Abstract
Purpose
Medical teachers are prone to burnout, but wellbeing state protects against it. This study aimed to evaluate the wellbeing of medical teachers and identify associated factors.
Methods
This cross-sectional study surveyed 174 active Indonesian medical teachers from 41 institutions using consecutive sampling. Data collected through online Google Forms included sociodemographic factors and wellbeing status assessed with the Indonesian version of the PERMA-Profiler questionnaire. The data analysis was performed using descriptive, bivariate non-parametric tests and post-hoc analysis.
Results
The median overall wellbeing score was 8.00. Among nine wellbeing domains, accomplishment had the lowest score (median=7.67). Higher educational degree (p=0.048) and academic rank (p=0.024) were significantly associated with the accomplishment score. Age (p=0.006), educational degree (p=0.046), and teaching experience (p=0.037) were significantly associated with overall wellbeing.
Conclusion
Despite a decent overall level of wellbeing, Indonesian medical teachers exhibited a low sense of accomplishment. Hence, both the government and medical institutions should establish supportive regulations and constructive faculty development programs to foster teachers’ professional identity formation and wellbeing.
Keywords: Accomplishment, Medical teacher, PERMA-Profiler, Wellbeing
Introduction
Although wellbeing has recently been the focus of much research, various definitions exist across the literature. Dodge et al. [1] concluded that wellbeing can be defined as a balance between an individual’s resources and challenges, including psychological, physical, and social elements. One widely used and validated measurement is based on the PERMA-Profiler construct of wellbeing, comprising both hedonic (related to life satisfaction) and eudaimonic (related to deeper life meaning) perspectives of happiness [2].
Wellbeing can be affected by several factors, including work-related elements [3]. Medical teachers experience threats to wellbeing at work, with high expectations, extensive administrative burdens, and uncertainties of medical environments. In Indonesia's context, the challenges are compounded by a rapid increase in the number of medical institutions, which often lack comprehensive faculty development programs [4,5]. Consequently, medical teachers are prone to psychological distress, sleep deprivation, and burnout, potentially decreasing their wellbeing [3]. Maintaining their wellbeing would enable them to thrive during stressful events, prevent burnout, and have higher work engagement. Teachers with higher wellbeing demonstrate better teaching quality, positively impacting students’ learning process [6,7].
Measurement of medical teachers’ wellbeing has been discussed only narrowly in previous studies. One study assessed the occupation-related wellbeing attributes of clinical teachers [8]. Compared to the PERMA-Profiler construct, several domains of wellbeing—such as meaning, engagement, and accomplishment—remain underexplored [2]. The current study aimed to evaluate the multidimensional aspects of medical teachers’ wellbeing using PERMA-Profiler construct (previously validated in Indonesian medical educational context [9]) and identify associated factors affecting their wellbeing.
Methods
This cross-sectional study was performed from May to August 2024. Using consecutive sampling technique, an online Google Form survey (Google LLC, Mountain View, USA) was sent personally (via online chat application or personal mail) to medical teachers from six main regions, comprising Java, Sumatra, Kalimantan, Sulawesi, Nusa Tenggara, and Papua. A minimum sample size (n) of 170 was estimated using OpenEpi ver. 3.0.1 (https://www.openepi.com/) with the following formula of [n>Z2 σ2/d2] assuming a significance level (Zα)=5%, an estimated standard deviation (σ) of 0.33 based on previous study [10], and a margin of error (d) of 0.05.
We invited 180 medical teachers from 41 institutions, and received a response rate of 96.67%. The final analysis included responses from 174 medical teachers. In this study, “medical teacher” is defined as an active lecturer in a medical institution in Indonesia who teaches at the undergraduate, clerkship, or postgraduate level. The exclusion criteria were being off-duty and not completing the questionnaire within the study period. Sociodemographic information of respondents includes age, gender, educational degree, academic rank, institutional type, daily teaching hours, teaching experience, and academic background. This study was approved by the Ethical Committee of the Faculty of Medicine, University of Indonesia and Cipto Mangunkusumo Hospital (registry code: KET-711/UN2.F1/ETIK/PPM.00.02/2024).
The status of wellbeing was assessed using the Indonesian version of the PERMA-Profiler questionnaire, comprising 23 questions about subjective perception of wellbeing. This Indonesian version was based on the adaptation by Mustika et al. [9] of the original instrument developed by Butler and Kern [2] but using a distinct 1–10 response scale. Questionnaire items represent nine domains: positive emotion (P), engagement (E), relationships (R), meaning (M), accomplishment (A), happiness (Hap), health (H), negative emotion (N), and loneliness (L). The overall wellbeing (OWB) score is defined as the average of five main domains (P, E, R, M, and A) and happiness (Hap), following the original formula by Butler and Kern [2]. This version has decent internal consistency with overall Cronbach’s α of 0.83 (range, 0.631 to 0.879) based on pre-survey validation testing (Table 1).
Table 1.
Internal Consistency of Each PERMA-Profiler Domain
| Subscales | No. of items | Cronbach’s α |
|---|---|---|
| Positive emotion | 3 | 0.843 |
| Engagement | 3 | 0.631 |
| Relationship | 3 | 0.722 |
| Meaning | 3 | 0.878 |
| Accomplishment | 3 | 0.707 |
| Health | 3 | 0.879 |
| Happiness | 1 | NAa) |
| Negative emotion | 3 | 0.848 |
| Loneliness | 1 | NAa) |
NA: Not available.
a)Because it contains only a single item.
Descriptive analysis was used to describe sociodemographic factors and average scores of wellbeing domains. Because the Kolmogorov-Smirnov test showed abnormal distribution (p<0.05), the associations between various factors and wellbeing were analyzed using Mann-Whitney test (for two groups) and Kruskal-Wallis test (for >2 groups). Post-hoc analysis using Dunn test with Bonferroni adjustment was performed to further identify the differences between >2 sub-group variables. Statistical tests were considered significant at p-value <0.05. The Epsilon squared (ε2) for Kruskal-Wallis test was calculated and interpreted as follows: weak effect (ε2=0.01–0.04), moderate effect (ε2=0.04–0.16), and strong effect (ε2>0.16) [11].
Results
As displayed on Table 2, the mean age of the 174 participants was 41 years (range, 26–80 years). Most participants were female (82.2%) and held a master’s degree (75.3%). Nearly half were junior lecturers (48.3%), and most were biomedical teachers (67.2%) working at state medical university (52.3%) with more than 5 years of experience in teaching (68.4%).
Table 2.
Sociodemographic Factors of Participants (n=174)
| Characteristic | No. (%) |
|---|---|
| Age (yr) | |
| <45 | 113 (64.9) |
| 45–59 | 55 (31.6) |
| >60 | 6 (3.5) |
| Gender | |
| Male | 31 (17.8) |
| Female | 143 (82.2) |
| Educational degree | |
| Master | 131 (75.3) |
| Doctorate | 43 (24.7) |
| Academic rank | |
| None | 11 (6.3) |
| Junior lecturer | 84 (48.3) |
| Assistant professor | 65 (37.4) |
| Associate professor | 8 (4.6) |
| Professor | 6 (3.4) |
| Working institution type | |
| State university | 91 (52.3) |
| Private university | 83 (47.7) |
| Daily teaching hours (hr) | |
| <4 | 142 (81.6) |
| >4 | 32 (18.4) |
| Teaching experiences (yr) | |
| <5 | 55 (31.6) |
| >5 | 119 (68.4) |
| Academic background | |
| Clinical | 57 (32.8) |
| Biomedical | 117 (67.2) |
The median overall wellbeing score was 8.00 (interquartile range [IQR], 7.87–9.00) (Table 3). For positive domains, the lowest domain score was accomplishment (median=7.67; IQR, 7.00–8.33), while the highest scores were for meaning (median=8.33; IQR, 7.67–9.33), relationships (median=8.33; IQR, 7.33–9.00), and positive emotion (median=8.33; IQR, 7.25–8.67). For negative domains, negative emotion score (median=4.33; IQR, 3.00–5.67) was higher than loneliness score (median=2.50; IQR, 2.00–5.00).
Table 3.
Well-being Domains Scores Using PERMA-Profiler Instrument
| PERMA-Profiler aspects | Median (IQR) |
|---|---|
| Positive emotion | 8.33 (7.25–8.67) |
| Engagement | 8.00 (7.00–8.67) |
| Relationship | 8.33 (7.33–9.00) |
| Meaning | 8.33 (7.67–9.33) |
| Accomplishment | 7.67 (7.00–8.33) |
| Health | 8.00 (6.67–8.67) |
| Happiness | 8.00 (8.00–9.00) |
| Negative emotion | 4.33 (3.00–5.67) |
| Loneliness | 2.50 (2.00–5.00) |
| Overall well-being | 8.00 (7.87–9.00) |
IQR: Interquartile range.
Only age (p=0.006), educational degree (p=0.046), and teaching experience (unadjusted p-value=0.037) were significantly associated with overall wellbeing. Through post-hoc analysis, a significant difference of OWB was found between the <45 years group and the 45–59 years group, with moderate effect (adjusted p-value=0.008; ε2=0.045) (Fig. 1A).
Fig. 1. Post-hoc analysis of associated factors toward overall well-being score (A) and accomplishment score (B). *p<0.05 (significant association between groups).
Other associations were found between higher academic rank (unadjusted p-value=0.024) and higher educational degree (p=0.048) with accomplishment scores. Post-hoc analysis on academic rank showed that accomplishment scores differed significantly between junior lecturer and professors, with estimated moderate effect (adjusted p-value=0.027; ε2=0.054) (Fig. 1B).
Some factors were associated with several wellbeing domains (Table 4). For instance, medical teachers with advancing age have significantly higher positive emotion (unadjusted p-value=0.010), along with higher meaning (unadjusted p-value=0.006) and loneliness scores (unadjusted p-value=0.033). Female medical teachers experienced significantly higher loneliness (unadjusted p-value=0.011). State university teachers had significantly higher engagement scores than private university teachers (unadjusted p-value=0.047). Higher negative emotion scores were found among medical teachers with longer daily teaching hours (unadjusted p-value=0.028). None of the factors were significantly associated with relationships, health, and happiness domains.
Table 4.
The Associated Factors of Medical Teachers’ Well-being
| Factors | Well-being aspects | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| P | E | R | M | A | H | NE | Lon | Hap | OWB | |
| Agea) | 0.010** | 0.554 | 0.101 | 0.006** | 0.060 | 0.203 | 0.086 | 0.033* | 0.497 | 0.006** |
| Genderb) | 0.506 | 0.639 | 0.299 | 0.732 | 0.634 | 0.082 | 0.595 | 0.011* | 0.446 | 0.703 |
| Educational degreeb) | 0.250 | 0.218 | 0.443 | 0.822 | 0.048* | 0.194 | 0.626 | 0.204 | 0.611 | 0.046* |
| Working Institution typeb) | 0.594 | 0.047* | 0.893 | 0.097 | 0.734 | 0.957 | 0.284 | 0.187 | 0.993 | 0.249 |
| Academic ranka) | 0.656 | 0.984 | 0.338 | 0.466 | 0.024* | 0.274 | 0.940 | 0.000** | 0.674 | 0.266 |
| Teaching durationb) | 0.334 | 0.190 | 0.199 | 0.824 | 0.797 | 0.607 | 0.028* | 0.260 | 0.180 | 0.391 |
| Teaching experienceb) | 0.035* | 0.248 | 0.354 | 0.070 | 0.085 | 0.108 | 0.894 | 0.001** | 0.562 | 0.037* |
| Academic backgroundb) | 0.344 | 0.218 | 0.558 | 0.588 | 0.780 | 0.412 | 0.888 | 0.570 | 0.637 | 0.815 |
P: Positive emotion, E: Engagement, R: Relationship, M: Meaning, A: Accomplishment, NE: Negative emotion, Hap: Happiness, Lon: Loneliness, OWB: Overall well-being.
*p<0.05 (The association was significant at unadjusted p-value of <0.05). **p<0.01 (The association was significant at unadjusted p-value of <0.01). a)Analyzed using Kruskal-Wallis test. b)Analyzed using Mann-Whitney test.
Discussion
Currently, Indonesian medical institutions are expanding, rising from 83 in 2016 to over 100 institutions today. This issue presents challenges for medical teachers in terms of teacher–student ratio disequilibrium and inconsistent faculty development preparedness across medical institutions [4,5]. Only 21% of Indonesian medical institutions have an excellent accreditation level (grade A), raising concerns about their readiness to support their faculties [4]. Based on the Job-Demand Resources (JD-R) model, higher workloads and lack of faculty development eventually produce burnout and threaten medical teachers’ wellbeing [3].
This study shows that Indonesian medical teachers generally demonstrate good overall wellbeing; they are perceived as fairly happy, with abilities to sense meaning in their work, to develop positive emotions, and to maintain adequate relationships. This finding is consistent with those of Larsen et al. [12], although they found differences in the level of specific wellbeing domains. In the study by Larsen et al. [12], positive emotion was the lowest domain score, whereas accomplishment was the lowest in our study. This discrepancy may be attributed to different sample composition; participants in the study by Larsen et al. [12] consisted solely of clinical teachers, while our study included both biomedical science and clinical teachers. Biomedical science teachers also struggle with wellbeing issues due to unclear career pathways, lack of incentives, and limited community of practice [13,14].
The post-hoc analysis indicated that medical teachers of advancing ages (>45 years age group), longer teaching experience (>5 years), and higher educational degree (Doctorate equivalent) displayed a significantly higher OWB. This result was quite predictable, as senior and experienced medical teachers may have higher salaries, broader teaching perspectives, and more effective coping mechanisms, which positively contribute to wellbeing [5,14]. We have described each of the contributing domains of PERMA-Profiler construct to emphasize more aspects of the medical teachers’ wellbeing.
Some results are rather predictable. Teaching for more than 4 hours daily was significantly associated with higher levels of negative emotion, consistent with the JD-R model [3]. Low accomplishment scores among medical teachers have been a less discussed domain, although it is equal in importance to other domains. A low sense of accomplishment might lead to reduced self-efficacy, burnout, and job withdrawal [3,7]. The low accomplishment score may stem from a lack of formal teaching training, inadequate recognition despite multiple work roles, and high expectations to adapt to the rapid changes in medical education [13,15]. According to our post-hoc analysis, the accomplishment score increased significantly only among teachers who had attained a doctorate degree or professorship. While such promotions may enhance their salary, academic recognition, and capacity to serve as impactful role models [15], achieving such milestones requires substantial time and effort—factors that may hinder current wellbeing.
The issue of medical teachers’ wellbeing is rather complex, requiring substantial contributions from both government and medical institution stakeholders. The government should be more accommodating toward medical teachers’ wellbeing with favorable regulations, such as medical faculty development standards supporting multiple roles of medical teachers [8]. Academic incentives and promotion metrics should be based more on teaching performance, in contrast to the current Indonesian educational policies that seem to be weighted toward teachers’ research-based achievements [15,16].
On the other hand, medical institutions could contribute to medical teachers’ wellbeing by nurturing their professional identity formation (PIF). Through PIF development, medical teachers could gain a better perspective of their personal and professional selves, enhancing their teaching motivation, career planning, and sense of fulfilment. Medical teacher PIF development could be established through several interventions, such as role-modelling, self-reflection, professional colleague shadowing, and peer mentoring-coaching [16,17]. Institutions should evaluate whether their ongoing faculty development programs have well-supported teachers’ professional development.
This study contains some limitations. First, with a cross-sectional design, the dynamics of the medical teachers’ wellbeing over time are imperceptible. Second, the participants are predominantly female teachers with a wide range of ages, which might lessen generalizability. This study did not explore other contributing factors, such as work environment and organizational support. However, this study could help raise awareness of the wellbeing of medical teachers worldwide. Future studies should focus on identifying the key attributes and appropriate faculty development programs to enhance medical teachers’ professional identity and wellbeing.
In conclusion, the overall Indonesian medical teachers’ wellbeing is generally favorable, although a low level of accomplishment is found. Factors such as age, educational degree, and teaching experience are associated with overall wellbeing. These findings underscore the necessity for coordinated effort by both government and medical institutions to develop supportive regulatory measures and constructive faculty development programs that support medical teachers’ PIF and wellbeing.
Footnotes
Acknowledgements
The authors would like to thank all teaching staff and associates from the Medical Education Department, as well as all members of the Indonesian Association of Medical Education (INAMED), who supported the participants’ recruitment and collection for this study.
Funding
This study funded under the grant name: Hibah Publikasi Terindeks Internasional (PUTI) 2024; grant number: NKB-648/UN2.RST/HKP.05.00/2024. Nonetheless, the authors claimed that our study findings were independent of the sponsor institution.
Conflicts of interest
No potential conflict of interest relevant to this article was reported.
Author contributions
Conceptualization: DS, RM. Data curation: LLN, DS. Methodology/formal analysis/validation: LLN, RM. Visualization: LLN. Project administration: LLN, RM. Funding acquisition: RM. Writing–original draft: LLN. Writing–review & editing: LLN, DS, RM. Final approval of the manuscript: all authors.
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