Improvement of medical students’ stress, dispositional mindfulness, well-being and flourishing during the first academic year of a medical curriculum integrating a well-being longitudinal strand

Abstract

Background

Given the high prevalence of mental health problems among medical students, a well-being longitudinal strand aimed at strengthening self-awareness, connection and caring skills was integrated into our renewed curriculum.

Objective

To evaluate the trajectory of perceived stress, dispositional mindfulness, well-being and flourishing in first-year medical students enrolled in this curriculum.

Method

A nonexperimental prospective census cohort study was conducted from March to December 2024. At baseline (t₀), at the end of the first semester (t₁) and at the end of the second semester (t₂), 116 students completed the Spanish versions of the Perceived Stress Scale, Mindful Attention Awareness Scale and Mental Health Continuum-Short Form. To determine the effect of time on stress, dispositional mindfulness and well-being levels, 915 scales were analyzed via longitudinal mixed models. To assess temporal changes in flourishing status, data from students who completed scales at the three time points were examined via McNemar’s test. A p value < 0.05 was considered statistically significant.

Results

Students’ stress, dispositional mindfulness, well-being and flourishing changed significantly over time. The stress level followed a biphasic trajectory, peaking at t₁ and decreasing markedly at t₂ (22.9 ± 6.8 versus 13.1 ± 5.9, p < 0.001). Dispositional mindfulness increased from t₁ to t₂ (3.2 ± 0.8 versus 3.7 ± 0.9, p < 0.001). Well-being initially diminished slightly at t₁ but then increased by t₂ (48.1 ± 10.7 versus 52 ± 9.2, p < 0.001). The proportion of flourishing students decreased from t₀ to t₁ (54% versus 40%) but subsequently increased markedly, reaching above-basal levels by t₂ (72%).

Conclusion

Medical students’ mental health significantly improves over their first academic year within a curriculum that integrates, among other innovations, a well-being longitudinal strand. This research may be valuable for medical programs looking at preventing students’ burnout and depression.

Introduction

High prevalence of mental health problems has been documented across North America, Europe, Asia, Middle East and Latin America. A meta-analysis of 42 studies involving over 26,000 medical students estimated an overall burnout prevalence of 37% [1], while a systematic review of 64 studies reported rates ranging from 5.6% to 88% depending on country and academic stage [2].

Compared with their college-aged peers, medical students are more vulnerable to mental health problems [3–5]. This has been associated with several factors, e.g., high academic workload, continued exposure to patients suffering and dying, the competitive nature of medical training culture, few self-care skills and limited access to psychological support [6, 7]. The deterioration of medical students’ mental health takes a toll not only on their academic performance [8] and quality of life [9] but also on their professionalism, as revealed by diminished empathy [10] and unprofessional conduct [11, 12].

Mental health status has an inverse correlation with perceived stress and a positive correlation with dispositional mindfulness, well-being and flourishing [13]. Dispositional mindfulness is understood as the capacity to attend to one’s sensations, thoughts and emotions in daily life [14]. Well-being is a multidimensional construct encompassing both hedonic dimensions, such as positive affect and life satisfaction, and eudaimonic dimensions, including personal growth, meaning and autonomy. Flourishing is the optimal expression of well-being. This status is characterized by positive emotions; strong social relationships; and a sense of purpose, self-acceptance and autonomy [15–18]. Perceived stress and dispositional mindfulness are inversely related, as mindful attention reduces rumination and enhances adaptive emotional regulation [19]. In turn, lower perceived stress predicts better well-being and higher likelihood of flourishing [20, 21]. Dispositional mindfulness also relates positively to well-being and flourishing, both as a trait and as a modifiable skill [22, 23].

In response to mental health issues, educational institutions worldwide have developed well-being initiatives, either as standalone activities or programs integrated into the curriculum [24, 25]. These interventions focus on stress management techniques, self-care education, emotional regulation and mindfulness training [22, 26]. Mindfulness-based interventions have shown compelling evidence for stress reduction and well-being enhancement in medical students and health care professionals [27–29].

Considering the high level of chronic stress and burnout among Chilean medical students [30, 31], in our renewed curriculum we integrated a well-being longitudinal strand aimed at strengthening self-awareness, connection and caring skills. It progresses throughout medical training aligned with students’ needs and responsibilities, advancing from self-awareness to the development of professional identity.

The objective of this study was to evaluate the trajectory of perceived stress, dispositional mindfulness, well-being and flourishing in first-year medical students enrolled in a renewed curriculum that, among other innovations, integrates a well-being longitudinal strand.

Method

Renewed curriculum

Driven by the need to train holistic and flexible health care professionals to face the future challenges of health care, in 2021 we started a formal process of curricular renewal with extensive participation from medical educators and students. First, we revised the contents, abilities and attitudes required for upcoming physicians and trends in medical education. Then, we defined 7 guiding principles: relevance, integration, immersion, progression, understanding versus memorization, ways of thinking and willingness to learn. The renewed curriculum features active learning, early clinical practice and professionalism. It lasts 12 semesters, is structured in 4 periods and includes 4 longitudinal domains (also referred as longitudinal strands) named: biomedical foundations, medical practice, use and generation of knowledge, and well-being [32].

Well-being longitudinal strand

The well-being longitudinal strand is grounded in the role that physician well-being has in the safety and quality of patients´ care [33]. It emphasizes the active engagement of medical students in fostering their physical, psychological and social well-being, and is anchored in three foundational pillars: self-awareness, connection and caring. The conceptual basis for these pillars as cornerstones of well-being is supported by psychological frameworks including positive psychology and Seligman’s well-being model (PERMA) [34], Ryan and Deci’s self-determination theory [35] and Epstein’s mindful practice [36]. Aligned with the evolving needs and responsibilities of students throughout their medical training, the longitudinal strand advances beyond viewing self-awareness, connection and caring as mere coping mechanisms. Instead, it positions them as proactive skills for sustaining well-being, nurturing positive interpersonal relationships and reinforcing professional identity. The objectives and contents of this longitudinal strand are structured across semesters (Table 1).

Table 1.

Pillars and contents of the well-being longitudinal strand during the 12 semesters of the renewed curriculum

pillars	semester 1 & 2	semester 3, 4 & 5	semester 6, 7 & 8	semester 9, 10, 11 & 12
Self-awareness	self-observation	connecting with character strengths	self-knowledge developing presence and resilience	fostering well-being and resilience
Connection	creating safe spaces	developing compassion	promoting self-compassion and compassion	fostering connection to patients, family and health team
Caring	self-care	seeing the others	caring for others	mindful practice

During the first academic year the longitudinal strand prioritized the promotion of personal well-being. Its central aim is to enable students to adopt principles, language and strategies derived from the science of well-being. Instructional methods include small-group sessions planned by well-being experts and facilitated by trained healthcare professionals (e.g. physicians, speech therapists, dietitians, biochemists) that encourage growth mindset, curiosity, acceptance, adaptability and resilience. Student groups and their assigned facilitators remain the same during the year to foster a safe learning environment, promoting active participation, reflection and interpersonal connection. Weekly sessions last for 100 min and focus on specific topics, e.g. positive emotions, engagement, being present [37–39]. Students are invited to share their personal experiences, after which they are presented with scientific evidence. They integrate both perspectives through individual or group activities and are encouraged to advance their personal improvement plans for the following week. Periodically, the students respond questionnaires related to stress, dispositional mindfulness and well-being to self-monitor their mental health. The information collected is also used by medical educators to follow up on students’ status. Course completion requires full attendance and submission of written reflections after each session. Assessment is conducted on a pass/fail basis contingent upon meeting the above requirements. Students who fail are offered a second opportunity to pass at the end of the semester.

Study design

Nonexperimental prospective census cohort study conducted from March to December 2024. This design is well established in medical education research for describing trajectories of student mental health, particularly when ethical constraints preclude randomization or the withholding of curricular interventions from a subset of students [40, 41].

Participants

One hundred sixteen medical students from the first-year cohort completed at least one set of three scales. The average age of the participants was 19.7 ± 0.7 years, 70% were women, 82% came from Santiago (capital city) and 92% were graduates of private high schools.

Instruments

Perceived stress level over the previous month was measured via the Spanish version of the 10-item Perceived Stress Scale (PSS-10), which was originally developed by Cohen et al. [42], translated and validated by Remor [43]. The items are rated on a five-point Likert-type scale. The achievable maximum score is 40. Higher scores indicate greater perceived stress.

Dispositional mindfulness level was measured via the Spanish version of the Mindful Attention Awareness Scale (MAAS), which was originally developed by Brown and Ryan [14], translated and validated by Soler et al. [44]. This 14-item instrument uses a six-point Likert-type scale. The results are expressed as an average general score with a maximum of 6 points. Higher scores indicate greater dispositional mindfulness.

Well-being level and flourishing status were determined with the Spanish version of the Mental Health Continuum Short-Form (MHC-SF), originally developed by Keyes [45], and translated and validated by Echeverria et al. [46]. This instrument assesses self-reported global, emotional, social and psychological well-being through 14 items rated on a 6-point Likert-type scale. The results are expressed as well-being scores (global and per dimension) and as states of positive mental health: languishing, moderate or flourishing [45].

Scales were selected for their robust psychometric properties and wide use in medical education literature, which facilitates the comparison of results across different cultural contexts [43, 44].

Reliability of the scales in the current sample was assessed using Cronbach’s alpha coefficient (0.909 for PSS-10; 0.860 for MAAS, and 0.778 to 0.855 for MHC-SF subscales). These values show high internal consistency and are aligned with previous validations of the instruments in Spanish-speaking populations [43, 44, 46].

Data collection

The three scales listed above were administered online and answered in person three times: at the beginning of the year (t₀), at the end of the first semester (t₁), and at the end of the second semester (t₂). The participants’ response rates were 85% (n = 98) at t₀, 81% (n = 94) at t₁, and 97% (n = 113) at t₂. Data across all three times were available for 66% of the students (n = 76). Of the 999 completed scales, 84 were excluded because of a lack of authorization for publication.

Statistical analysis

The levels of stress, dispositional mindfulness and well-being are presented as mean ± standard deviation (SD). The distribution of students’ flourishing status is presented as percentages.

To account for the hierarchical structure of the data (repeated measures within individuals) and to maximize statistical power by including data from participants with incomplete assessments, the complete dataset (915 scales) was analyzed via linear mixed models fitted in Jamovi software, version 2.6.26.0. For each continuous variable (stress, dispositional mindfulness and well-being), a separate linear mixed model was conducted. Each model included time as a fixed effect. To account for individual variability, the participants’ identification number was included as a random intercept. To explore significant main effects and interactions, post hoc pairwise comparisons were conducted via estimated marginal means with Bonferroni adjustment.

Changes in flourishing status over time were studied in a sample of 76 students who completed all three set of three scales. Only 3 participants were categorized as languishing across all time points, with none at t₂. To obtain a robust analysis of changes in positive mental health states, the languishing category was combined with the moderate category, creating a binary outcome (not flourishing versus flourishing). The transitions between flourishing status and not flourishing status were assessed via McNemar’s test for every pair of time points.

To determine the associations among stress, dispositional mindfulness and global well-being levels, Pearson’s correlation coefficients were calculated at all three measurement times.

A statistical comparison using Fisher’s r-to-z transformation was conducted to determine whether the change in the strength of an association between two points in time was statistically significant.

A value of p < 0.05 was considered statistically significant.

Results

Evolution of stress, dispositional mindfulness and well-being levels

The trajectories of students’ stress, dispositional mindfulness and well-being during the first academic year are shown in Fig. 1. All three variables demonstrated significant changes over time, as indicated by time-effect values of p < 0.001 for each.

Fig. 1.

Perceived stress (a), dispositional mindfulness (b) and well-being (c) levels across the first academic year. The data shown correspond to the mean ± SD of each variable at baseline (t0; n = 98), at the end of the first semester (t₁; n = 94) and at the end of the second semester (t₂; n = 113). The values of p for time effects were obtained via longitudinal mixed models and post hoc pairwise comparisons were conducted via Bonferroni adjustment. * t₁ versus t₀, p < 0.001, ** t₂ versus t₀, p < 0.001

Post hoc pairwise comparisons revealed an increase in stress at t₁, followed by a decrease to below baseline levels by t₂ (22.9 ± 6.8 versus 13.1 ± 5.9, p < 0.001).

The dispositional mindfulness level increased from t₁ to t₂ (3.2 ± 0.8 versus 3.7 ± 0.9, p < 0.001).

Global well-being initially diminished slightly at t₁ but then increased by t₂ (48.1 + 10.7 versus 52 + 9.2, p < 0.001). The same was observed for emotional, social and psychological well-being scores.

Evolution of flourishing status

The proportion of flourishing students exhibited a biphasic evolution, decreasing from 54% at baseline (t₀) to 40% at t₁ and then rising to 72% by t₂ (Fig. 2.a).

Fig. 2.

Distribution (a) and transition (b) between not flourishing and flourishing status across the first academic year. The bars correspond to the percentages of not flourishing and flourishing students at baseline (t₀), at the end of the first semester (t₁) and at the end of the second semester (t₂) (n = 76)

Analysis of the students’ transitions revealed that 16 students moved from flourishing to not flourishing status between t₀ and t₁ (X² = 5.76, df = 1, p < 0.001) (Fig. 2.b). Conversely, a marked increase in the number of flourishing students occurred from t₀ to t₂ (X² = 14.6, df = 1, p < 0.001). Thirty-four of the 55 students reporting flourishing status at t₂ had the same status at baseline (t₀); the remaining 21 corresponded to students who transitioned from not flourishing to flourishing status.

Association of stress, dispositional mindfulness and global well-being levels

The Pearson’s correlation coefficients among stress, dispositional mindfulness and global well-being levels are shown in Table 2. At all time points, strong negative correlation was observed between stress and dispositional mindfulness (p < 0.001), as well as between stress and global well-being (p < 0.001). Conversely, dispositional mindfulness and global well-being were positively correlated (p < 0.01).

Table 2.

Correlations among stress, dispositional mindfulness and global well-being levels

time	0	1	2
stress vs. dispositional mindfulness	-0.56**	-0.66**	-0.45**
stress vs. global well-being	-0.48**	-0.54**	-0.43**
dispositional mindfulness vs. global well-being	0.35**	0.41**	0.25*

The data shown correspond to Pearson’s correlation coefficient between variables at baseline (t_0, n = 98), at the end of the first semester (t_1, n = 94) and at the end of the second semester (t_2, n = 113)

*p < 0.01, **p < 0.001

Fisher’s Z transformations were conducted to compare the magnitude of Pearson correlation coefficients across the three time points. The relationships between stress and global well-being, as well as between dispositional mindfulness and global well-being, showed no significant differences across time (p > 0.05 for all comparisons). However, the negative correlation between stress and dispositional mindfulness significantly weakened from t₁ to t₂ (Z = 2.18, p = 0.029).

Discussion

This study investigated the trajectory of perceived stress, dispositional mindfulness, well-being and flourishing in first-year medical students enrolled in a renewed curriculum that, among other innovations, integrates a well-being longitudinal strand. Our findings revealed a dynamic trajectory: an initial period characterized by heightened stress and reduced well-being, followed by a meaningful improvement by the end of the year. This recovery was marked by elevated levels of dispositional mindfulness and a greater proportion of students experiencing a flourishing mental health status.

The observed initial increase in stress aligns with the literature and may reflect the response of freshmen to yet unfamiliar academic challenges [6]. Most longitudinal studies corroborate our findings, indicating that medical students’ stress increases during the first academic year [47]. For instance, Voltmer et al. [41] reported a sustained increase in stress, anxiety and depression during the initial two years of medical studies, a pattern also reported by Moffat et al. [48]. In contrast to these trends, our students reported a reduction in stress levels by the end of the first academic year. To the best of our knowledge, this is a unique finding within the literature.

The increase in dispositional mindfulness by the end of the academic year further supports growing evidence that dispositional mindfulness, traditionally considered a stable trait, can indeed be cultivated [49]. For example, a longitudinal study on Norwegian medical and psychology students demonstrated a positive impact on dispositional mindfulness and coping skills following a seven-week mindfulness-based course [23]. Other delimited interventions yielded improvements in dispositional mindfulness, perceived stress and study engagement [50].

A particularly compelling finding of this study was the marked increase in students´ well-being by the end of the first academic year. This unprecedented result is encouraging because when individuals flourish, they exhibit emotional vitality and positive functioning in both the personal and social spheres, demonstrating engagement, personal growth and an active pursuit of their full potential [45]. Consistent with this, a longitudinal study of medical residents participating in resilience training revealed a strong positive correlation between flourishing and resilience factors, such as high levels of coping skills and low levels of negative emotions (e.g. stress and anxiety), both cross-sectionally and modelled over time [51].

The negative correlations of stress with dispositional mindfulness and well-being, and the positive correlation between dispositional mindfulness and well-being observed in our study are consistent with previous reports [13, 20, 21]. Individuals with greater mindfulness usually report greater psychological well-being and reduced strain, anxiety, and depression [52]. This association is understandable, as higher dispositional mindfulness is known to facilitate healthy self-regulation, moderating the processing of negative events and exerting mental health benefits [53].

The comparison of strengths of correlations at different time points indicated that the only association that changed significantly with time was between stress and dispositional mindfulness. This correlation peaked at the end of the first semester (t₁), which was also the point of highest reported stress, suggesting that dispositional mindfulness may play an even more critical regulatory role during periods of high academic pressure [7, 15]. The correlation between stress and dispositional mindfulness dropped from a strong negative association in t₁ to a moderate one in t₂, suggesting a ‘decoupling’ between them. By the end of the year, students were able to sustain their mindfulness levels independently of their stress burden. This suggests that mindfulness transitioned from being a variable highly vulnerable to environmental stressors to acting as a coping resource.

The cultivable nature of mindfulness positions it as a suitable target for well-being interventions, reducing stress and promoting mental health flourishing across various populations [54, 55].

While the descriptive nature of this study precludes the inference of causal relationships, two interacting plausible explanations come to mind when attempting to explain the improvement in perceived stress and well-being at the end of the year. First, natural adaptation to academic life stressors consists of more effective routines and study methods and stronger social support networks, all of which are known to mitigate perceived stress and enhance well-being [56, 57]. Second, the positive influence of supportive elements integrated within the renewed curriculum, particularly the inclusion of activities promoting self-awareness, connection and caring skills, is important. These elements may have contributed to the acquisition of evidence-based stress-coping and flourishing-promoting strategies, leading to a reduced perception of stress and increased well-being, a mechanism supported by previous research [22, 58, 59].

The main limitation of this study is the absence of a control group that restricts the ability to infer causal relationships. Additionally, reliance solely on self-report measures introduces potential social desirability bias. Since the study was conducted at a single and private institution the generalizability of findings is restricted. Furthermore, the cross-sectional nature of the correlation analysis does not allow conclusions about the directionality of the variable’s relationships.

Despite these limitations, the study has several strengths. First, it extends beyond merely assessing stress levels to include measurements of positive psychosocial resources such as dispositional mindfulness, well-being and positive mental health. Second, its longitudinal design provides valuable insights into the dynamic changes in stress, dispositional mindfulness and well-being over time. Third, the high response rate, because scales´ completion was a regular activity within the well-being longitudinal strand, contributes to the robustness of the data.

This research may be valuable for programs looking at preventing students’ burnout and depression because it shows that medical students can indeed complete their first-academic year with less stress and greater well-being.

Authors' contributions

CBi, CM, PC, ER, CP, RR, MB and CBe conceptualized and designed the study. CM and ER collected the data. CBi, PC and MB analyzed the data and written the manuscript. All authors revised and approved the submission of the manuscript.

Funding

The authors report no funding associated with the work in this article.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request **.**.

Declarations

Ethics approval and consent to participate

Our research complies with the requirements of the Declaration of Helsinki.

Given that data collection was part of mandatory curricular activity, the institutional review board, named Comité Ético Científico, Faculty of Medicine Clínica Alemana Universidad del Desarrollo, waived the need for ethics approval and the obtainment of informed consent. The committee requested participants´ authorization to use anonymized data for publication purposes, which was obtained. The final version of this manuscript was submitted to and approved without ethical considerations by the ethics committee.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.