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International Perspectives in Dental Education |
Key words: dental student, stress, education, gender, year of study
Submitted for publication 01/13/05; accepted 03/18/05
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Abstract |
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It has been reported that dental students express considerable stress symptoms during their training1,9,10 and that they are more anxious than the general population,11,12 showing higher levels of depression, obsessive-compulsive disorders, and interpersonal sensitivity than age-matched norms.13,14 Studies of dental school life, occupational pressures, health issues, alcohol use, and mortality suggest that both dental education and practice contain stress provoking elements that generally have negative effects on individual well-being.3,15 Moreover, recent research suggests substantial levels of psychological distress and emotional exhaustion among first-year students at seven European dental schools.16
The aim of this investigation was to identify sources of stress among dental students at the University of Athens School of Dentistry and to explore the role of year of study and gender on perceived stressors.
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Methods |
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The questionnaire used in this research was based on the Dental Environment Stress (DES) questionnaire.2 The DES questionnaire was modified to make it applicable to a Greek background and to reflect what the students could refer to by removing items and adding topics. The modified version contained thirty stress-related items; twenty items were used per se from the original DES questionnaire, whereas ten items were added.
Students were asked to assess the questionnaire items as "not stressful at all," "somewhat stressful," "quite stressful," and "very stressful" on a four-point Likert scale. Univariate statistical analysis was conducted with the use of Wilcoxon rank sum test and Kruskall-Wallis test, and multivariate analysis relied on ordinal logistic regression modeling. In the multiplicative models, study level and gender were always included as possible predictors in order to simultaneously assess the effect of the above factors on students’ responses. Data was analyzed using the STATA® 8.0 statistical package.
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Results |
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, indicating an overall response rate of 94.4 percent. It should be noted that the student body can be characterized as homogenous in terms of educational background, ethnicity, and other sociocultural parameters.
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). Workload, performance pressure, and self-efficacy beliefs constituted the most stress-provoking factors as perceived by the students. Specifically, a higher percentage of respondents perceived the following factors as "quite stressful" or "very stressful": "amount of class work" (82 percent), "examinations and grades" (76 percent), "lack of confidence in self to become a successful dentist" (70 percent), "completing graduation requirements" (68 percent), "lack of time to do assigned school work" (64 percent), and "lack of time for relaxation" (64 percent).
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Multivariate analysis relied on ordinal logistic regression modeling and revealed that, irrespective of gender, a number of stress-provoking factors remained significantly different between years of study. Odds ratios were calculated for six items, for which significant differences remained, both by gender and by year, after multivariate analysis (Table 3).The results of the multivariate analysis indicated that entering students found the "difficulty of class work" 80 percent more stressful than students in the fourth and fifth clinical years. In addition, female students were 40 percent more likely than their male peers to perceive the "difficulty of class work" item as more stressful. Moreover, females felt twice as stressed compared to males about their "fear of failing course or year." In this question, third-year students seemed to be the most concerned, whereas older students appeared the least stressed. Regarding the acquisition of manual skills, females had higher stress scores in "laboratory and preclinical training" as well as in "learning of clinical procedures and protocols." Third-year students were the most concerned with regard to the first factor, whereas the fourth-year students were the least stressed about the familiarization with clinical procedures and protocols. Furthermore, clinical year students were the most stressed about "insecurity concerning professional future" and "patients being late or not showing up for their appointments," as were the female versus the male respondents.
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Discussion |
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The results of this study support the existing evidence in the literature, indicating that dental students are subject to numerous work-related and academic stressors that may adversely affect their physical and psychological health.8,9,17,18 The primary sources of stress in the Greek dental school are assigned workload, performance pressure, and self-efficacy beliefs. This is consistent with findings of other studies.2,6,19 In addition, year of study has been previously reported as a modifier of stress-provoking factors.20,21
The cross-sectional nature of the study and the sociocultural background of the Greek student population may limit the applicability of the conclusions to other institutions. In this investigation, the observed differences by year of study indicate that entering and preclinical students are mostly concerned with factors closely related to workload, as well as examinations and grades, whereas clinical year students were more stressed about patient treatment and insecurity concerning their professional future. Further, students in the third year of studies were the most affected by the acquisition of manual skills in laboratory and preclinical work and demonstrated a significant concern when considering the treatment of uncooperative patients. These findings indicate that third-year students may be overloaded by the high academic demands of their year of study, whereas the absence of early clinical exposure may be triggering anticipatory stress reactions in regard to the upcoming encounter with clinical training. "Lack of continuous self-assessment," although not a significant stressor overall, appears to be a significant concern for the fourth-year students. This finding combined with the perceived "lack of clinical staff in the clinics" reveals that fourth-year students face difficulties in assessing their clinical work and may be uncertain about some aspects of their clinical competence. Moreover, first- and fourth-year students were the most concerned about "lack of time for relaxation," a finding that may be attributed to the introduction to dental studies and the initiation of clinical training, respectively. Finally, an observation of significance is the overall low ranking of financial responsibilities, as well as administration and student-faculty relations, which is in contrast to the finding of Garbee et al.2 and may be attributed to characteristics of the Greek dental school. It is possible that the informal nature of social relationships in Mediterranean nations such as Greece helps students feel comfortable interacting with faculty and staff in a public dental school environment where there is minimal financial commitment from the students.
Regarding the relationship of gender and perceived sources of stress, females reported higher stress in certain aspects of the educational process, contrary to other findings that did not support any gender difference22 or showed that males experienced greater stress.21 The following factors have been previously found to evoke greater stress among female students2,9,23 and were supported by this survey: lack of confidence to be a successful student and to become a successful dentist, fear of failure, examinations, and grades. Female students also seemed more concerned about financial responsibilities. Previous investigators have reported conflicting findings about the relationship of student gender and financial concerns. Musser and Lloyd13 reported a gender difference for financial concern, but Health et al.24 reported no such difference. The fact that female students report significantly higher distress can be attributed to additional strains they may face in the dental school environment or their different patterns of response to stressful events.3,25 It has also been suggested that females receive less peer support than male students.15 Sanders and Lushington,14 however, suggested that gender differences in most of the perceived stressors could be explained by their differing patterns of psychological morbidity and because males are simply less expressive of their concerns.
The results of this study suggest that a variety of changes need to be considered at the University of Athens Dental School. Faculty members at this school primarily employ traditional educational methods consisting of a teacher-centered learning environment, which is lecture-oriented and without opportunity for discussion and/or group work. Furthermore, even the idea of study support groups is foreign to the Greek student. The reconsideration of the existing educational system towards a more student-centered orientation could facilitate collaborative learning and interpersonal support among students, which may have a protective effect against difficulties faced while in university.26 A second change concerns clinical training where unit requirements (quotas) may need to be eliminated. According to Dodge et al.,27 students report significantly lower stress when clinical training and evaluation are not based on unit requirements—the successful completion of which seems to be a significant source of stress. The Dodge study suggested that predoctoral clinical programs can maintain quality and productivity in the absence of unit requirements.
Third, a stress reduction program could be implemented. A broad spectrum of intervention studies has evaluated such programs for dental students, including specific courses, stress-reduction sessions, introduction to behavioral sciences, and faculty-incorporated advising systems. Howard et al.28 states that although some professionals have viewed stress management interventions as "band-aid" techniques to the overwhelming problem of faculty-induced stress, such techniques do have significant impact. Tisdelle et al.5 support that such training schemes foster coping behaviors that are useful on a daily basis, as well as preventative measures to reduce chronic stress effects. According to Schwartz et al.,29 the establishment of student advisors and counselors within a dental school, combined with a faculty advising system and student-oriented programs, have contributed to an improved educational environment.
In conclusion, the primary sources of stress as perceived by nearly 600 students at one public dental school in Greece were assigned workload, performance pressure, and their self-efficacy beliefs. In this study, females expressed higher levels of stress in certain areas of dental training. Moreover, students in different years of study perceived different sources of stress.
Although some of the high-rated stressors appear to be inherent in professional education and prevalent to diverse dental educational settings, a contemporary dental school should address potential stress sources effectively, thus promoting the educational and professional well-being of dental undergraduates.
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Footnotes |
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REFERENCES |
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This article has been cited by other articles:
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  A. Pau, M. L. Rowland, S. Naidoo, R. AbdulKadir, E. Makrynika, R. Moraru, B. Huang, and R. Croucher Emotional Intelligence and Perceived Stress in Dental Undergraduates: A Multinational Survey J Dent Educ., February 1, 2007; 71(2): 197 - 204. [Abstract] [Full Text] [PDF]
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