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J Dent Educ. 71(2): 242-248 2007
© 2007 American Dental Education Association
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Transfer of Advances in Science into Dental Education

The Origins of Fear of Occupational Exposure in the Clinical Dental Setting

David W. Chambers, Ed.M., M.B.A., Ph.D.; Nader A. Nadershahi, D.D.S., M.B.A.; Howard Chi, D.M.D., M.A.

Key words: occupational exposures, fear of injury, dental clinical injury, needlesticks, path analysis

Submitted for publication 07/07/06; accepted 10/24/06


   Abstract
Top
 Abstract
Methods
 Results
 Discussion
 References
 
Although there is a growing literature on the incidence of occurrence and reporting of occupational exposures in clinics in dental schools, the contributing factors to fear of such injuries and their dynamic evolution over time remain unstudied. It is hypothesized that fear of occupational exposures is a function of estimated likelihood of such events and their perceived importance. Individual personality factors and situational circumstances are also thought to play a role, although it is believed that these factors recede in importance as students gain direct knowledge through clinical experience. Path analysis methods are applied to longitudinal survey data in a single dental school to confirm these hypotheses.

There is a growing body of literature on the incidence and importance of occupational exposures involving the potential for bloodborne infection in the dental clinical setting. Emphasis has tended to focus on quantifying the likelihood of occurrence or assessing perceptions of the seriousness of these incidents.1–19 The facts that controlled experiments cannot be conducted on such events and that they are unpredictable and of low occurrence contribute to the paucity of research designed to understand clinical accidents.

Fear of clinical accidents, as a personal, enduring emotion of some depth, might influence behavior such as choosing to enter or leave a profession or engagement in behaviors that have expected benefit for lowering risk. Thus, it would be valuable to better understand the origins and dynamics of this emotional state. What factors contribute to high levels of such fear? Are the sources of fear of clinical injury realistic, predictable, or controllable? Is there an understandable dynamic driving the formation of these fears? In short, can we begin to understand how fear of injury in the dental clinic looks from the perspective of dental students?

The psychological literature generally explains propensity for approach or avoidance (and their attendant emotions) in terms of 1) the likelihood of an outcome occurring and 2) the importance of the outcome should it occur.20–22 Factors that contribute to significant fear of occupational exposure, such as needlesticks, could include a combination of the estimation that such occurrences are likely and that they are threatening to one’s life or career or extremely inconvenient to manage. It has been established that the combined effect of likelihood and importance is best expressed by multiplying the two elements. Hence, serious outcomes that are thought to be improbable and outcomes with high probability but low significance both have low expected value and are given less attention than outcomes that have high expected value—often presenting as moderately important and moderately likely potential outcomes. This line of research is known as expected value theory.23,24 While both estimated likelihood of occurrence and perceived seriousness have been recognized in the literature on occupational exposures, there are no studies explicitly using these variables in combination to account for fear of such occurrence.

In addition to its potential origins in expected value (likelihood x importance), fear of occupational exposures is probably affected by personal and situation factors. It is widely recognized that some individuals are risk averse. It is also possible that differences might exist among health care professionals with regard to personal background, knowledge of relevant issues, myths of magical protection or vulnerability, etc. that operate independently to influence estimates of fear.25,26 Such individual differences may contribute more greatly to fear of occupational exposures early in one’s professional career, before realistic estimates of likelihood can be formed.

It is also probable that there are situational components to the estimate of fear of occupational exposure. Working on patients who are known to be HIV-positive or working in a surgery or emergency room situation are examples of factors that would probably increase situational estimates of fear of injury.

This research explores in a preliminary fashion which antecedents might be predictive of personal estimates of fear of occupational exposure in a dental school clinical setting. Specifically, the following hypotheses are tested:

  1. Fear of occupational exposure is a personal expected value calculation involving the multiplication of estimated likelihood by significance of outcome.
  2. Fear of occupational exposure is also a function of personal and situational characteristics.
  3. Fear of occupational exposure is an evolving concept during professional education, in which personal factors assume a more predictive role in the early years and the expected value calculation assumes more prominence with increased clinical experience.

Causal modeling is a useful conceptual tool for building prototype understanding of phenomena such as the concept of fear of occupational exposure.27 This method identifies statistically significant predictive relationships among variables and arranges them in causal patterns. Because these are represented graphically as arrows connecting those elements of an explanation that have demonstrated causal connections, the method is sometimes called "path analysis."

What are some of the technical aspects of causal modeling? Beginning with a complete matrix of correlations among all variables in a study, causal modeling allows the depiction of statistically significant paths leading backwards in chains from the target variable (in this case, fear of injury). Each path is labeled for its strength of causal contribution: a partial correlation that makes appropriate adjustments of other predictors that share a path. These measures of path strength are expressed in values ranging from 0.000 to 1.000, with higher values representing greater predictive power. The predictive paths can be combined to estimate the overall explanatory value of the model. The resulting models are "pictures" of the underlying structure of the situation being studied. Generally, causal modeling satisfies the conditions for causal inference: 1) covariation, 2) logical precedence, and 3) non-occurrence of the predicted outcome in the absence of non-occurrence of the predictor.27


   Methods
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 Abstract
 Methods
Results
 Discussion
 References
 
This study of fear of occupational exposure in a dental clinic situation was conducted using a dataset comprised of 1,281 questionnaires completed by students at the University of the Pacific, Arthur A. Dugoni School of Dentistry in San Francisco. The sampling plan is shown in Table 1Go. Three hundred ninety-nine surveys (of a potential 424) were collected from students in the Classes of 2005, 2006, and 2007 during the first week of school prior to any clinical or other dental school experience (Year 0). Three hundred seventy-eight surveys (of a potential 417) were collected from the Classes of 2004 through 2006 at the beginning of their second year (Year 1). This followed the first year of school, when students are in the clinical setting for half a day each week, performing primarily noninvasive procedures on each other. Year 2 surveys were completed at the beginning of the final clinical year, following twelve months of patient treatment for up to five half-days each week. Three hundred seventy-one (of a potential 415) students from the Classes of 2003, 2004, and 2005 completed these surveys. A group of 133 (of a potential 139) students from the Class of 2005 completed surveys during the final week of school. This group represented Year 3, and these students had completed their final clinical year, working forty weeks, up to ten half-days each week. A fuller description of the study design and analysis of types of injuries feared and experienced was published in the October 2006 issue of this journal.28


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  		Table 1. Sampling plan and surveys received for study of dental clinic occupational injuries
 
The same survey was used on all occasions and included demographic self-reports of incidence of injury and personal estimates of likelihood and fear of various types of exposures. Demographic variables included sex, age, whether one had worked in a dental office prior to dental school (and if so for how long and in what capacity), and whether the respondent had a relative who was a dental health care professional. Self-reported incidences were measured by a single question: "Have you had a blood/body fluid exposure during the previous year?" If a positive response was indicated, students were asked to identify the type (source) of injury. Students were asked to indicate their perceived likelihood of injuries from the following sources: 1) dental bur, 2) syringe needle, 3) scalpel, 4) endodontics file, 5) hand instrument, and 6) suture needle. Finally, respondents were asked to indicate their fearfulness of experiencing injuries to 1) themselves, 2) patient, 3) instructor, 4) staff member, 5) non-patient classmate, 6) adult patient, 7) child patient, and 8) special needs patient. All surveys were anonymous.

Perceived likelihood of injury from various sources was coded in the conventional fashion (1=not likely, 2=somewhat likely, and 3=very likely). In addition to average scores for each potential source of injury, an overall measure of likelihood for each respondent was calculated by taking the average of estimates across all potential sources. Fear measures were quantified in a similar fashion (1=not fearful, 2=somewhat fearful, and 3=very fearful). An average fear variable was created for each respondent comprised of the average of fear ratings across the various potential sources. The importance measure (exposure during the previous year) was expressed as a dichotomous variable (exposure/no exposure) for each potential source (using the same set of sources rated in the question regarding perceived likelihood). A summary variable for previous experience was created by coding "1" if the student reported any incident and "0" if no incident of any type was self-reported. Multiplicative expected value (importance x likelihood) variables were created for each respondent by multiplying self-reported incidence by perceived likelihood for each potential source and for the overall or average ratings.

A test was performed to verify the assumptions underlying the use of the average value variables created by averaging across reports of various types and sources of occupational exposure. Variance, unrotated, principal components analyses were performed. In all three cases, a general factor emerged first that accounted for more than 50 percent of the variance, thus confirming the use of average or overall measures. Statistically significant secondary factors were also found. Fear of injuring oneself stands out as distinct from fears of injuring other parties. Previous injury and likelihood of injury from needlesticks exist as distinct factors, independent of the overall measure of other injuries or estimates of likelihood of injury.

Separate causal models predicting fear of injury were constructed for each of the four groups of students (Years 0 through 3). Separate models were constructed to predict average fear (to all injured parties) and to predict self-injury—creating a total of eight models. Potential predictor variables included the following: 1) personal factors—sex, age, dental relative, previous dental office experience, and length of previous dental office experience; 2) importance—previous injury from each of the six coded sources and from any source (the overall measure); and 3) likelihood—estimate of potential for injury from any of the six coded sources and from any source (the average likelihood of injury).

The matrix of cross-correlations for all nineteen variables was examined for each model, but only paths with partial correlations whose statistical significance was p<.05 were retained. Point-biseriel correlation coefficients were used to estimate strength of association between dichotomous and continuous variables. Pearson correlations were used where appropriate. The customary procedure for calculating partial correlations was used to correct paths for common variance.


   Results
Top
 Abstract
 Methods
 Results
Discussion
 References
 
The eight causal models predicting fear of occupational exposure in the dental clinic are shown in Figure 1Go. There are two models for each year—from dental school matriculation (Year 0) through graduation from the three-year dental program (Year 3). There is one model each for average or general fear of injury sustained by any individual and one for fear of injuring oneself. Only statistically significant paths are displayed.


Figure 1
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  		Figure 1. Eight causal models predicting fear of occupational exposure in the dental clinic

 
The first hypothesis—that the combination of importance and estimated likelihood will predict fear of injury (Avg Fear and Self Fear)—is confirmed, but with substantial reservations. Previous personal exposure to needlesticks (Needle Inc) is the strongest index of importance. Exposure to any previous incident (Avg LK) is marginally significant in the Year 3 model, but needlestick exposure is used to represent the importance variable because of its greater salience. The Year 3 segment of the model accounts for 22 percent of the variance in general fear and 25 percent of the variance in the personal fear ratings. This group of predictive factors is independent of the personal or demographic factors. But the effect only emerges in the final year of the dental educational program. Further, the hypothesized multiplicative relationship between importance and likelihood (Needle Inc x Ave LK, r = –.186 and –.141) is negative rather than positive.

Personal factors are generally predictive of fear ratings, especially in the early years of the educational program (Sex, Age, Dent Rel, Prev Exp). Sex and age are useful personal predictors. Younger students are more fearful during the first year of dental school, and female students are significantly more fearful throughout. Having a dental relative, having worked previously in a dental office, and months of experience in dental offices prior to dental school were slightly related to lower fear during the early years of dental education. Thus, the second hypotheses were confirmed.

The third hypothesis can be evaluated most directly by considering the proportion of variance in fear estimates explained by various sources (R2). The models for general fear and fear of self-injury are similar in each year. Considering general fear, personal factors account for 13 percent of the variance in Year 0, 17 percent in Year 1, 14 percent in Year 2, and 2 percent in Year 3. By contrast, the expected value model (importance x likelihood) explains 4 percent of the Year 0 variance, followed by 7 percent in Year 1, 10 percent in Year 2, and 25 percent in Year 3. Hence, fear of injury becomes increasingly a function of knowledge gained in clinical contexts and decreasingly a function of individual personal factors.

Absence of variables from the models in Figure 1Go signifies that they failed to enter the causal models at conventional levels of statistical significance.


   Discussion
Top
 Abstract
 Methods
 Results
 Discussion
References
 
Self-reports of dental students’ personal characteristics, previous exposure to clinical injuries, and estimates of the likelihood of various events collected and analyzed in this study provide preliminary materials to begin building a theory of fear of clinical injuries in the dental clinic context. Personal characteristics are used to a certain extent during the first years of dental school as a foundation for impressions of general fear and fear of self-injury. It is reasonable to expect that students would draw on such sources in the absence of direct clinical experience of their own. Personal characteristics such as sex and age appear to influence fear perceptions through estimates of likelihood of injuries during the middle years of dental education. Perhaps this represents a transition or a filtering of clinical experience through previous convictions or personal values.

From the beginning and throughout dental education, female students in this study expressed greater fear of occupational exposure. This remains true in the final year when sex makes an independent contribution to fear estimates, unaffected by being passed through actual experience of clinical injuries or estimates of their likelihood. Chamberlain et al., in a study of personality traits associated with clinical performance among Canadian dental students, conclude that "female students were more anxious, self-conscious, and vulnerable than their male colleagues" (p. 1234).29 Similar findings have been reported by Younai et al.30 and Kuthy et al.31

The expected value of injury grows in predictive strength as students continue in their education. The product of personal estimates of likelihood of injury multiplied by personal estimates of the importance of such an injury, should it occur, becomes more strongly associated with reported fear of occupational injury. This is reasonable based on their increased personal experience with these two variables. By graduation, expected value accounts for one-quarter of the variation among students’ reports of fear of clinical injury.

What is unexpected is the negative predictive value of the multiplicative (likelihood x importance) variable. The literature predicts a significant positive predictive relationship. The key to this finding might be found in work by Higgins and Spiegel.32 They propose that individuals favor either a promotion orientation or a preventive orientation: the former value achieving success; the latter value avoiding failure. A promotion orientation in clinic would be expected to lead to preoccupation with accomplishing the maximum of treatment, even if there were a few cases of less than optimal results. Higgins and Spiegel theorize that such individuals, or individuals induced to work under such conditions, calculate expected value in the customary fashion. Those with a preventive orientation would count a good day in the clinic one in which everything was under control and no chances of a surprise were allowed, even though little patient care was actually rendered. The "first, do no harm" perspective is associated with a negative combination of likelihood and importance when calculating expected value. Therefore, "the prevention-focused people—who pursue their goals using a vigilant strategy that involves ensuring correct rejections and safety—view these goals as necessities when success is highly valued. Prevention-focused people are thus expected to demonstrate a negative expectancy x value multiplicative effect on goal attainment such that the effect of expectancy on commitment (while continuing to have an importance) becomes smaller as the value of goal attainment increases" (p. 173).32

Katz-Navon et al.33 describe a curvilinear relationship regarding hospital safety. A moderate level of safety procedures has the greatest positive effect on reducing errors: both low and high procedure detail are associated with higher error rates.

This research is similar in conception and findings to work done on dental students’ attitudes towards treating patients who are HIV-positive. Decreased fear of treating HIV-positive patients has been found to be associated with greater previous experience and contact,31,34,35 age (in a curvilinear fashion),31 sex (females more fearful),31,35,36 and familiarity with the condition.36 All of these studies, however, were cross-sectional in design and do not support conclusions regarding the dynamics of the emerging fear construct during professional education.

A cautionary note is appropriate regarding the depth of analysis on a dataset that was not designed for the use that has been made of it. If better measures of expected value, especially the importance variable, had been available, it is likely that models could have been developed that would have greater explanatory power. It is further possible that different or additional personal variables would have been more predictive. It is certainly true that situational factors were excluded entirely because of the existing dataset, and both their direct contribution and the potential of their interaction with personal and expected value factors as predictors of fear of clinical injury should be investigated. In the end, it is felt that the introduction of even a sketchy model of the dynamics of fear of clinical injury will be valuable in stimulating further development of needed theory.


   Footnotes
 
Dr. Chambers is Associate Dean for Academic Affairs and Scholarship; Dr. Nadershahi is Chair, Department of Dental Practice and Community Services; and Dr. Chi is Director, Stockton AEGD Clinic—all at the University of the Pacific, Arthur A. Dugoni School of Dentistry. Direct correspondence to Dr. David Chambers, University of the Pacific, Arthur A. Dugoni School of Dentistry, 2155 Webster Street, San Francisco, CA 94115; 415-929-6438; dchambers{at}pacific.edu. No reprints will be available.


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