RESEARCH

 

Perceived stress among dental students at the University of the Western Cape

 

 

VJ Wilson^I; CA Rayner^II; NA Gordon^III; AB Shaikh^IV; K Crombie^V; S Yasin-Harnekar^VI

^IBChD, MChD. Department of Restorative Dentistry, Faculty of Dentistry, University of the Western Cape
^IIDipl OH, BA (Hons), MA. Department of Oral Health, Faculty of Dentistry, University of the Western Cape
^IIIDipl OH, BA, MPH, Dipl Adult Education. Department of Oral Health, Faculty of Dentistry, University of the Western Cape
^IVBChD, MSc (Dent), MChD. Department of Orthodontics, Faculty of Dentistry, University of the Western Cape
^VNationa Dipl Diagnostic Radiography, Higher Educ Dipl, MSc (Dent). Department of Radiology, Faculty of Dentistry, University of the Western Cape
^VIBChD, MSc (Dent), PDD (Orthodontics). Department of Paediatric Dentistry, Faculty of Dentistry, University of the Western Cape

Correspondence

 

 

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ABSTRACT

INTRODUCTION: A high prevalence of stress among dental students has been reported.
AIM: To determine perceived stress among dental students at the University of the Western Cape.
METHOD: A self-administered questionnaire to students (n=411) was used to collect data. Variables measured included demographic characteristics of students and their perceived stress in the dental environment using the Dental Environment Stress (DES) survey and the Maslach Burnout Inventory (MBI).
RESULTS: The response rate was 78%. Respondents were in the 18 to 21 age category; mostly female (n=207); multilingual, with 63% having English as their home language. Huge problems identified from the DES were lack of time for relaxation, inadequate breaks during the day, fear of failing a year or module, work load, inconsistency between clinical supervisors and patients being late for appointments. The MBI found high EE (28.91), low DP (7.13) and high PA (30.06) scores. Fourth year students experienced the highest degree of stress on the DES and MBI.
CONCLUSION: Stressors identified are consistent with international dental literature. Levels of stress increased over the academic years and peaked in the fourth year. Stressors experienced may impact student academic and future professional development, motivating a need for intervention at Faculty level.

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INTRODUCTION

Stress among students has been well documented in the international arena with a high prevalence of stress

identified among dental students.^1-14 Some of the stressors identified in these studies include the learning environment, fear of failure, heavy workload, difficulties in dealing with patients and with transitions in curricula and challenging relationships with academic staff. Differences in student experiences of stress were related to geographical and educational background, culture and ethnicity. There are sparse published reports on stress among dental students in the South African context.^14-16

It has been shown that students' perceived stress increases over their successive academic years with detrimental effects on their performance and health.^2,8,13,17 A potential longterm consequence of occupational stress is professional burnout.⁸ A significant aspect of the burnout syndrome is "increased feelings of becoming emotionally exhausted", with other characteristics being "the development of a negative cynical attitude towards one's clients" and "a tendency to evaluate oneself and one's accomplishments negatively."¹⁸ A potential for burnout among dental students has been reported.^8,12,19

In contrast to international studies, Hendricks et al.¹⁴found that dental students at the University of the Western Cape (UWC), South Africa ranked non-academic stressors higher than academic stressors. The investigators suggested that their questionnaire may not have been "sensitive enough to identify the determinants of stress within the Apartheid educational structures". The current post-Apartheid cohort of dental students at UWC constitutes a diverse group. Therefore, it would be useful to explore their perceived stressors within a global context.

 

AIM AND OBJECTIVES

The aim of this study was to determine perceived stressors among dental students at the UWC. The objectives were to determine the demographic characteristics, stres-sors experienced, effects of stressors on students and whether major stressors varied across academic years.

 

METHODS

A cross-sectional, descriptive study of dental students (N=411) was conducted in 2012. Data was collected by means of a self-administered questionnaire using a quantitative approach. The questionnaire was distributed to students in their classrooms and completed questionnaires were collected by the researchers.

The three parameters measured were: 1) demographic characteristics, 2) burnout, using the Maslach Burnout Inventory (MBI) and 3) sources of stress, using a modified Dental Environment Survey (DES). The MBI²⁰ and DES⁴ questionnaires were adapted appropriately for the local and academic environment.

The MBI consisted of 22 statements each scored on a seven point Likert scale ranging from 0 (never) to 6 (every day) which is divided into three scales namely emotional exhaustion (EE), personal accomplishment (PA) and depersonalisation (DP). Mean scores were calculated for the three subscales and these subscales were then categorised as low, average or high. High scores on EE (> 27) and DP (> 10) and low scores on PA (> 40) are indicative for burnout in the occupational subgroup of medical workers (MBI-Human Services Survey (MBI HSS).²¹

The DES consisted of 79 statements enquiring about: the study environment (n=27), theoretical (n=14), preclinical (n=13) and clinical aspects (n=25) of the educational environment. Students were required to indicate whether each statement posed "no problem", "a small problem" or "a huge problem" in terms of their studies. Preclinical and clinical components were completed as applicable to the year of study.

A pilot study was conducted with 10 students and appropriate minor modifications made to the questionnaire. Data was entered and analysed into IBM SPSS version 21. Descriptive statistics included frequency distributions; means and standard deviations. The Wilcoxon Rank sum test or the Kruskal-Wallis test (when there were more than two groups) was used to compare year groups.

Ethical approval was obtained from the University Research and Ethics committee. Informed consent was obtained from the participants. This project was funded by the University of the Western Cape.

 

RESULTS

Demographics of respondents

The response rate was 78% (n= 318). Respondents were primarily in the 18 to 21 age category; mostly female (n=207); multilingual with 63% having English, the medium of education of the University, as their home language.

Respondents were primarily from the Western Cape Province (51%), Kwa-Zulu Natal (18.9%) and the Eastern Cape (13.2%). Most (77%) had attended public schooling. A third (33%) lived with family while the remainder lived in University residence or on their own.

Student response to the DES questionnaire

The five most frequent stressors in each category of the DES were ranked (Table 1). The theoretical component of the DES scored highest overall (mean = 47.98%) in terms of huge problems compared with the other categories.

There was considerable variation across the year groups in terms of stressors experienced. Fourth year students scored highest in all components except in the clinical component where there was a marginal difference between fourth and fifth year groups.

Additional stressors reported as huge problems were: lack of effective lectures/teaching, by first years (49%); lack of self-motivation to study, by second (39.2%) and fourth years (47.9%); scheduling of continuous assessments, by third years (46.1%); lack of student input into faculty decision making and lack of response by faculty administration to needs of students, by fourth and fifth years (40-50%). In the fourth and fifth years, additional stressors included clinical supervisor/assistant student ratio and inconsistent clinical feedback (ranging from 41 to 51%) (Table 2).

Student response to Maslach Burnout Inventory (MBI)

The means for statements in each subscale of the MBI are ranked in descending order (Table 3). The overall mean values (mean, SD) for EE, PA and DP were: 28.91 (10.28), 30.06 (7.51) and 7.13(6.03) respectively. There were significant differences across the year groups for subscales EE and DP. The fourth year group was significantly different compared with the first, second and third years for EE (p<0.001) and DP (p<0.0001). Students living on their own differed from those living with parents or at university residence in the subscale DP (p<0.001). (Table 3).

 

 

MBI Subscales per year group

High scores on EE (> 27) and DP (> 10) and low scores on PA (> 40)) are indicative for burn-out (MBI-Human Services Survey (MBI HSS).²¹

The percentage of students in each sub-scale per year group varied (Table 4). Although EE, the key dimension of burnout, is rated as high for all years except the second year group, none of the year groups met the criteria considered as actually experiencing burnout.²¹ However, the fourth year group appeared to be at greater risk for burnout compared with the other groups.

 

DISCUSSION

This study, based on the modified DES questionnaire of Al-Saleh et al.,⁴ reported similar findings. However, the overall "dental environment and theory" components in this study were scored as more stressful than the "clinical" components.

Within the dental environment component, lack of time for relaxation was scored highest, as it is also in studies reported in the international literature.^4,11,22,23 Non-academic stressors (a shortage of extra-curricular time and inadequate time for social activities) were also reported as the highest stressor among a UWC study population in 1994.¹⁴ Of interest is that fourth years scored this item highest whilst it was the third years who reported that opinion in other studies.^11,23 Four of the five top stressors identified as "personal or administrative problems" by Al-Saleh et al.⁴were also reported in this study. These results suggest that are stressors within the dental environment may be experienced universally. However, in modifying the DES questionnaire, one has to take cognisance of socio-cultural differences. A top stressor: "responsibility of having children", identified by Al-Saleh et al.⁴ was excluded in the current study due to the profile of UWC students.

Tables 1 and 2 show that students across the year groups experience stressors differently. This could be attributed to the respective stages reached in the curriculum, the demands of the curricula and the maturity of students in coping with academic and personal demands.²⁴

Overall the stressors in the dental environment, theory and preclinical components, were highest in fourth year. Sanders and Lushington¹¹ found that among Australian dental students stress increased over time and peaked in the fourth year of study. The five year curriculum at UWC is structured such that first, second and third year students have mostly preclinical and didactic teaching, with a limited experience of the treatment of patients, which commences in the third year. In the fourth and fifth years all modules have clinical components.

Perceived stressors changed from the preclinical to clinical components depending on the year of study.^5,25

Patients being late for appointments posed a huge problem, leading possibly to an inability to catch up with clinical work and failure to complete clinical requirements on time. It is the responsibility of students to find and book appropriate patients to satisfy their clinical requirements, This appears to be a major concern which can, however, be addressed by appropriate screening of patients and referral between departments in the Faculty.

The Maslach Burnout Inventory

The MBI showed that overall subscale scores do not place dental students at risk for burnout. However, the high EE scores for all, except second years, are a cause for concern. High EE scores in dental students have also been reported by Gorter et al. and Pöhlmann et al.^8,19A longitudinal study of European dental schools found the number of students that scored high in the EE dimension increased from 22% in their first year to 39% in their fifth year.⁸ The present study concurs with the literature which indicates that the prevalence of emotional exhaustion among dental students is of concern in view of EE being a key dimension of burnout.

Fourth year students appear to be at greatest risk as they meet two of the three criteria (high EE and high DP) indicative of burnout (Table 4). A high DP is characterised by emotional detachment from the needs of patients and peers. Pöhlmann et al.¹⁹suggest that high DP scores may reflect student insecurity in dealing with patients in an environment where treatment demands are high. In addition, a lack of social competence manifests in relationships on a personal and a professional level. During the clinical period, fourth and fifth years experienced emotional exhaustion (10%), a severe lack of accomplishment (17%) and high depersonalisation (28%).¹⁹ Emotional exhaustion was explained by factors such as lack of leisure time (30%), examination anxiety (10%) and the transition stress of entering the clinical phase of training (4%).¹⁹ Similarly, a lack of leisure time, worrying about physical health, fear of failing, and patients being late were identified as huge problems in the current study. Campos et al.,¹⁷using the MBI student survey (SS), identified burnout syndrome in 17% of dental students. The authors found a significant relationship between the prevalence of burnout syndrome and the student's academic performance, use of medication because of studies and thoughts of dropping their course. A lack of motivation to study was reported by 47.9% of fourth year students in the current study.

The fact that all groups scored high on PA, with scores ranging from 57%-70%, suggest that most UWC dental students evaluate themselves and their accomplishments positively, in spite of feelings of emotional exhaustion. A positive shift in EE, particularly in the first and third years may result in a ripple effect on the subsequent years. High levels of PA combined with low levels of EE and DP is indicative of 'engagement with work' which may be a goal to work towards for interventions.²¹

The nature of dentistry as a profession provides for multiple stressors for the future dentist in terms of the patient, staff, equipment and other factors. Gorter et al.²⁶found that dentists with a high risk for burnout also report health complaints to a greater extent than dentists with a low risk for burnout; dentists with a high burnout risk also report an unhealthier lifestyle than dentists with a low burnout risk. There is evidence to suggest that the concerns of clinical students echo those of qualified practitioners. Therefore, the results of this study should be seen and acted upon in the context of the education and training of future dentists.

 

CONCLUSION

This study found that dental students at UWC experience stress to an extent similar to that reported in studies appearing in the international dental literature. The level of stress increased over the academic years and peaked in the fourth year. These stressors may impact student academic performance and future professional development, motivating a need for intervention at a Faculty level.

 

ACRONYMS

DES: Dental Environment Stress

DP: depersonalisation

EE: Emotional Exhaustion

MBI: Maslach Burnout Inventory

HSS: Human Services Survey

PA: Personal Accomplishment

 

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Correspondence:
V J Wilson
Private Bag X1, Tygerberg 7705, South Africa.
Tel: 021 937 3077; 021 370 4415 Fax: 021 9312287
E-mail: vwilson@uwc.ac.za