The Potential Protective Effect of Hope on Students’ Experience of Perceived Stress and Burnout during Medical School


Ashten R Duncan MPH1; Chan M Hellman PhD2

Perm J 2020;24:19.240 [Full Citation]
E-pub: 12/02/2020


Background: A major problem facing today’s physicians and medical students is burnout. Christina Maslach and fellow researchers have described burnout as a product of chronic stress and a lack of protective psychological factors like hope. The purpose of this study was to explore the relationships between hope, stress, and burnout among medical students.

Methods: This study involved an online survey of 329 first- through fourth-year allopathic and osteopathic medical students. Validated psychometric scales were used to measure the primary variables. We conducted Pearson correlation, hierarchical regression, and mediation analyses to test the relationships between hope, stress, and burnout and to determine whether hope directly impacts stress and burnout.

Results: We found significant correlations between hope, stress, and burnout. Hierarchical regression revealed that hope accounted for significant variance in burnout over and above psychological stress and that stress and hope together accounted for 48% of this variance. We discovered that hope may be partially mediating the relationship between stress and burnout.

Conclusion: Hope may play a significant protective role in the stress-burnout relationship in the context of medical students: higher levels of hope are associated with lower levels of stress and burnout. Our study supports the idea of using hope-based interventions in medical student populations and investing more resources into this area of research.


A major problem facing today’s physicians and medical trainees is burnout, a phenomenon described by Christina Maslach, PhD, psychology professor at the University of California, Berkeley, as a combination of exhaustion, depersonalization, and diminished professional efficacy.1,2 The progression of burnout symptoms in professional settings often leads to dissatisfaction with one’s profession and an overall feeling of disillusionment.2-5 Aside from professional detachment, burnout also has the potential to produce a number of other negative outcomes for those experiencing it, including absenteeism from work and deterioration of social support systems; within medical settings, burnout can contribute to a marked decrease in patients’ perception of health care quality and safety.1,6,7

Medical provider burnout follows a pattern of increasing symptomatic severity that begins in medical school.3,8,9 Research has shown that many medical students in their third year of training experience high levels of distress and, in some cases, fail to cope effectively, which can lead to chronic, unresolved negative stress.10 The cyclical nature of chronic stress can ultimately lead to negative behavioral patterns that promote progression to burnout, which may have physical health implications like elevated stress-related biomarkers.11,12 Moreover, prolonged stress and burnout are associated with lower academic performance among medical students.13 A number of different protective factors, such as workplace support and job control, have been identified that are associated with significantly lower rates and levels of chronic stress and burnout.14 Early exposures to chronic professional stress left unchecked by protective psychological factors may further exacerbate the burnout epidemic.

Certain protective psychological factors have been recognized as being potentially beneficial in the stress-burnout relationship.2,10,15 One such factor is hope, a measurable trait related to upstream factors like goal attainment and motivation to pursue goals that can affect the manifestation of psychological stress.15 Originally described by a research team led by Charles “Rick” Snyder, hope theory is a form of positive psychology that defines the interaction of 2 cognitive processes: pathways thinking and agency thinking.16,17 Pathways thinking refers to the appraisal of available resources and options when pursuing a desired goal, and agency thinking refers to the perceived capability and motivation to achieve the goal.16,17

These 2 manners of thinking about a goal are inextricable: deficient levels of agency with sufficient pathways identification, or vice versa, result in overall decreased levels of hope.17,18 Moreover, people often exhibit a pattern of “grief” related to the inability to achieve a desired goal according to this theory: as pathways to goals become blocked and alternative pathways cannot be identified, people may experience intense frustration referred to as rage followed by despair and apathy.17 The more significant a goal is, the more likely that barriers may lead to this process.17,18 Theoretically, people with fewer and larger goals are more susceptible to decreased hope levels and possible despair and apathy should major challenges arise that are not easily overcome.15-18

Research demonstrates the negative relationship between hope and burnout: high hope correlates with a lower rate of burnout.19 Hopeful individuals are more likely to experience confidence in their ability to achieve new goals, which, in the context of burnout symptomology, means those individuals are less likely to struggle with chronic stress and downstream burnout symptoms.20,21 In addition, high levels of hope have been reported as being associated with improved academic performance, notably among law and undergraduate students.22,23

The aim of this study was to document the levels of burnout, stress, and hope in a sample of medical students enrolled in an allopathic medicine program and an osteopathic medicine program. We hypothesize that there would be negative correlations between hope and stress and between hope and burnout and that there would be a positive correlation between burnout and stress. This hypothesis is based on the observation that high levels of hope enhance one’s ability to cope more effectively with novel and more intense stressors and that burnout arises from chronic stress. We further hypothesize that hope may be mediating the relationship between perceived stress and burnout in medical students.


Target Population

We recruited participants from the first- through fourth-year classes of 2 medical schools in a Midwestern state of the United States. One of these schools provides allopathic medical training, and the other provides osteopathic medical training. In total, 1101 students from the 2 medical schools were sent email requests to complete an anonymous Qualtrics survey over a 4-week period. All study recruitment occurred between January and April 2018.

Ethical Approval

This study was initially approved following expedited review by the University of Oklahoma Health Sciences Center Institutional Review Board (IRB) on January 13, 2018 (IRB number 8778; reference number 674302). Modifications to the study that expanded the sample population were approved by the same review board on March 11, 2018 (IRB number 8778; reference number 675576).

Study Measures

The majority of the survey consisted of validated psychometric instruments designed to measure dispositional hope, perceived stress, and burnout. We measured hope using the Adult Dispositional Hope Scale (range = 8-64), which was created and validated by Snyder and fellow researchers.16,24 We measured burnout using the English version of the Oldenburg Burnout Inventory (range = 16-80). This validated measure was selected because of its utility in measuring burnout in academic and work environments, which is theorized to apply to clinical training environments.25,26 We assessed stress using the Perceived Stress Scale (range = 10-50).27


Demographic questions were included to collect information about each respondent’s biological sex, age, marital status, employment status, race, and classification by year in medical school.

Statistical Analysis

All data were analyzed using the Statistical Package for Social Sciences (version 24).28 The 2 schools’ individual data sets were maintained and analyzed separately and then were consolidated for aggregate analysis. Descriptive and inferential statistics were generated for each group and then for both groups combined. Before the data were analyzed in aggregate, analysis of variance was performed to ensure that the medical students did not differ significantly in terms of their psychometric scale scores based on year in school, biological sex, or school attended. Pearson correlation and hierarchical regression analyses were performed to describe the relationships among the variables of interest.


Number of Respondents and Response Rates

Of the 1101 students asked to participate in the study, 329 respondents successfully completed the survey (overall response rate = 29.9%). For the allopathic medical school, 236 of 652 eligible participants completed the survey (response rate = 36.2%). For the osteopathic medical school, 93 of 449 eligible participants completed the survey (response rate = 20.7%).

Demographic Characteristics of Study Participants

Table 1 details the demographic characteristics of the study participants, showing each program’s numbers and the total participant numbers. The distribution of respondents captured in the study sample was similar to the characteristics of the student population at the 2 medical schools. The overall distribution of the respondents based on biological sex was fairly evenly split between men (48.6%) and women (51.1%). The median age of the respondents was the same for the 2 programs (median = 25 years). When asked about their relationship status, the majority of respondents identified as single (71.1%), with the next most represented group identifying as married (26.1%). In terms of racial characteristics, the majority of respondents identified as being Caucasian (84.8%), followed by Asian (13.4%) and American Indian (8.5%). There were more second-year medical students (37.4 %) represented in this study than any other year in school, followed by first-year students (25.5%). Third- (19.8%) and fourth-year (17.3%) medical students were underrepresented in the sample.

Table 1. Sociodemographic characterisitcs of allopathic and osteopathic medical studentsa

Characteristic MD students(n = 236) DO students(n = 93) All students(N = 329)
Biological sex
 Men 111 (47.0) 49 (52.7) 160 (48.6)
 Women 124 (52.5) 44 (47.3) 168 (51.1)
 Other 1 (0.4) 0 (0.0) 1 (0.3)
Median age, y 25 25 25
Relationship status
 Married 55 (23.3) 31 (33.3) 86 (26.1)
 Common-law 2 (0.8) 1 (1.1) 3 (0.9)
 Separated 0 (0.0) 1 (1.1) 1 (0.3)
 Divorced 2 (0.8) 2 (2.1) 4 (1.2)
 Single 177 (75.0) 57 (61.3) 234 (71.1)
 Widowed 0 (0.0) 1 (1.1) 1 (0.3)
Employment status
 Yes 14 (5.9) 11 (11.8) 25 (7.6)
 No 222 (94.1) 82 (88.2) 304 (92.4)
 American Indian 17 (7.2) 11 (11.8) 28 (8.5)
 Asian 39 (16.5) 5 (5.4) 44 (13.4)
 African American 3 (1.3) 3 (3.2) 6 (1.8)
 Caucasian 197 (83.5) 82 (88.2) 279 (84.8)
 Hispanic 7 (3.0) 5 (5.4) 12 (3.6)
 Other 5 (2.1) 2 (2.2) 7 (2.1)
Year in school
 First 52 (22.0) 32 (34.4) 84 (25.5)
 Second 100 (42.4) 23 (24.7) 123 (37.4)
 Third 48 (20.3) 17 (18.3) 65 (19.8)
 Fourth 36 (15.3) 21 (22.6) 57 (17.3)

aData are presented as n (%) unless indicated otherwise.

bPercentages for race are based on the number of responses for a particular choice over the total number of responses for the column because respondents were allowed to select more than 1 race if applicable.

Distributions of Primary Variables of Interest

Analysis of variance testing showed that the scale scores did not differ significantly when comparing students from each program based on their demographic characteristics, psychometric scale scores, and year in school. Cronbach’s alpha testing of the validated psychometric scales used in this study showed appropriate levels of internal consistency for both data sets. This outcome prompted the analysis of the 2 data sets in aggregate. The average scale scores for all 329 student responses were as follows: hope (53.0 ± 6.6), perceived stress (26.6 ± 7.3), and burnout (43.3 ± 9.7); these results indicate that on average, the sample experienced high levels of hope, moderate levels of perceived stress, and moderate levels of burnout.16,25,27

Relationships Between Stress, Burnout, and Hope

Table 2 presents the Pearson correlation results: the analysis demonstrated a significant positive relationship (r = 0.663; p < 0.001) between stress and burnout, a significant negative relationship (r = –0.504; p < 0.001) between hope and burnout, and a significant negative relationship (r = –0.571; p < 0.001) between hope and stress. The data were further investigated using hierarchical regression analysis. Tests for multicollinearity indicated that no significant level of multicollinearity was present. As shown in Table 3, hierarchical regression revealed that stress accounted for about 46% of the variance in burnout (△R2 = 0.46; F(1, 321) = 267.076; p < 0.001) and that hope accounted for a small yet significant amount of variance in burnout over and above stress (△R2 = 0.02; F(1, 320) = 15.111; p < 0.001). In addition, the analysis revealed a significant negative relationship between hope and medical student burnout. In the final model, hope and stress accounted for approximately 48% of the variance in medical student burnout.

Table 2. Correlation matrix for hope, perceived stress, and burnouta

Variable Hope Perceived stress Burnout
Hope 1    
Perceived stress –0.571b 1  
Burnout –0.504b 0.663b 1

aData are presented as Pearson correlation coefficients (N = 329).

bp < 0.001 (2-tailed).

Table 3. Hierarchical regression analysis of medical student burnout

Hierarchical model and results B SE Beta p-Value
(Constant) 24.866 4.678   0.000
Perceived stress 0.925 0.057 0.695 0.000
Step 1
 R2 = 0.46        
 F(1, 321) = 267.076a        
(Constant) 42.925 6.523   0.000
Perceived stress 0.770 0.068 0.578 0.000
Hope –0.286 0.073 –0.194 0.000
Step 2 
 △R2 = 0.02        
 F(1, 320) = 15.111a        

ap < 0.001. Final R2 = 0.48.

Mediation Analysis of Stress, Burnout, and Hope

Figure 1 provides the details regarding the relationships among the 3 variables of interest wherein we hypothesized that hope was mediating the relationship between stress and burnout. This model was predicated on the assumption that chronic stress leads to burnout. The simple mediation model showed that the relationship between stress and hope was significantly negative (B = –0.52; t(325) = –12.54; p < 0.001), hope predicting burnout was significant (B = –0.29; t(324) = –3.95; p < 0.001), and the direct relationship between stress and burnout was significant (B = 0.88; t(324) = 15.94; p < 0.001). Furthermore, the model demonstrated that the relationship between stress and burnout with hope removed was significantly decreased (B = 0.73; t(324) = 11.12; p < 0.001). The mediation analysis revealed that hope may be partially mediating the relationship between stress and burnout and that this indirect effect was significant (B = 0.15; ZSobel = 3.76; p < 0.001). In other words, this model showed that stress reduces hope and that reduced hope leads to increased burnout.


Figure 1. Mediation for hope, perceived stress, and burnout.


This study explored the relationships between perceived stress, burnout, and hope among a sample of medical students. Our alternative hypotheses were as follows: 1) there will be negative correlations between hope and stress and between hope and burnout; 2) there will be positive correlations between burnout and stress; and 3) hope may be mediating the relationship between perceived stress and burnout in medical student populations. The findings from the Pearson correlation analysis are of sufficient statistical significance to reject the null hypotheses associated with the first 2 alternative hypotheses. These relationships were explored further using hierarchical regression analysis, which showed that higher levels of hope have a statistically significant association with lower levels of burnout among medical students over and above the influences of stress. The null hypothesis associated with the third alternative hypothesis was rejected on the grounds that mediation analysis showed that hope may be partially mediating the relationship between stress and burnout.

We found that while hope is high among medical trainees, there is room for improvement for many students. Given that increasing hope could lead to better academic performance in addition to improved well-being indicators in medical student populations,17,22,23 we argue that building foundations of hope should be a focus of modern student wellness programs. One example of how this could be accomplished involves active self-reflection activities in which students can map out how their daily activities feed into larger goals that are connected to the ultimate goal of practicing medicine. The results reinforce the relationships between stress, hope, and burnout and suggest possible relationships hope may have with other positive psychological factors reported in different studies.29-31 Furthermore, these findings suggest that leveraging hope has the potential to decrease the impact of chronic stress on medical students as well as mitigate the impact of burnout.

These findings are consistent with other studies that revealed higher-than-normal levels of stress and burnout among medical trainees relative to the general population.8-10 To our knowledge, no other study to date has attempted to measure dispositional hope in medical students and then explore how hope is related to stress and burnout. What this study contributes to the literature is evidence that hope helps to explain more of what is occurring in medical student burnout, especially when considering students’ levels of perceived stress. One possible explanation for this is that, according to hope theory, hope levels decrease when pathways to goals become blocked and alternative pathways cannot be identified.17 When this occurs, demands begin to exceed the perceived availability of resources to get through to the next step along the goal pursuit sequence, leading to increased psychological stress and, eventually, symptoms of burnout.32 The main implication of this explanation is that students can better manage their stress if the pathways leading to success as a future physician are perceived as being more available, which could entail showing how one can make contributions to medicine outside of the competencies directly assessed by standardized examinations. These contributions may consist of activities like patient advocacy, critical or creative writing on topics related to health and health care, and interdisciplinary collaboration to address important community health problems.

According to the current literature on hope theory, there are many possible applications of hope, even in academic contexts.33,34 For example, hope therapy and similar strategies consisting of guided discussions related to the primary constructs in the hope theory framework (ie, pathways, agency, goals, and barriers) have been effective at increasing hope in different populations.35 In addition, there is evidence from a study involving children who were exposed to domestic violence that offering activities that are productive and promote self-worth might be able to increase dispositional hope in adults.36 Given that high levels of both agency thinking and pathways thinking are needed for high levels of hope,16,17 we argue that finding ways to make incremental changes to medical school culture surrounding the value of life outside of school might be beneficial for increasing dispositional hope and decreasing the burden of chronic stress and burnout on trainees. These changes could involve slightly restructuring the preclinical and clinical curricula to build in more time for quality improvement or research projects that are of deep personal interest and formative for physicians in training. Regardless of which approach is used, the relationships demonstrated in this study are promising for future medical education environments if appropriate interventions can be adopted by medical school administrations.

The limitations of the study included the fact that the data are cross-sectional in nature, are all self-report from students, and were collected from a geographically limited sample (ie, all from 1 state). Although the majority of respondents were about 25 years of age and Caucasian, these characteristics were expected based on national demographic data of medical students.37 People from underrepresented groups generally suffer more social stressors, and this fact may contribute to possible sample bias since most of the respondents were Caucasian.38 There was a sampling bias in the responses toward first- and second-year students who were completing preclinical coursework (62.9%) compared to those completing their clinical training (37.1%). The competing priorities of students involved in clinical rotations may help to explain this bias. However, no differences were found for the variables of interest among the respondents based on their year in school.

The strengths of this study include the use of validated measures and inclusion of both allopathic and osteopathic medical students. This study’s findings help bring attention to the potential utility of hope among health care professionals in training, especially given the United States’ struggle to combat burnout in different industries, including health care.39 Our results show that there may be empirically based hope interventions for medical schools working to combat and prevent burnout that are inexpensive to implement on an institution-wide level.

These data were collected with the intention of better understanding the association between hope and burnout in medical students. A follow-up study focused on different hope- and burnout-related modifying factors would benefit this area of research. For example, research could improve our understanding of how systems-level factors, such as standardized examination cutoffs for certain residency training programs, might be contributing to hope, burnout, and stress because our findings suggest that, if we can address those systems, we may be able to improve hope and students’ overall well-being. Moreover, further research on this topic could build on this knowledge by studying specific applications of hope-based interventions in medical student education. An increasing number of studies have explored such interventions in certain populations, such as in patients with cancer and those diagnosed with mental illnesses.40-44 There appears to be a need to expand the literature in the area of hope-based interventions and medical education.45


The data collected in this study provide a promising avenue for future research in the areas of hope-based interventions, positive psychology overall, and the relationship between certain protective psychological factors and burnout in medical student populations. We found that hope is significantly associated with stress and burnout and that this protective psychological factor may be partially mediating the stress-burnout relationship. Our findings suggest that medical school administrations can leverage hope to approach the issue of burnout in medical education in a more focused, less resource-intensive fashion. They also suggest that systems-level factors are likely important targets for intervention. The growing body of research supports hope as an important protective factor in one’s ability to cope with stress. Hope also reflects a cognitive process that can be learned and sustained through targeted interventions. Our study supports the use of hope-based interventions in medical student populations.

Disclosure Statement

The author(s) have no conflicts of interest to disclose.


The authors thank the following individuals for their invaluable contributions: Heather Chancellor, MS, Krista Kezbers, PhD, and Kent Teague, PhD, for their generous support of and assistance with the design of this study; Marianna Wetherill, PhD, for reviewing the article and offering constructive edits; and Sarah Beth Bell, PhD, for performing the mediation analysis.

Author Affiliations

1School of Community Medicine, University of Oklahoma, Tulsa, OK

2Anne and Henry Zarrow School of Social Work, University of Oklahoma, Tulsa, OK

Corresponding Author

Ashten R Duncan, MPH ()

Author Contributions

Ashten R Duncan, MPH, developed the idea for this project, designed the study survey, prepared the IRB protocol and application, administered the survey to the participating medical schools, communicated with prospective participants via email, directly managed the data collection, performed data analyses, drafted the majority of the contents of the manuscript, and submitted the manuscript for consideration in this journal. Chan M Hellman, PhD, provided expert guidance throughout the entire project, offered constructive feedback during the idea development phase, revised and submitted the IRB application, met regularly with the lead author to assess progress, led the data analyses presented in the manuscript, and assisted with revising the manuscript based on feedback from reviewers. All authors have given final approval to the manuscript.

How to Cite this Article

Duncan AR, Hellman CM. The potential protective effect of hope on students’ experience of perceived stress and burnout during medical school. Perm J 2020;24:19.240. DOI: 10.7812/TPP/19.240


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Keywords: burnout, hope theory, perceived stress, student well-being, undergraduate medical education


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