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Self-Reflected Well-Being via a Smartphone App in Clinical Medical Students: Feasibility Study

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Background: Well-being in medical students has become an area of concern, with a number of studies reporting high rates of clinical depression, anxiety, burnout, and suicidal ideation in this population. Objective: The aim of this study was to increase awareness of well-being in medical students by using a smartphone app. The primary objective of this study was to determine the validity and feasibility of the Particip8 app for student self-reflected well-being data collection. Methods: Undergraduate medical students of the Dunedin School of Medicine were recruited into the study. They were asked to self-reflect daily on their well-being and to note what experiences they had encountered during that day. Qualitative data were also collected both before and after the study in the form of focus groups and "free-text" email surveys. All participants consented for the data collected to be anonymously reported to the medical faculty. Results: A total of 29 participants (69%, 20/29 female; 31%, 9/29 male; aged 21-30 years) were enrolled, with overall median compliance of 71% at the study day level. The self-reflected well-being scores were associated with both positive and negative experiences described by the participants, with most negative experiences associated with around 20% lower well-being scores for that day; the largest effect being "receiving feedback that was not constructive or helpful," and the most positive experiences associated with around 20% higher scores for that day. Conclusions: The study of daily data collection via the Particip8 app was found to be feasible, and the self-reflected well-being scores showed validity against participant's reflections of experiences during that day.
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Original Paper
Self-Reflected Well-Being via a Smartphone App in Clinical
Medical Students: Feasibility Study
Elizabeth K Berryman*, BHSc (Nursing), MHSc, MBChB; Daniel J Leonard*; Andrew R Gray*, BA, BCom (Hons);
Ralph Pinnock*, BSc (Med), MBChB, MHSc, MClinEd, DCH, FRACP; Barry Taylor*, MBChB, FRACP
Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
*all authors contributed equally
Corresponding Author:
Elizabeth K Berryman, BHSc (Nursing), MHSc, MBChB
Dunedin School of Medicine
University of Otago
PO Box 56
Dunedin, 9054
New Zealand
Phone: 64 274067940
Email: berel235@student.otago.ac.nz
Abstract
Background: Well-being in medical students has become an area of concern, with a number of studies reporting high rates of
clinical depression, anxiety, burnout, and suicidal ideation in this population.
Objective: The aim of this study was to increase awareness of well-being in medical students by using a smartphone app. The
primary objective of this study was to determine the validity and feasibility of the Particip8 app for student self-reflected well-being
data collection.
Methods: Undergraduate medical students of the Dunedin School of Medicine were recruited into the study. They were asked
to self-reflect daily on their well-being and to note what experiences they had encountered during that day. Qualitative data were
also collected both before and after the study in the form of focus groups and “free-text” email surveys. All participants consented
for the data collected to be anonymously reported to the medical faculty.
Results: A total of 29 participants (69%, 20/29 female; 31%, 9/29 male; aged 21-30 years) were enrolled, with overall median
compliance of 71% at the study day level. The self-reflected well-being scores were associated with both positive and negative
experiences described by the participants, with most negative experiences associated with around 20% lower well-being scores
for that day; the largest effect being “receiving feedback that was not constructive or helpful,” and the most positive experiences
associated with around 20% higher scores for that day.
Conclusions: The study of daily data collection via the Particip8 app was found to be feasible, and the self-reflected well-being
scores showed validity against participant’s reflections of experiences during that day.
(JMIR Med Educ 2018;4(1):e7) doi: 10.2196/mededu.9128
KEYWORDS
mental health; medical students; medical education; bullying; teaching; mhealth
Introduction
Background
There is an increasing number of studies that have suggested
that medical students experience high rates of depression and
suicidal ideation [1]. A systematic review conducted in 2016
by Rotenstein et al from 167 cross-sectional studies (n=116,628)
and 16 longitudinal studies (n=5728) from 43 countries found
that depressive symptom prevalence is substantially higher
among medical students than among individuals of similar age
in the general population. The finding in the longitudinal
analysis of this review showed an increase in depressive
symptom prevalence with the onset of medical school. The
overall pooled crude prevalence of depression or depressive
symptoms was 27.2%, compared with 2 large representative
epidemiological studies, which estimated depressive symptom
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prevalence in nonmedical students ranging from 13.8% to 21.0%
[1,2].
Furthermore, the Australian National Mental Health Survey of
Doctors and Medical Students showed that approximately one
in 5 medical students (20%) had thoughts of suicide in the
previous 12 months [3]. Similarly, the Rotenstein review showed
a prevalence rate for suicidal ideation, extracted from 24
cross-sectional studies (n=21,002) from 15 countries, of one in
10 medical students. Currently, there are no available data on
suicide rates in medical students. However, two systematic
reviews of qualified doctor suicides conducted by
Schernhammer and Colditz in 2004 and Damasceno et al in
2017 revealed the aggregate suicide rate ratio for male doctors,
compared with the general population, was 1.41. For female
doctors in the same studies, the ratio was 2.27 [4].
Many factors contribute to poor well-being and may include
occupational factors, emotionally demanding situations,
unrealistic expectations, and confrontations with illness, death,
and dying [5-8]. Degrading experiences such as bullying or
harassment at work have been shown to be associated with
suicidal thoughts [9]. The New Zealand Medical Students’
Association (NZMSA) surveyed their members in 2015 and
reported that 54% had experienced bullying or sexual
harassment while on clinical placement [10]. It has been
suggested that sometimes accusations of bullying can be linked
to situations that are an inevitable part of training [7]. For
example, trainers giving feedback to trainees that they are not
performing at the expected level [11]. However, research has
clearly shown that perceived mistreatment regardless of the
intention of the perpetrator is viewed by medical students as a
major source of stress and well-being depletion [5,12].
Due to the reported high prevalence of depressive and suicidal
thoughts in medical students, there is a need for additional
research to identify the root causes of emotional distress.
Recommendations from past studies have suggested adopting
prospective study designs, so that the same individuals can be
assessed over time [1].
Objectives
The primary objective of this study was to assess the feasibility
of utilizing a smartphone app, such as the Particip8 app, for the
collection of students’ individual self-reflected experiences and
sense of individual well-being. Secondary objectives were to
correlate daily experiences with the self-reflected well-being
score and to assess the use of the “safety pop-up feature” in
prompting students to access help at an earlier stage. Qualitative
data were also collected to assess the effectiveness of the
Particip8 app in increasing self-awareness of well-being.
Methods
Study Design
The methodology used for this feasibility study was a mixed
qualitative and quantitative approach. The quantitative aspect
utilizes the ecological momentary assessment (EMA) methods
as described by Shiffman et al [13]. The qualitative data were
based on grounded theory methodology and analyzed with a
narrative thematic approach based on descriptions in Glaser and
Strauss (2017) and Braun and Clarke (2006), respectively
[14,15]. The data for the qualitative analysis were obtained from
prestudy focus groups, as well as poststudy email surveys. An
overview of the methodology is set out in Figure 1. The
necessary sample size for the feasibility component of the study
was determined to be 30 participants, and the duration of the
study was determined to be 28 days. This was to allow sufficient
opportunities for participants to explore the Particip8 app under
different conditions and to achieve effective saturation of their
experiences. Participants were asked to use the Particip8 app
on a daily basis to record their self-reflection on well-being.
Participants were able to select a face emoticon scale to indicate
how they felt on that particular day. Additionally, participants
were also asked to select from a list provided, the experiences
that they had been exposed to during that day. Participants could
choose multiple experiences for the day; however, they could
only log one self-reflected well-being score.
Consultation with key stake holders was undertaken before
applying for ethics approval. These key stake holders included
the Pro-Vice Chancellor of Health Sciences, the Dean of M ori,
and the Dean of Pacifica. Other key stakeholders such as student
groups that included the Otago University Medical Students
Association, Te Oranga Aotearoa, NZMSA, and the Pacific
Island Health Professional Student Association were also
consulted. Feedback from these stakeholders was taken into
consideration during the study, and as a result, previous aspects
were changed and amended. Ethics approval was granted by
the University of Otago Head of Department (Ethics no.
D16/308).
Participant Recruitment
The participants were students recruited from the Dunedin
School of Medicine. Recruitment was conducted via posters in
student areas, lecture announcements, and through social media
posts. A total of 29 students voluntarily applied for the study,
and all 29 students met the inclusion criteria. As a result, all 29
students were enrolled in the study. The inclusion criteria
included (1) The ownership of a personal Android or apple
smartphone device; (2) Enrolled at the Dunedin School of
Medicine in the bachelor of medicine and surgery (MBChB)
degree; (3) Were currently in their 4th, 5th, or 6th year of the
undergraduate MBChB program; and (4) Currently undertaking
a clinical placement. The participants were provided with a code
for downloading the Particip8 app once they had inquired about
the study, or when they attended the prestudy focus group. A
webcast was made available to students with instructions on
how to download and use the Particip8 app. Both iPhone
operating system (iOS, Apple Inc) and Android platforms were
made available. The Particp8 app was not available for those
who owned a Windows phone, or for nonsmartphone mobile
devices.
The app was named “Particip8” because students were required
to be active participants in their own well-being. There were
eight daily questions that the students were required to answer.
For example, one question asked what placement the student
was on that day, another question had five questions from the
World Health Organization’s (five) Well-Being Index (WHO-5),
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and other questions related to the experiences that the student had experienced that day.
Figure 1. Methodology flowchart. SRW: self-reflected well-being.
Upon downloading the Particip8 app, the initial log-in page had
the details of the study and asked for the participant’s consent
to participate in the study. All participants gave consent via the
Particip8 app to be in the study. Participants were offered no
financial incentives or reimbursement for participation in the
study. The second page of the Particip8 app required each
participant to enter their baseline demographic data such as their
age, entry into medical school (either from secondary school
after completing the health science first year (HSFY) program,
after completing a previous degree (postgraduate), or from the
“other” category that included those who have an undergraduate
or postgraduate degree and have worked in allied health for a
minimum of 5 years, ethnicity, as well as their gender. The
webcast that had the download instructions also had instructions
on how to complete the survey and how to customize the time
setting for the daily push notification reminder.
Evaluation of the Screening Tool Used
The Particip8 app was specifically developed for clinical
medical students, by clinical medical students. It involved using
an international validated survey, the WHO-5. The question
wording and order in the WHO-5 did not change. The time
period of interest, however, was changed from “the last 14
days,” to asking “the last 24 hours” to suit daily recording. This
adaptation was reviewed by the New Zealand World Health
Organization Quality of Life Group and deemed suitable to be
used in this shortened time frame. Notably, however, no other
published research has used it as a daily survey before. The
WHO-5 was chosen because it has a sensitivity of 0.93 and a
specificity of 0.83 in the detection of depression [14].
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Figure 2. Screenshots of the app.
The Particip8 app asked the WHO-5 questions daily and utilized
the visual aid of a facial emoticon scale. The emoticon scale
was selected to help with ease, speed, and accuracy of answering
the five questions. The next page of the Particip8 app was a list
of experiences that the student possibly could have experienced
during the day. These experiences were chosen from the
“NZMSA 2015 Bullying and Harassment Survey” and
commonly experienced situations of clinical medical students
[10]. Screenshots from the Partcip8 app are presented in Figure
2.
Statistical Methods
The size of the study, being a total of 30 participants, was
determined to be sufficient for the quantitative component. The
size of the study would provide sufficiently precise estimates
for standard deviations, correlations between repeated measures,
and rates and patterns of missing data for designing larger
studies in the future.
Appropriate summary statistics were calculated for all variables
of interest. Analysis included linear mixed models (LMMs),
with a random participant effect to accommodate the repeated
measures over the study days. The LMMs were used to examine
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associations between each of the WHO-5 items and its combined
score and each of the situational (day of week, location),
experiential (eg, learning something new), demographic (age,
gender, ethnicity, and entry pathway), and study-related (day
of study and delay before reporting) variables. Model diagnostics
included examining model residual normality and
homoscedasticity. Subsequently, the experiential variables (yes
or no) were examined for associations with the situational,
demographic, and study-related variables by using mixed logistic
regression models. All statistical analyses were conducted using
Stata (StataCorp) 14.2, with two-sided P<.05 considered
statistically significant in all cases. No formal adjustment was
made for the multiple comparisons, and marginal results should
be interpreted with caution.
Results
Participant Characteristics
A total of 29 participants were analyzed in this study. Participant
characteristics (Table 1) showed the age range from 21 to 29
years, with a median age of 23 years (starting at age 19 years
with high school leavers completing HSFY entry method, the
majority of students would be either aged 21 years or above in
4th year medical school). The majority of participants (69%,
20/29) identified as female, with the remaining participants
(31%, 9/29) identifying as male. Ethnicity was 24% (7/29)
M ori, 38% (11/29) New Zealand European, and 38% (11/29)
identifying as “other” (Indian, Sri Lankan, Chinese, South East
Asian, and Pacific Islander). Entry pathway and student type
and gender percentage were both reflective of the cohort group
from which the participants were selected.
Table 1. Participant demographics.
n (%)Variable
Student-level
Age (years)
3 (10)21
6 (21)22
8 (28)23
4 (14)24
3 (10)25
5 (17)25+
Gender
20 (69)Female
9 (31)Male
Year
15 (52)Advanced learning in medicine (ALM) 4th year
5 (17)ALM 5th year
9 (31)Trainee intern
Entry pathway
21 (72)Health science first year program
2 (7)Other
6 (21)Postgraduate
Student type
26 (90)Domestic
3 (10)International
Prioritized ethnicity
7 (24)M ori
11 (38)European
11 (38)Other
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App Feasibility Analysis
Compliance was measured as completing the daily survey within
the allotted time period. In total, 471 days were completed over
the 28-day study period, resulting in an overall median
compliance rate of 71% at the day level. A total of 13
participants (45%, 13/29) completed 80% to 100% of the days,
achieving the required compliance threshold for EMA studies;
4 (14%, 4/29) completed between 50% to 80% of days; and 12
participants (41%, 12/29) completed less than 50% of the days.
The longitudinal data showed that compliance rates steadily
declined over the 28 days (data not shown. Females were
nonstatistically significantly more compliant than men, and
there was no evidence for associations with compliance for any
of the other student demographics (age group, ethnicity, or year
of study).
Well-Being by Day of the Week and Type of Day
For the overall score (Multimedia Appendix 1), there were
differences between various days of the week (overall P=.003).
Tuesday had the lowest overall well-being mean (2.91/.00), and
Saturday had the highest mean (3.51/5.00). The same pattern
was observed for the five individual questions, but only feeling
cheerful (Q1), waking up fresh and rested (Q4), and day filled
with things that interested (Q5) were statistically significantly
different by the particular day of the week. Days off
(mean=3.44) had higher well-being scores than days where the
students attended placements (3.01, P<.001). Four of the
questions showed statistically significant differences, except
feeling active and vigorous (Q3).
Ethnicity
M ori students were 1.22 times more likely to engage in sports,
social activities, or hobbies than New Zealand European students
and 2.27 times more likely compared with non-New Zealand
European students (overall test for ethnicity P=.009, results not
shown).
Entry Pathway Into Medicine
Postgraduate and “other” students were 2.2 times more likely
to feel that they “did not learn anything” (19.5% vs 8.9%,
P=.02). Postgraduate and “other” students were 2.5 times more
likely to feel more unsure of their knowledge and skills (46.9%
vs 18.4%, P=.009) and were 3.4 times more likely to worry
about exams (68.1% vs 19.8%, P=.01; results not shown).
Rural Location
Another finding was that there were differences in the results
between students who were on placement in Dunedin and those
who undertook placement outside of Dunedin. Some areas, such
as the West Coast of the South Island, are the most isolated
locations in New Zealand. Although anecdotal reports from
students are that the learning and experiences in these isolated
locations are extremely beneficial, the results from the study
show that well-being scores are lower when students undertake
a placement outside of Dunedin. Students undertaking
Dunedin-based placements were 2.4 times more likely to receive
constructive feedback compared with their colleagues based
outside of Dunedin (P=.04). Students on placements away from
Dunedin were 2.1 times as likely to experience stress or worry
(P=.009; Table 2 OR results not shown) and in Multimedia
Appendix 1, reported 0.6 lower (21%) scores in relation to the
question about waking up feeling refreshed and well rested (Q4;
P=.02).
Well-Being Scores by Placement
There were apparent differences in well-being scores between
students assigned to different specialties for their clinical
placement (Multimedia Appendix 1, overall P<.001) (Figure
3). General practice scored highest of all the specialties (mean
4.02/5.00), followed by “other” (emergency department,
intensive care unit, and public health; 3.78), and surgery (3.13).
The lowest scores were reported by students undertaking the
lecture-based whole class learning week (2.63), psychological
medicine (2.63), and women and children’s health (2.51).
Experiences Effect on Well-Being
Multimedia Appendix 2 details what participants experienced
and the effect on well-being score. A total of five incidents of
bullying or harassment were reported by students during the
study. These incidents showed to have had a significant adverse
effect (AE) on the participant’s well-being, and in particular,
there was an AE recorded for three of the five questions; for
example, feeling cheerful (Q1), feeling calm and relaxed (Q2),
and day filled with things that interest me Q5). However, the
daily score (P=.06; Multimedia Appendix 2) was not statistically
significantly lower overall. “Receiving feedback that was not
constructive or helpful” had the greatest impact on a
participant’s overall well-being score, being associated with
1.18 lower mean scores, equivalent to a 37% reduction in a
participant’s well-being (P<.001). Other large overall well-being
decreases included “Felt like I didn’t learn anything” (29%
lower for overall score, P<.001), followed by “Felt like I was
treated unfairly” (21% lower for overall score, P<.001), and
“stress or worry about something outside of medical training”
(20% lower for overall score, P<.001). On the other hand, the
recorded experiences that increased well-being scores were as
follows: “Felt confident about my knowledge or skills” (19%
higher, P<.001), “engaged in a hobby, sport, or social activity”
(18% higher, P<.001), and “received feedback that was
constructive or helpful” (17% higher, P<.001).
Constructive Feedback
Due to the low levels of participants in the category “other
specialities,” it is difficult to interpret these results. However,
for the other placements, there was sufficient data to analyze.
With respect to “receiving constructive feedback,” although
there was no overall evidence for differences (P=.19), general
practice was the highest at 40.0%, followed by surgery (30.5%),
psych medicine (24.6%), and women and children’s health
(24.4%). Not surprisingly, whole class learning week, which is
lecture and small tutorial-based learning, had the least amount
of constructive feedback for students (14.8%).
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Table 2. Experiences versus mean well-being score.
P valueDifference1 or more daysNot experiencedExperience
Increased well-being
<.001+0.573.593.02Felt confident about my knowledge or skills
<.001+0.533.452.92Engaged in a hobby, sport, or social activity
<.001+0.523.573.05Received feedback that was constructive or helpful
<.001+0.453.412.96Felt I learnt something new
<.001+0.403.453.05Felt like I helped someone
Decreased well-being
<.0011.182.033.21Received feedback that was not constructive or helpful
.0051.082.333.41Felt I was bullied or harassed
<.0010.942.343.28Felt I didn’t learn anything
<.0010.672.633.29Stress or worry about something outside of medical training
<.020.662.533.19Felt I was treated unfairly
.0010.632.743.37Worried about exams
Figure 3. Mean well-being scores by placement.
Qualitative Results
The results are from a narrative analysis of the focus group
verbatim text and the “free-text” email surveys. Participants felt
that using the Particip8 app to track well-being was feasible
because they often had small amounts of time available to
complete the survey.
Theme 1: Finding the Time
Some of the participants stated the following:
I feel like it would be quite easy because as a 4th year
there is a lot of times there is waiting around and a
lot of those times I tend to go on my phone, so I think
that it will be easy to find time for a few minutes to
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go on [and do the Particip8app]. [4th-year medical
student participant]
There is a lot of down time sitting outside out-patients,
waiting for consultants, etc, it is a good way to use
the time productively and easily. [6th-year medical
student participant]
Students are taught that regular reflection is important, but it is
difficult to establish a habit. Participants also thought that an
app would help establish these patterns and habits.
Theme 2: A Tool to Help Create Habits on
Self-Reflection
Some of the participants stated the following:
I think that it would be difficult at the start to get into
the habit of it, but, if I say do it every day at 5 o’clock,
I would like to get into the habit of it, like doing it on
the bus or something. [4th-year medical student,
participant]
...thinking about these questions every day, kind of
makes you a bit more mindful of it, then you then,
“ah,” like if you are having a particularly good day,
“I've had a really good day,” or if things haven’t
gone so well, you actually sort of think about that and
sort of realise things that you might have otherwise
missed. [4th-year medical student participant]
Theme 3: Daily Reflection Increased Self-Awareness of
Well-Being
Some of the participants stated the following:
Sometimes it is hard to know that you are actually
quite stressed out. [4th-year medical student
participant]
I think as well that the environments that we’re
working in the hospitals, can be quite stressful
environments, so it’s important that we are able to
take care of our well-being so that we are able to best
respond to those stressful environments in a way
that’s not going to be like self-destructive or
damaging to ourselves. [4th-year medical student
participant]
I think that it is very important. It is the kind of the
core of what we need to do, to do anything else you
need to be well. [5th-year medical student participant]
On the email poststudy survey questionnaire, students confirmed
that their overall awareness of well-being had increased by 20%
on a Likert scale from poststudy qualitative results.
Analysis of the Safety Feature
Participants who had logged 3 days of low well-being scores
triggered a safety feature on the Particip8 app, which alerted
them and suggested places that were available for help and
assistance. During the study, 41.7% (12/29) of all participants
received the safety pop-up message at some stage during the
study period. When asked if they sought support, most
participants said that they talked to a trusted person, and 5
participants went to student health services. No participants
stated that they had gone to the Medical School Associate Dean
of Student Affairs for assistance.
After taking part in the study, over 90% (26/29) of students say
a measure of their own wellness was useful. A further 75%
(22/29) of participants said that they would be happy for their
data to be reported back to the medical school faculty with some
identification, such as demographics. The remainder of the
participants (25%, 7/29) agreed to the data being reported to
the medical school faculty on the provision that their data
remained completely anonymous.
Discussion
Principal Findings
This study provides several important academic and practical
outcomes. This feasibility study has examined the ability to
collect self-reflected well-being data from medical student users
via a smartphone app. The results collected, including focus
group feedback and compliance percentages, show that this was
overall a feasible method of collecting these data, although
strategies to increase compliance would be advisable and
worthwhile.
Prior studies in psychology suggest that use of the face emoticon
scale can make participation more enjoyable. The study did not
encounter any issues with regard to the inconvenience to
participants to use the Particip8 app. A suggestion for the future
development of the Particip8 app would be to add a dashboard
page with a graph of a personal self-reflected well-being results
over a week. Such a mechanism would allow participants to
view the trends of their data and enable them to look back on
past logged days themselves. The academic implication shown
by this study is that surveys can be administered with ease and
minimal burden to participants. This has potential generalized
implications on future study methodologies, which require
participants to complete short questionnaires at regular intervals.
The recorded well-being data was associated with experiences
in ways that seem plausible, providing some degree of
validation.
There are many challenges and practical implications that arise
from conducting research by utilizing a smartphone app such
as Particp8. Studies such as this are able to provide “real-time”
data on the experiences of medical students and can generate a
wealth of accurate prevalence data on well-being scores.
However, the issue of “big data” and how to best analyze and
interpret this becomes the next challenge.
Limitations
Several limitations influence the conclusions and
recommendations drawn from this research. First, the sample
was small, self-selected, and drawn from a medical student
population. This allowed, as intended, for a detailed exploration
of an at-risk group who are likely to benefit from reflection of
personal well-being. However, this adds limitations as the
sample may differ from other young people, and the extent to
which the themes discerned here are applicable across other
populations or university groups is unclear. Second, there is
also the limitation that comes with all self-reported data,
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whereby the participants may not be completely honest and
candid in their reflections. One advantage of the methodology
used in this study that counters this concern is that the daily
survey detects change in the participants’ self-reflected
well-being score when experiencing different situations. This
comparison with the WHO-5 score increases the credibility of
the self-reflections, rather than relying on the WHO-5 score
alone.
Third, there may be concerns that the collection of data, with
only a small number of survey questions, may not be adequate
to accurately decipher trends. On the basis of findings from this
research, it is argued that because daily reporting via the
Particip8 app increases the amount of data received overall, this
compensates for any disadvantage of the kind identified.
Furthermore, the data collected from this study were sufficient
to demonstrate several statistically significant results.
Finally, another concern is that daily self-reflection could
become a burden or inconvenience to users of the Particip8 app.
Users may become annoyed and resentful toward the Particip8
app’s daily “pop-up alerts” and push notifications to complete
surveys. Despite this concern, the focus groups and poststudy
results did not indicate any issue with annoyance or
inconvenience. In fact, participants felt that because the survey
could be usually completed in less than 1 min, the Particip8 app
itself was not burdensome. Participants also noted that they
appreciated the ability to complete the Particip8 app whenever
they wanted, rather than at predetermined times stipulated by
the researchers. Nonetheless, this feasibility study provides an
initial understanding of the opportunities for successful
smartphone-based collection of real-time self-reflected
well-being data.
Future Research
As this was only a feasibility study with a small sample size
and was of a relatively short duration, future studies should
investigate the feasibility over longer durations, in particular,
to assess any further decline in compliance rates.
Future research is now focused on developing an updated
Particip8 app. Such an app will have additional functions such
as anonymous reporting of inappropriate behavior experienced.
Notably, the anonymous reporting of inappropriate behavior is
something that over half of participants said that they would
find useful. Participants in the study also requested a “free-text”
area so that they could write and record more detailed accounts
of experiences during the day. This free-text area would be
similar to a reflective journal and would be useful to the user.
Another potential area for further research is the incorporation
of “interventions” into the Particip8 app. These could be either
online interventions that are contained within the Particip8 app
itself, such as a mindfulness recording, or could be “in-person”
interventions, such as attending workshops. Any changes to a
user’s baseline well-being could be monitored by real-time
monitoring from the Particip8 app’s self-reflected well-being
scores. Furthermore, the data from these studies could be used
to determine whether there is any correlation between
improvements in self-reflected well-being scores and reduced
clinician burnout, depression, anxiety, and suicide. Ultimately,
this would result in optimal patient outcomes in the long term.
Given the limitations of this study, its findings serve as research
questions for future investigations and studies, rather than for
providing definitive answers.
Conclusions
In conclusion, the findings of this study suggest that the 28-day
longitudinal collection of daily self-reflection well-being data
via the Particip8 app was feasible. Further research is required
to determine how to sustain the compliance with methodology
over a longer period of time, as well as how to use the data to
improve the well-being in clinical medical students.
Acknowledgments
The authors would like to thank The Creating Positive Learning Environments research group based at Bioethics Department,
The University of Otago, for their support and ongoing advice regarding this study. They would also like to thank Professor Tim
Wilkinson, Professor Lynley Anderson, Dr Althea Blakey, Dr Kelby Smith-Han, and Emma Collins.
Conflicts of Interest
EB and DL were both undergraduate medical students at the University of Otago, Dunedin School of Medicine, during the study
period. The development of the app and software was self-funded by EB and DL. There were no financial contributions by any
organization toward this feasibility study.
Multimedia Appendix 1
Demographic and situational predictors of well-being scores.
[XLSX File (Microsoft Excel File), 39KB-Multimedia Appendix 1]
Multimedia Appendix 2
Experiential predictors of well-being scores.
[XLSX File (Microsoft Excel File), 41KB-Multimedia Appendix 2]
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Abbreviations
AE: adverse effect
EMA: ecological momentary assessment
HSFY: health science first year
LMM: linear mixed model
MBChB: bachelor of medicine and surgery
NZMSA: New Zealand Medical Students’Association
Edited by G Eysenbach; submitted 06.10.17; peer-reviewed by F Moir, M Earl, B Worm; comments to author 26.10.17; revised version
received 15.12.17; accepted 02.01.18; published 07.03.18
Please cite as:
Berryman EK, Leonard DJ, Gray AR, Pinnock R, Taylor B
Self-Reflected Well-Being via a Smartphone App in Clinical Medical Students: Feasibility Study
JMIR Med Educ 2018;4(1):e7
URL: http://mededu.jmir.org/2018/1/e7/
doi: 10.2196/mededu.9128
PMID: 29514774
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Most writing on sociological method has been concerned with how accurate facts can be obtained and how theory can thereby be more rigorously tested. In The Discovery of Grounded Theory, Barney Glaser and Anselm Strauss address the equally Important enterprise of how the discovery of theory from data-systematically obtained and analyzed in social research-can be furthered. The discovery of theory from data-grounded theory-is a major task confronting sociology, for such a theory fits empirical situations, and is understandable to sociologists and laymen alike. Most important, it provides relevant predictions, explanations, interpretations, and applications. In Part I of the book, "Generation Theory by Comparative Analysis," the authors present a strategy whereby sociologists can facilitate the discovery of grounded theory, both substantive and formal. This strategy involves the systematic choice and study of several comparison groups. In Part II, The Flexible Use of Data," the generation of theory from qualitative, especially documentary, and quantitative data Is considered. In Part III, "Implications of Grounded Theory," Glaser and Strauss examine the credibility of grounded theory. The Discovery of Grounded Theory is directed toward improving social scientists' capacity for generating theory that will be relevant to their research. While aimed primarily at sociologists, it will be useful to anyone Interested In studying social phenomena-political, educational, economic, industrial- especially If their studies are based on qualitative data. © 1999 by Barney G. Glaser and Frances Strauss. All rights reserved.
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Mistreatment and abuse of medical students has been recognized as a significant problem in medical schools. We believe, however, that the problem of mistreatment has been viewed incorrectly. This misperception of mistreatment exists in two primary ways. First, mistreatment has tended to be viewed as a "diagnosis" of unprofessionalism of the perpetrator when it may be more appropriately viewed as a symptom with a range of possible underlying causes. The second misconception that appears to be prevalent is the belief that the link between mistreatment and student well-being, distress, and falling empathy is clear. It is not. We present (1) evidence that other factors in the clinical learning environment may be having a greater negative impact on student mental health and well-being and (2) recommendations for changes that may produce enhancement to medical student mental health in the clerkship year.
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Because of the high prevalence of burnout among medical students and its association with professional and personal consequences, the authors evaluated the help-seeking behaviors of medical students with burnout and compared their stigma perceptions with those of the general U.S. population and age-matched individuals. The authors surveyed students at six medical schools in 2012. They measured burnout, symptoms of depression, and quality of life using validated instruments and explored help-seeking behaviors, perceived stigma, personal experiences, and attitudes toward seeking mental health treatment. Of 2,449 invited students, 873 (35.6%) responded. A third of respondents with burnout (154/454; 33.9%) sought help for an emotional/mental health problem in the last 12 months. Respondents with burnout were more likely than those without burnout to agree or strongly agree with 8 of 10 perceived stigma items. Respondents with burnout who sought help in the last 12 months were twice as likely to report having observed supervisors negatively judge students who sought care (odds ratio [OR] 2.06 [95% confidence interval (CI) 1.25-3.39], P < .01). They also were more likely to have observed peers reveal a student's emotional/mental health problem to others (OR 1.63 [95% CI 1.08-2.47], P = .02). A smaller percentage of respondents would definitely seek professional help for a serious emotional problem (235/872; 26.9%) than of the general population (44.3%) and age-matched individuals (38.8%). Only a third of medical students with burnout seek help. Perceived stigma, negative personal experiences, and the hidden curriculum may contribute.