact with the clinical practices of podiatry.

The main limitation of the present study is the male–female imbalance of the study population, which made it necessary to normalise the sample. In addition, in the cross-cultural validation, the issues related to validity should be assessed by the expert panel. Moreover, further items related to clinical practice could have been added to the questionnaire. On the other hand, in the validation that was performed, after the initial digitisation it was necessary to perform data cleansing, which led to some items being excluded, in part due to the real-life practice of podiatry in Spain which tends to be not in specialist or multidisciplinary teams, but often involves working alone.

In future research, it would be useful to observe the behaviour of stressors over time, in a longitudinal study, and also to conduct a quantitative evaluation of our questionnaire. Nevertheless, it is unarguable that clinical simulation for students is a necessary part of their preparation, and that this allows students to experience a close-to-real-life situation, highlighting the importance of scientific knowledge and skill, and their responsibility to provide the podiatry care that patients need. In addition, it would be useful to expand the focus to consider other podiatry-teaching institutions in Spain and/or the rest of the world, and to consider other branches of university study within the health sciences, where practicums with patients take place, to determine whether these present a similar pattern of reaction to stress. Such a focus would provide a broader perspective, help identify the main stressors experienced and enable us to design and apply strategies to decrease their intensity, thus enhancing students’ satisfaction with their education and promoting high-quality, safe healthcare. Finally, students who have completed their studies in other branches of health science should be evaluated to determine whether the impact of stressors decreases with greater experience.

The main strength of the present study is that it introduces the first self-administered questionnaire that can be used to measure the stressful situations encountered by university students of Podiatry in their practicum. Moreover, it contributes to our understanding of podiatry by showing that the main stressors that affect students are related to a perceived lack of competence and to difficulties in relationships. The findings presented, therefore, represent documentary support for teachers and course designers in the field of podiatry with which to create strategies aimed at reducing the factors shown to aggravate stress among these students.

Conclusions

The podiatry version of the KEZKAK is a self-administered questionnaire that is valid and reliable for measuring stressors during students’ practicum. However, further analysis may be needed, examining the use of this instrument with a larger population and incorporating a longitudinal follow-up. The use of this questionnaire is expected to improve students’ capacity for self-evaluation and critical reflection concerning their responsibility to learn and to acquire the healthcare skills needed.

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