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Milieu in Dental School and Practice |
Key words: dental students, problems, psychological stress, support services, help-seeking
Submitted for publication 10/19/04; accepted 06/09/05
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Abstract |
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The problems encountered by dental students are well documented. Studies in the United States and abroad have shown that problems commonly reported include lack of sufficient time and the inability to manage time effectively, concern about grades and academic performance, the fear of failing or of falling behind in school, and difficult interactions with faculty.2–13 Research has also found that dental students may have serious financial problems while in school, may begin to question or doubt their motivation and commitment, and may struggle with personal disappointment over their performance.3–5,7,9,12
Researchers have attempted to determine which students, or groups of students, might be at greater risk for educational stress. There is consistent evidence to suggest that certain demographic characteristics may be indicators of a greater or lesser susceptibility to problems confronting dental students. Age, gender, relationship status, personality type, and year in program have been found to explain the variation in stress experienced by students.5,7,9,10–16 Research has also suggested that students who possess certain skill sets, such as strong social networks and well-developed coping strategies, may be in a better position to cope with educational stress.14,17–20 One study conducted in Europe21 found that living at home reduced the effects of educational stress on dental students.
While the stress of professional training can be a motivator for some, for others it can have serious consequences. Studies have shown that for some students high stress levels can result in increased anxiety and depression, physical ailments, impaired cognitive functioning including problems with learning and decision making and poor academic performance.2,4,9,11,13,16,20,22–24 Other studies have suggested that high stress levels may impair professional judgment9,20 or place students at greater risk for substance abuse.2,20 Garbee et al.4 even posited that unmanageable stress levels may play a role in a student’s premature decision to withdraw from an educational program.
Although not all students are negatively affected by problems common to dental education, the potential seriousness of high stress levels on the student’s emotional and physical well-being is hard to ignore. For many years the pressures inherent in the educational process in the health sciences were considered part of the overall experience, a way to prepare future practitioners for the reality of private practice. As a growing body of research documented the consequences of increased levels of educational stress, however, thinking among health care educators changed. The need for support programs to help students manage the rigor of the educational process and to buffer the deleterious effects of stress became evident.
In the last two decades, a wide variety of support programs and interventions has been reported in the literature. In general, student support is available in one of two modalities, formal or informal, and from one of three sources: peer, faculty, or other professional. Given the variety and nature of the problems professional students encounter, source/modality combinations are common: an informal conversation with a faculty member may solve one student’s problem, while a formal peer support program is necessary for another’s.
A common support system is one where students help one another. The value of peer-to-peer interaction in venues such as tutoring programs, support groups, and other student-led and -managed activities has been recognized.5,14,19,25 Many schools have some type of peer support program, whether organized informally by students or formally by schools. Faculty members are another valuable resource in supporting students. Studies suggesting the usefulness of faculty advising and mentoring programs to assist dental students during their training are frequent.14,19,26 Wexler’s24 call for the establishment of counseling centers in schools staffed by trained, licensed mental health professionals has found support.13,16,27 Today it is not uncommon for a school to have a psychiatrist, psychologist, or other trained counselors on faculty or staff. And curricular innovations designed to help professional students manage educational stress have been explored. The positive results of curricular interventions such as stress reduction seminars and formal instruction in relaxation and other stress management techniques have been reported.6,8,19,20
It is clear that dental educators have acknowledged the potential impact of high levels of educational stress on dental students and that substantial efforts have been made to provide support services to students in need of them. Most of the published research over the last twenty years, however, has reported on individual programs evaluated in isolation. While reporting of this kind is necessary and helpful, evaluating a single program cannot address two important points: 1) whether one type of program or service is perceived to be more effective than another in addressing the range of problems encountered by dental students; and 2) whether student use of support services indicates a preference for one resource over another. Understanding these concepts could prove useful for deans, faculty, and student affairs officers charged with designing and implementing student support programs at dental schools.
The purpose of this study was to determine the severity of problems common to the first year of dental school and to assess the use and perceived effectiveness of formal and informal peer and professional support programs in addressing those problems. Participation in the study was limited to first-year dental students at a private west coast school where a range of peer, professional, formal, and informal support programs were available. The decision to concentrate on this population was made based on the investigators’ access to and experience with working with this type of student as well as research suggesting that first-year dental students were likely to experience high levels of stress.13,21,24,27
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Methods |
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Based on the literature and a combined total of thirty years of dental student advising, the investigators compiled the list of seventeen problems that were included in the survey. An eighteenth item, "other problem," was on the original list, but was dropped from data analysis due to a lack of responses. To aid data analysis, the researchers divided the seventeen problems into four categories based on their experience with first-year students: performance/skill-based, adjustment to school, emotional, and commitment/motivation. The final problem list and categorization breakdown is presented in Table 1
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Two problems were presented on each page of the survey. Immediately below each problem, students were asked to use a four-point scale to rate the severity for them of the problem (1=not a problem, 4=severe problem). For each problem marked with a severity rating of "2" or higher, students were instructed to check any of seventeen listed support options they used to address the problem. Students were further asked to use a four-point scale to rate the effectiveness of each resource checked (1=not effective, 4=very effective). Problems and resources were presented in random order.
The survey was administered in the spring of 2002 at the close of a regularly scheduled morning lecture. The time required to complete the survey was approximately fifteen minutes. Oral instructions were provided in addition to detailed written instructions, and both investigators were present to answer questions. Students were told that their responses were anonymous. The survey was granted "exempt from review" status by the Institutional Review Board.
SPSS Version 6.0 was used for data analysis. Given the nature of the data, both parametric and nonparametric tests were run. A comparison of the results revealed minimal differences. Of the fifty-six findings presented here, differences of .01 were noted in the value of two correlation coefficients, and p-values from the one-way ANOVA changed in four instances from .0008 to .02. One result is not reported due to a change in its statistical significance in the nonparametric test. Due to increased statistical power, the results of the parametric tests are provided. Means and standard deviations were calculated for severity of problem and perceived effectiveness of service used. Percentage of students using each service for any problem type and for use of a resource across all problems was computed. Correlation coefficients were calculated to examine relationships among demographic variables as well as relationships among demographic variables, problem severity, and use and effectiveness ratings. To evaluate differences in severity of problem, use, and effectiveness ratings by gender and change in relationship status, t-tests were run. Differences by relationship status were evaluated using one-way analysis of variance. Statistical significance for all tests was set at p=.05.
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Results |
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Thirty-five percent of respondents were female. Nearly 22 percent were nineteen to twenty-two years old, 57 percent were twenty-three to twenty-six years old, 17 percent were twenty-seven to thirty years old, and 5 percent were over thirty. (Percentages are rounded to the nearest whole number.) Forty-three percent of those completing the survey reported being single, 30 percent reported being single but in a committed relationship, 25 percent were married or partnered, and 1 percent were divorced or separated. Roughly 22 percent reported a change in relationship status during the first year of dental school. Thirty-five percent reported their class rank at the close of the third quarter to be in the first quartile, 22 percent in the second, 26 percent in the third, and 13 percent in the fourth. Roughly 21 percent of respondents reported they attended undergraduate schools of fewer than 5,000 students; 16 percent attended schools with between 5,000 and 10,000 students; 23 percent with between 10,000 and 20,000 students; and 40 percent with more than 20,000 students. Due to the anonymity of responses, a comparison of demographics between respondents and non-respondents was not possible.
Severity of Problems
Mean severity ratings for all problems were generally modest (Table 3). The highest average severity ratings were for two problems in the emotional category. Personal disappointment with performance was perceived as the most severe problem in this sample (M=2.64, SD=.86), followed closely by stress (M=2.56, SD=.95). The four other problems in the emotional category were judged to be less severe: self-doubt (M=1.96, SD=.90), emotional well-being (M=1.90, SD=.96), relationship issues (M=1.69, SD=.89), and fear of treating live patients (M=1.54, SD=.70). Students in this sample perceived all four performance issues to be the second most serious type of problem they encountered. Time management had a mean severity rating of 2.16 (SD=1.02) followed by substandard technique performance (M=2.13, SD=.85), study skills (M=2.06, SD=.85), and substandard didactic performance (M=1.98, SD=1.01). Adjustment issues as a group had lower overall mean severity ratings. The mean for separation issues was 1.85 (SD=.92); for transition to dental school, 1.88 (SD=.86); for physical well-being, 1.84 (SD=.94); for living accommodations, 1.78 (SD=.93); and for financial problems, 1.55 (SD=.82). The lowest rated of all problem types were in the commitment/motivation category: questioning commitment to dentistry rated 1.48 (SD=.82) and questioning commitment to the three-year curriculum rated 1.43 (SD=.70) on the four-point severity scale.
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Use of Resources
Use of resources was investigated by examining the percentage of students who reported using each service and the average frequency of use of a resource across all problems. Results are presented in Table 4.
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Use of support services was further illuminated by examining the average number of problems for which a resource was consulted. Results showed that "self" was used for the greatest number of problems on average (M=3.80, SD=4.02). The resource used for the second largest number of problems was informal peers (M=3.40, SD=3.40). Classmates were consulted for an average of 3.78 problems (SD=3.44) whereas upperclassmen were used for an average of 2.93 problems (SD=3.34). This result may be due to the close physical proximity of classmates in contrast to upperclassmen. The resources used for the third largest number of problems were those outside the school. Outside resources were used for an average of 2.02 problems (SD=2.47). Professional and formal peer programs were roughly tied as the type of resource used for the least number of problems on average. Responses indicated that each type of program was used for approximately one problem, considerably fewer than for "self" or informal peers. The preclinical row instructor was consulted for more problems on average than other professional resources (M=2.01, SD=2.60), whereas the Big Sibling program was used for more problems than were peer tutors, M=2.46 (SD=3.29) compared to .72 (SD=1.89) for technique tutors and 0.60 (SD=1.88) for didactic tutors. The findings on frequency of use should be interpreted with caution. They give general information on the use of resources by students, but practical differences between an average of 3.4 and 3.8 or 1.30 and 1.48 problems are likely to be minimal. Moreover, the skewness of the data is evident in some of the results reported here.
Perceived Effectiveness of Resources
Mean perceived effectiveness ratings for each resource are presented in Table 4. These figures were based on responses of students who indicated they used a resource.
Outside resources were perceived by students to be the most effective in resolving the problems for which they were consulted. The mean effectiveness rating for this resource was 3.37 (SD=.56) on the four-point scale, suggesting that spouses, family members, friends, or a physician were perceived to be helpful in solving problems for which they were consulted. "Self" was also perceived to be effective, with a mean effectiveness rating of 3.11 (SD=.70). Also perceived effective were informal peer resources (M=3.04, SD=.74). Classmates and upperclassmen were viewed as roughly equally effective in solving problems (classmates, M=3.06, SD=.69; upperclassmen, M=3.01, SD=.85). Professional and formal peer support programs were perceived by students to be less effective in resolving problems. As a group, professional resources were rated 2.69 (SD=.94) and formal peers were rated 2.56 (SD=1.08). Effectiveness ratings for individual resources ranged from 2.12 for didactic tutors (SD=1.16) and advisors (SD=.85) to 2.94 (SD=.96) for the Office of Student Services. Only one of the formal resources rated above 3.0 on the four-point scale.
Demographic Variables and Use and Perceived Effectiveness
Demographic variables were analyzed relative to problem severity, use, and perceived effectiveness ratings. This was done to examine patterns of resource use and perceived effectiveness by type of student or student characteristic. Statistically significant findings are presented in Tables 5–7.
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shows the correlation coefficients for student age and class rank with problem severity, frequency of resource use, and perceived effectiveness rating. Correlations were generally small to moderate. Older students were more likely to have a low class rank (r=.21), to consult with the school psychologist to resolve problems (r=.33), and to come from larger undergraduate schools (r=.24).
Students with low class rank reported more severe performance problems than students with high rank. Class rank was moderately correlated with substandard didactic performance (r=.62) and study skills (r=.50), but less so with time management (r=.34). Responses from low ranking students also indicated they perceived the transition to dental school to be more difficult (r=.29) and were more likely to be disappointed in their performance (r=.25) compared to high ranking students. Students in this group were significantly more likely to use all available in-school resource types to help resolve problems. Although they tended to make more use of professional resources (r=.43), they also used formal peer resources (r=.38) and informal peers (r=.37) for help. Low rank was not significantly associated with use of "self" or outside resources to solve problems, in contrast to the trend for the overall sample as reflected in the use data in Table 4.
Students with low class rank perceived resources in the informal peer, formal peer, and the professional categories to be more effective in helping them with problems. Responses indicated that these students were more likely to rate upperclassmen (r=.31), didactic tutors advisors (r=.41), course directors (r=.50), the Dean’s Office (r=.53), and the Office of Academic Affairs (r=.51) as effective in helping them with problems. Low class rank was not significantly associated with the perceived effectiveness of "self" or outside resources. As noted elsewhere, practical differences in the effectiveness ratings are likely to be minimal.
Table 6 summarizes significant results of t-tests run to examine differences in responses between males and females. Female respondents were significantly more likely than males to report experiencing problems in the emotional category. Severity ratings for stress, emotional well-being, and relationship problems were significantly higher for women than for men. Responses also indicated that, in comparison to males, female students were more likely to use outside resources (z=2.52) and to perceive them to be effective. Still, the data suggested that, compared to males, female students who used professional or informal peer resources or who relied on themselves for help perceived these resources to be effective. In particular, this was true of upperclassmen (z=2.1), row instructors (z=2.48), and course directors (z=2.08).
Data on students reporting a change in relationship status during the first year of dental school are reported in Table 7. Not surprisingly, responses from this group indicated a greater severity of problems in the emotional category (z=2.4). Relationship issues and emotional well-being were perceived to be more severe for these students than for those whose relationship status did not change. In addition, financial problems and questioning commitment to the three-year curriculum appeared to have been felt more severely by students whose relationship status changed. A change in relationship status, however, did not impact the perceived severity of performance problems in this sample. No significant differences were found in performance problems between students who reported a change in relationship status changed and those who did not. Interestingly, survey responses suggested that neither formal nor informal peer resources were perceived to be significantly more effective in helping students whose relationship status had changed. In fact, only course directors were perceived by this group to be more effective in addressing problems for which they were approached (z=1.98).
Table 8 summarizes significant results of a one-way ANOVA that compared students who categorized their relationship status at the time of the survey as single, in a committed relationship, or married. Severity, use, and perceived effectiveness ratings were dependent variables in the analyses. Students in committed relationships reported experiencing greater relationship problems than their single or married classmates, whereas single students were more likely to struggle with technique problems than their married or committed colleagues. Single and committed students were more likely than married students to use informal peers and row instructors to help with a problem. However, committed and married students were significantly more likely to rely on themselves to solve a problem than their single classmates. Single students were also more likely to consult with course directors than married or committed classmates. The perceived effectiveness ratings of resources did not vary significantly by relationship status.
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Discussion |
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In this study, mean severity ratings of problems were generally modest and appeared to be consistent with the findings from a study of Canadian dental student problems.3 On the other hand, although it is impossible to compare directly the results from studies using different measures of dental student stress or problems, students in this sample appeared to be less stressed than a sample of European dental students.21 In the European study, over a third of respondents reported significant psychological distress, and 22 percent recorded high scores on emotional exhaustion. In comparison, 16 percent of respondents in the current study perceived stress as a severe problem, and 6 percent indicated serious problems with their emotional well-being. One factor that may explain these findings was the timing of the survey. Student perception of the severity of problems may have diminished by the time the survey was administered at the end of the first year, especially if, as suggested, the beginning of the school year is more stressful for dental students than the end.27 It is also possible that the supportive environment at the school or strong coping skills among students influenced the perception of problem severity and stress in this sample.
Several demographic factors were clearly associated with problem severity. First, as might be expected, students with a low class rank were more likely to report higher severity of a number of problems in the performance, emotional, and adjustment categories. Contrary to the findings of Tedesco,29 however, no significant relationship between low class rank and stress per se was observed. Second, females were significantly more likely than males to report high levels of stress and concern about emotional well-being and relationship issues. These findings are consistent with numerous studies that show that female dental students tend to report higher levels of stress and more problems with life situations than males1,3,6,9–11 and that females, in general, tend to appraise stressors as more severe than males do.32 Finally, students reporting a change in relationship status were significantly more likely to have problems in the emotional, adjustment, and commitment categories than students whose relationship status did not change. Specifically, this group reported more financial problems and greater concerns about emotional well-being and relationship issues and were more likely to question their commitment to the dental program. Surprisingly, a change in relationship status did not appear to impact performance.
In contrast, there were few differences in reported problem severity by relationship status. Students in a committed relationship had more serious relationship problems, and single students had more difficulty with technique performance. The fact that there were no significant differences in perceived stress or most other problems between single and married students is consistent with the finding of Musser and Lloyd,8 who also reported no differences in stress levels between single and married dental students. In the Musser and Lloyd study, marital status was used as a proxy for social support. However, it seems likely that social support, which has long been thought to provide a buffer against stress,5,14 is not limited to spouses but includes a broad network of social contacts including peers and family.
Contrary to other studies, results presented here revealed no association between age and severity of any problem. Henning et al.16 compared stress levels of medical, dental, pharmacy, and nursing students and concluded that younger dental students reported more stress than older dental students. Pau and Croucher1 found the opposite, namely, that students over the age of twenty-one reported higher levels of stress. The small number of students under the age of twenty-one in this sample may partially account for this result.
Use and Perceived Effectiveness of Support Services
One of the most striking findings of this study was the heavy reliance on informal peers for advice and help. As a group, informal peer resources (classmates and upperclassmen) were used by 87 percent of first-year dental students in this sample. In comparison, 72 percent of respondents reported using the formal peer programs. Not only were informal peer resources used by a large number of students; they were also consulted for a greater number of problems on average than professional or formal resources. Furthermore, as suggested by a mean effectiveness rating of 3.04 (SD=.74), informal peers were perceived to be more effective than all other internal resources. This finding could be attributable to the ease of access and proximity to informal peers or to the fear of disclosing problems to faculty members or other professionals in the school. Regardless, this result reinforces the importance of peers in supporting students during the first year of a dental program.
Also noteworthy was that 80 percent of survey respondents indicated that they had tried to solve a problem on their own and that they felt this approach was at least as effective as using informal peer resources. This may suggest a particularly self-reliant population or that certain types of problems were more easily solved privately.
Responses indicated that while outside resources were used by the fewest number of students (59 percent) and for fewer problems on average than informal peers and "self" (2.02), they had the highest mean effectiveness rating of any resource (M=3.37, SD=.56). Except for two mentions of physicians, external resources identified by students were almost exclusively social support: spouses or significant others, family, and friends. It may be that respondents felt the most effective help for certain types of problems was outside of the school environment. Additional research is needed before more definitive conclusions can be drawn.
Despite the apparent preference for informal peer support and "self," 80 percent of students reported using at least one professional resource for help with a problem. Certain resources, such as the school psychologist and the Dean’s Office, were used by comparatively few students. Others, such as the business office and the Office of Student Services, were used by over a third of the students, albeit for a relatively narrow range of problems. Approximately 40 percent of students reported consulting their advisor, a course director, or other faculty member about an issue. The professional resource used by the most students was the preclinical technique row instructor. Sixty-four percent of respondents indicated that they talked with their row instructor about a problem, and frequency data showed that row instructors were consulted on issues beyond the expected concerns with technique performance. Considering that students spend a large number of contact hours in the first year in the technique lab, the relatively high use of row instructors might further support the conclusion that proximity and convenience may drive student choice of support more than a serious consideration of who might best be able to help them.
The mean perceived effectiveness ratings of the professional support services varied considerably, however. Only one resource in this category, the school’s business office, had a mean effectiveness rating above 3.0 on the four-point scale, suggesting that students perceived the help they got in managing financial matters to be effective. In contrast, the perceived effectiveness of the first-year faculty advisors and the school psychologist, resources specifically designed to counsel first-year students, was low relative to all other sources of support. It is likely that this perception was influenced by the nature and severity of the problems for which help was sought. Students who seek support from an advisor or psychologist may have long-standing and complex problems that are not easily resolved. It is also likely that many students turn to counseling only when other avenues, such as "self," peers, and social support, have been exhausted.
A number of studies have sought to describe the help-seeking behavior of college students, particularly as it pertains to the likelihood that a student will seek professional help.33–35 Factors that have been found to influence this behavior include attitudes toward and expectations of counseling, severity and type of problem for which help is sought, characteristics of students who use and do not use help, and characteristics of preferred sources of help. One student characteristic associated with help-seeking is willingness to self-disclose. Whether accurate or not, students often fear that problems of an emotional nature, as opposed to an academic nature, may wind up on their permanent record and negatively influence faculty perception of their competence. Another characteristic that influences help-seeking behavior is fear of stigmatization. A student may be reluctant to have others know they are seeking help and may avoid it if anonymity is uncertain. The literature also strongly suggests that college students prefer informal sources to professional ones, although the ultimate choice of a resource may depend upon the type and severity of the problem and demographic factors.34 The results of this study seem to indicate that similar help-seeking behavior may exist among dental students, although further research in this area is recommended.
When use and perceived effectiveness of support services were examined in relation to demographic variables, several findings stood out. First, the results clearly indicated that students with academic problems as reflected in low rank made more use of the school’s peer and professional resources. Students with low class rank were more likely than other students to seek help from upperclassmen, their Big Sibling, their advisor, course directors, the school psychologist, and the Office of Academic Affairs. Furthermore, they were more likely to perceive these resources, particularly informal peer support, as effective. This finding suggests that students with academic problems take advantage of and value support services. It should be noted, however, that in our program students on academic probation are required to seek help from professional and peer resources including advisors, course directors, and tutors. The study design did not permit an examination of how much of the help-seeking behavior reported by the low ranked students was the result of self-motivation or the requirements of the school.
Data also indicated that single students were more likely than married students to seek help from informal peers, row instructors, and course directors, while married students and those in committed relationships were more likely to handle problems themselves. One possible explanation for these findings is that single students generally spend more time in the dental school and thus have a greater opportunity to interact with peers and faculty than married students, who may spend less time at school. It is also conceivable that married students or those in committed relationships feel a stronger sense of responsibility for handling problems on their own.
One of the most studied demographic variables in the help-seeking literature is gender. Research on undergraduate students has suggested that females are more likely than males to seek help, but that preferences for type of resource do not differ between males and females.34 In this study the only significant difference in resource use between males and females was that females used outside resources for more problems than males. This finding may be consistent with the widespread notion that women are more likely to seek social support,32 although if that were true, one would expect to find a greater use of informal peers. Another interesting finding was that females perceived a variety of resources, including themselves, outside resources, informal peers, row instructors, and course directors, to be more effective in dealing with their problems than did males. This finding may be unique to our population and requires further study.
Race and ethnicity have also been shown to be related to attitudes toward help-seeking behavior. It has been reported, for example, that some Asian/Pacific Islander subpopulations prefer to solve problems within the family and are generally less positive about the need for professional help.35 Since the survey instrument used in this study did not collect information on race or ethnicity, we were not able to examine this variable. Given the continued large number of Asian/Pacific Islanders and the increasing number of minorities in dental school, future research on support services should explicitly consider race and ethnicity.
This study had a number of limitations. The length and complexity of the survey may have impacted the thoughtfulness of student responses and therefore the integrity of the data. As noted, administering the survey at the end of the first year may have diminished student perception of the severity of problems they experienced earlier in the year. Small sample sizes in some categories may have impacted the results and contributed to the skewed responses. Responses may have been further biased by the absence of some possibly low ranking students on the day the survey was administered. Response data showed that more than one third of respondents put themselves in the top quartile of class rank and only 13 percent in the bottom quartile. Lastly, since this study is a snapshot of the first-year dental class at one school, results may not generalize to other classes or schools.
Additional research on the use and effectiveness of a variety of student support services is needed to add support to the results presented here. In particular, it would be interesting to see how many dental schools offer a variety of support programs and to learn how the programs are used and perceived by dental students. A study of whether certain resources are used for certain types of programs would be welcome, as well as an investigation of student motivation to seek particular types of support. Lastly, given the continued emphasis on increasing the number of underrepresented minority students in dental education, future studies should focus explicitly on this issue.
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