From shielded stress to shared support: A sequential, mixed-methods study on informal help-seeking behavior in health...

Although peer support is known to foster well-being among students in health professions education, the mechanisms driving informal help-seeking behavior remain insufficiently understood. Ongoing psychological distress and persistent barriers to faculty-based support increase the need for accessible resources for these future health care professionals. This study explored whether students reach out when experiencing performance pressure and which opportunities they identify to strengthen their peer support network.

This sequential, mixed-methods study was conducted at the Radboud University Medical Center, the Netherlands and spanned a six-year period through two distinct phases of data collection (2018-2024). In Part 1, 26 students in Medicine and Biomedical Sciences completed one-on-one interviews. Qualitative analysis identified six key barriers to informal help-seeking; 'Stigma' (S), 'Harm' (H), 'Inutility' (I), 'Ego' (E), 'Load' (L), and 'Disapproval' (D), together forming the SHIELD-framework. In Part 2, 946 students completed a survey developed from Part 1 findings. A mixed-format question design and advanced statistical analyses were used to examine latent patterns in their informal help-seeking behavior.

Across both study parts, most students concealed their internal struggles, creating a gap between experience and expression. Their motivations were consistently reflected in the SHIELD-framework across gender, program and year of study. 'Stigma' and 'Disapproval' captured fear of judgment. 'Harm' and 'Load' reflected concerns about burdening others or worsening personal distress. 'Inutility' referred to doubts about the usefulness of disclosure, while 'Ego' related to students' self-image. Many students described suppressing difficult thoughts and emotions, keeping stress confined to their inner world.

Students' tendency to shield their stress reflected a complex interplay of personal and contextual barriers. Our SHIELD-framework offers a practical and conceptual handhold for students and educators to better understand these dynamics. Supporting a shift from shielded stress to shared support requires intentional efforts that normalize vulnerability and foster meaningful peer connection.