Measuring psychological flexibility in medical students and residents: a psychometric analysis
Open accessAbstract
PURPOSE: Psychological flexibility involves mindful awareness of our thoughts and feelings without allowing them to prohibit acting consistently with our values and may have important implications for patient-centered clinical care. Although psychological flexibility appears quite relevant to the training and development of health care providers, prior research has not evaluated measures of psychological flexibility in medical learners. Therefore, we investigated the validity of our learners' responses to three measures related to psychological flexibility. METHODS: Fourth-year medical students and residents (n=275) completed three measures of overlapping aspects of psychological flexibility: (1) Acceptance and Action Questionnaire-II (AAQ-II); (2) Cognitive Fusion Questionnaire (CFQ); and (3) Mindful Attention and Awareness Questionnaire (MAAS). We evaluated five aspects of construct validity: content, response process, internal structure, relationship with other variables, and consequences. RESULTS: We found good internal consistency for responses on the AAQ (α=0.93), MAAS (α=0.92), and CFQ (α=0.95). Factor analyses demonstrated a reasonable fit to previously published factor structures. As expected, scores on all three measures were moderately correlated with one another and with a measure of life satisfaction (p<0.01). CONCLUSION: Our findings provide preliminary evidence supporting validity of the psychological flexibility construct in a medical education sample. As psychological flexibility is a central concept underlying self-awareness, this work may have important implications for clinical training and practice.
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The intervention supports students to engage with and manage feelings, thoughts, and emotions that could act as a useful tool for enhancing the quality of patient care.
“suggesting that the intervention supports students to engage with and manage feelings, thoughts, and emotions that could act as a useful tool for enhancing the quality of patient care [78, 79].”
From Enhanced Stress-Resilience Training (ESRT) for graduate-entry medical students: a randomised-controlled, mixed-method investigation (2025) · cites this paper as [78]
The Introduction describes psychological flexibility as acknowledging thoughts and feelings while still acting compassionately toward patients, and the Abstract says it may have implications for patient-centered care. But this paper evaluates measures in medical students and residents; it does not show that an intervention helped those students manage their feelings or improved patient care. Its Discussion treats interventions as a potential avenue for further study. (LLM, conf=0.88)
Experimental — accuracy not yet measuredAcceptance and commitment therapy (ACT) has been reported to be effective in reducing burnout and depression among a variety of healthcare professionals as well as medical students.
“Acceptance and commitment therapy (ACT), a psychotherapy that targets the facilitation of psychological flexibility, has been used and reported to be effective in reducing burnout and depression among a variety of healthcare professionals as well as medical students [23, 32–35].”
From The mediating role of psychological flexibility in the association of autistic-like traits with burnout and depression in medical students during clinical clerkships in Japan: a university-based cross-sectional study (2023) · cites this paper as [32]
The Introduction (page not provided) reports that an intervention based on psychological flexibility significantly improved burnout among providers counseling substance-abusing clients. It does not report reduced depression or effectiveness among medical students or a variety of healthcare professionals. This paper assessed measures of psychological flexibility in medical students and residents rather than testing ACT as a treatment. (LLM, conf=0.87)
Experimental — accuracy not yet measuredPsychological and behavioral responses to demands and stressors play a role in burnout development among medical students, whose risk of burnout is almost doubled when maladaptive coping patterns are adopted.
“Psychological and behavioral responses to demands and stressors play a role in burnout development among medical students, whose risk of burnout is almost doubled when maladaptive coping patterns are adopted [30-33].”
From Evaluation of an App-Delivered Psychological Flexibility Skill Training Intervention for Medical Student Burnout and Well-being: Randomized Controlled Trial (2023) · cites this paper as [31]
The Introduction describes how psychological flexibility can shape responses to thoughts and feelings, and the Discussion says its association with distress could potentially affect learners’ burnout. The paper does not establish that maladaptive coping nearly doubles medical students’ burnout risk; it presents burnout as a possible implication, not a measured outcome. (LLM, conf=0.84)
Experimental — accuracy not yet measuredMedical students who report low psychological flexibility demonstrate diminished satisfaction with life and greater personal distress when seeing others in harm.
“Medical students who report low psychological flexibility also demonstrate diminished satisfaction with life and greater personal distress when seeing others in harm, which may increase burnout risk during their careers [31].”
From Evaluation of an App-Delivered Psychological Flexibility Skill Training Intervention for Medical Student Burnout and Well-being: Randomized Controlled Trial (2023) · cites this paper as [31]
These findings support previous literature highlighting the potential benefits of training medical students in psychological flexibility skills.
“These findings support previous literature highlighting the potential benefits of training medical students in psychological flexibility skills [31,61,62]”
From Evaluation of an App-Delivered Psychological Flexibility Skill Training Intervention for Medical Student Burnout and Well-being: Randomized Controlled Trial (2023) · cites this paper as [31]
Methodological quality of studies evaluating the AAQ-II ranged from excellent to poor.
“Methodological quality of studies evaluating the AAQ-II ranged from excellent to poor (Bond et al., 2011; Palladino et al., 2013; Scott, McCracken, & Norton, 2016).”
From Psychometric properties of acceptance measures: A systematic review (2019) · cites this paper as Palladino et al., 2013
The Results (Internal structure; page unavailable) report the AAQ-II’s internal consistency and factor structure in this sample, not the methodological quality of studies evaluating it. The Discussion (page unavailable) describes this study’s limitations but does not appraise multiple studies or rate their quality from excellent to poor. Searches for the claimed quality range and for study-quality appraisal found no supporting passage. (LLM, conf=0.76)
Experimental — accuracy not yet measured
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- Authors
- Palladino, C. L., Ange, B., Richardson, D. S., Casillas, R., Decker, M., Gillies, R. A., House, A., Rollock, M., Salazar, W. H., Waller, J. L., Zeidan, R., & Stepleman, L.
- Affiliations
- Augusta University (US)
- Ohio Christian University (US)
- Corresponding author
- Palladino, Christie L.
- Venue
- Medical Education Online
- Publisher
- Informa UK Limited
- Published
- 2013-01
- Volume
- 18
- Issue
- 1
- Pages
- 20932
- ISSN
- 1087-2981 (ISSN-L)
- PMC
- PMC3744841
- OpenAlex
- W2085350768
- Cited by
- 51
- References
- 24
- Citations by year
- 2026: 4 · 2025: 5 · 2024: 6 · 2023: 9 · 2022: 7 · 2021: 5 · 2020: 1 · 2019: 4 · 2018: 3 · 2017: 2 · 2016: 1 · 2015: 4
- FWCI
- 1.85
- Type
- journal article
- Language
- en
- Open access
- hybrid
- doi.org
- Licence
- cc-by
- Locations
- Medical Education Online (publishedVersion, cc-by)
- Europe PMC (PubMed Central) (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion)
- Topics
- Social Sciences › Psychology › Clinical Psychology › Mindfulness and Compassion Interventions
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Innovations in Medical Education
- Health Sciences › Health Professions › General Health Professions › Healthcare professionals’ stress and burnout
- Keywords
- psychological flexibility, medical students, medical residents, Acceptance and Action Questionnaire-II, Cognitive Fusion Questionnaire, mindfulness, construct validity, psychometric properties, self-awareness, life satisfaction, medical education
- MeSH terms
- Adaptation, Psychological, Cross-Sectional Studies, Education, Medical, Graduate, Education, Medical, Undergraduate, Humans, Internship and Residency, Medical Staff, Hospital, Psychometrics, Students, Medical
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