Canadian dental students' perceptions of stress

Professional Issues Canadian Dental Students’ Perceptions of Stress Contact Author Vanessa Muirhead, BSc, BDS, MSc; David Locker, BDS, PhD Dr. Muirhead Email: vanessa. [email protected] ABSTRACT In this paper, we report the results of a survey on dental student stress carried out in April 2005. A questionnaire was used to collect data from 171 students (62% response rate). Identified stressors were academic, clinic-related, social and financial. “Examination and grades” produced the most academic stress, and inconsistent feedback from instructors created the most clinic-related stress. Students found that having a dual role — wife or husband and dental student — was the most burdensome social stressor. Approximately 60% of students reported marital problems and stress associated with “relations with members of the opposite sex.” Survey results showed that students who expected a high graduating debt had higher total and academic stress scores. Total stress was not related to age, gender or marital status. Students living with parents during term time had significantly higher total stress scores than students living in other arrangements. Students residing with parents also had significantly higher debts on entry to dental school. Students with more predental education had (non-significantly) lower stress scores but also had higher student debts. Undergraduate subject major (biological science or non-science) had no bearing on reported stress. This study highlights the negative effects of student debt, the necessity for staff training and the need for further studies exploring relations among stress, psychological wellbeing and academic performance. For citation purposes, the electronic version is the definitive version of this article: www.cda-adc.ca/jcda/vol-73/issue-4/323.html D entistry has long been viewed as a highstress profession,1,2 and dental school is often where stress begins. In numerous studies carried out in United Kingdom, United States and Australian dental schools, students reported elevated perceived stress. 3–7 The last Canadian survey of dental school stress was carried out 16 years ago.8 Stress is psychologically debilitating and can have a deleterious effect on academic performance. 5,6 The main areas causing stress in undergraduate dental students include academic and clinical work, interpersonal relations and living environment.9 Dental educators have an obligation to monitor this stress, take steps to alleviate avoidable stressors and ensure that the dental school curriculum provides students with lifelong stress management tools. Dental school tuition costs are a hotly debated issue in Canada, particularly since deregulation in 1998, the result of reduced provincial government spending.10 Deregulation gives universities the discretion to set their own tuition fees to balance the cost of running university dental clinics. Since 2000–2001, d�������������������������������������������� ental school tuition fees have increased by 53.6%11; in 2005, annual operating costs stood JCDA • www.cda-adc.ca/jcda ����� �� • May 2007, Vol. 73, No. 4 • 323 ––– Muirhead ––– at $9 million.12 Tuition fee increases undoubtedly affect student debt. I��������������������������������������������� n a 1996 study of 6 Canadian dental schools, McDermott and Fuglerud13 found a mean dental school entry debt of $2,013.89 and a mean expected graduating debt of $25,671.30. Given the increase in tuition, it is likely that the debts of starting and graduating dental students have multiplied over the past decade;��������������������� finances are now an additional and important source of student stress. Student finances can also influence term-time living arrangements. A University of Toronto commissioned student cost of living survey in 200314 found that living expenses incurred by a single student living with parents in Toronto and a single student living in an off-campus Toronto apartment were $3,396 and $5,288, respectively. Students with higher current and anticipated debts may opt to reside with parents to allay housing costs. Several studies have shown that students living with their parents have lower stress levels than those residing in student residences or with other students.15,16 Therefore, although finances may have a direct effect on dental student stress, with high debt associated with higher stress levels, they may have an indirect moderating effect on stress through the relation between student finances and student living arrangements. The objectives of this study were to identify stressors reported by undergraduate dental students and to assess the impact of student debt, living arrangements, predental education and sociodemographics (age, gender, marital status and living arrangement) on stress. Materials and Methods In March and April 2005, all 275 undergraduate dental students enrolled at a Canadian dental school were asked to complete an anonymous questionnaire, which was distributed at the end of whole class lectures for each of the academic years. Separate questionnaires were used for preclinical (first and second year) and clinical (third and fourth year) dental students to take into account the limited exposure of the former to patient care.14 Both questionnaires included measures of dental school related stress, family commitments, student finances, predental education and social support measures. Questions on dental school stress were taken from the Dental Environment Scale (DES)3,15 and a United States study of predental education4 to produce a 36-item list divided into 3 categories: academic stressors, clinic-related stressors and social stressors. The options and response codes for each item were: 1, “not stressful”; 2, “slightly stressful”; 3, “moderately stressful”; and 4, “very stressful.” Total scores and scores for each category were obtained by summing the response codes in those categories. Finance questions were derived from McDermott and Fuglerud’s13 Canadian study of dental student debt. Demographic questions were included (age, gender, parity and marital status) to adjust for 323a potential confounders. The study was approved by the Health Sciences Committee of the University’s Research Ethics Office and granted scientific merit by the faculty’s scientific review committee. Data were analyzed using SPSS version 12 (SPSS Inc., Chicago, Ill.). Individual DES items were analyzed along with academic, clinic-related and social stress scores and a total stress score. Academic stress scores and total stress scores were adjusted to control for the different number of items in the preclinical and clinical student questionnaires yielding item-adjusted academic and total stress scores. This allowed for comparison of stress across academic years. Data analyses included frequency distributions, Student’s t tests, Kruskal-Wallis nonparametric tests, 1-way ANOVA and Pearson’s correlations. Statistical significance was set at p < 0.05. Results Among the students surveyed, 171 completed and returned their questionnaires, representing a 62% response rate. Of the respondents, 58% were female. The mean age of respondents was 24.6 years (standard deviation [SD] = 2.1 years; range 21–32 years). Academic and Clinic-Related Stressors Table 1 shows the mean scores for the DES items in decreasing order. “Examination and grades” produced the most academic stress for all students irrespective of academic year. “Lack of time for relaxation” also ranked among the top 5 stressors for students in all academic years. “Ensuring I get good marks,” “Lack of time to do assigned coursework,” “Completing course requirements” and “The amount of assigned class work” were also prominent sources of stress. The highest-ranking clinic-related DES stress item was “Inconsistency of feedback on your work between different instructors.” Approximately 73% of students reported that this item was “moderately” or “very stressful.” “Receiving criticism about work” was also a salient clinic-related stressor. Social Stressors Social stress items were among the lowest ranked. The highest scoring social stressor was “Having a dual role of wife/mother or husband/father and dental student.” Twenty-one students (12.3%) expressed marital problems and 80 students (46.8%) reported stress associated with “Relations with members of the opposite sex.” Financial Stressors The mean financial debt of students entering dental school was $10,970.80 (SD = $19,314.20; range $0–150,000) and the mean expected debt on graduation was $97,185.30 (SD = $58,846.00; range $0–270,000). Most students felt that their financial situation was “moderately stressful” (32.4%) or “very stressful” (23%). JCDA • www.cda-adc.ca/jcda • May 2007, Vol. 73, No. 4 • ––– Student Perception of Stress ––– Table 1 Mean Dental Environment Scale stressors listed in descending order Stressor Mean score (SD) 1. Examination and grades 3.43 (0.69) 2. Lack of time for relaxation 3.14 (0.92) 3. Ensuring I get good marks 3.11 (0.87) 4. Inconsistency of feedback on your work between different instructors 3.00 (0.92) 5. Lack of time to do assigned coursework 2.89 (0.97) 6. 6. Fear of being unable to catch up if I get behind Completing course requirements 2.87 (0.98) 2.87 (1.00) 7. Amount of assigned classwork 2.84 (0.87) 8. Receiving criticism about work 2.74 (0.88) 9. Lack of confidence in self to be successful dental student 2.72 (1.04) 10. Patients being late or not showing for their appointments 2.61 (1.23) 11. Financial problems 2.62 (1.01) 12. Lack of confidence in self to be successful dentist 2.60 (1.06) 13. 13. Difficulty in learning clinical procedures Rules and regulations of the school 2.58 (0.86) 2.58 (0.98) 14. 14. Responsibilities for comprehensive patient care Fear of failing course 2.56 (0.94) 2.56 (1.13) 15. 15. Difficulty learning manual skills for laboratory work Difficulty of classwork 2.51 (0.83) 2.51 (0.86) 16. Lack of input into decision-making processes 2.49 (0.85) 17. 17. Difficulty in learning manual skills required for clinical work Course more difficult than I imagined 2.46 (0.88) 2.46 (0.97) 18. Personal physical health 2.38 (0.96) 19. Atmosphere created by being on a clinical course 2.26 (0.92) 20. Students breaking the rules in dental school 2.07 (0.99) 21. Insecurity concerning professional future 1.96 (0.87) 22. Working on patients with dirty mouths 1.90 (0.88) 23. Having a dual role of wife/mother or husband/father and dental student 1.87 (1.32) 24. Lack of cooperation by patients in their home care 1.85 (0.91) 25. Forced postponement of marriage or engagement 1.79 (0.89) 26. Relations with members of the opposite sex 1.73 (0.90) 27. Trying to work whilst family in the house 1.65 (0.87) 28. Lack of atmosphere in living quarters 1.59 (0.77) 29. Necessity to postpone having children 1.49 (0.82) 30. Marital problems 1.43 (0.82) 31. Discrimination due to ethnic group 1.38 (0.67) SD = standard deviation. Demographic Factors and Stress Age was not related to academic (p = 0.10) or adjusted total stress (p = 0.67) scores. However, older students did report higher social stress scores than younger students (p = 0.008). Female students were more affected by criticism about their work than their male counterparts (p = 0.02). Female students also scored higher on “lack of confidence” stress items (p = 0.004) and were more concerned about keeping up with the course load (p = 0.01). Despite differences in individual stress items, there were no significant differences between male and female mean adjusted academic, clinic-related, social stress and adjusted total stress scores. JCDA • www.cda-adc.ca/jcda ����� �� • May 2007, Vol. 73, No. 4 • 323b ––– Muirhead ––– Table 2 Stress scores according to marital status Marital status Mean adjusted academic stress score (SD) Mean clinic-related stress score (SD) Mean social stress score (SD)a Mean adjusted total stress score (SD) Single 67.25 (15.1) 25.46 (4.9) 3.93 (2.4) 124.82 (26.4) Married 62.20 (15.6) 23.11 (5.1) 6.00 (2.3) 123.32 (28.5) Student in a “longterm relationship” 66.89 (13.8) 25.00 (4.8) 4.44 (2.9) 126.70 (26.5) 0.33 0.44 0.006 0.87 p valueb SD = standard deviation. a According to Bonferroni post-hoc test, social stress scores for married students were significantly higher than those of single students (p = 0.005). b 1-way ANOVA. Table 3 Stress scores by academic year Academic year Mean adjusted academic stress score (SD)a Mean clinic-related stress score (SD) Mean social stress score (SD) Mean adjusted total stress score (SD)b 1st 65.26 (16.6) – 4.11 (2.5) 120.20 (30.2) 2nd 72.64 (14.5) – 4.02 (2.8) 131.85 (27.3) 3rd 69.94 (11.9) 27.96 (3.8) 4.67 (3.2) 135.24 (20.8) 4th 54.45 (14.8) 22.98 (4.5) 4.7 (2.1) 114.38 (19.0) < 0.001 < 0.001 0.86 0.001 p value SD = standard deviation. a According to Bonferroni post-hoc test, second- and third-year students experienced more academic stress than fourth-year students (p < 0.001 and p = 0.005, respectively). b According to Bonferroni post-hoc test, second- and third-year students experienced more total stress than fourth-year students (p < 0.006 and p = 0.006, respectively). Approximately 60% of students were single and 11.1% were married; the remaining students (29.8%) indicated that they were in a “long-term relationship.” Table 2 shows the mean stress scores for each marital-status category. Married students had the lowest total stress scores and students in non-marital long-term relationships had the highest stress scores, although these differences were not statistically significant (p = 0.87). As expected, married students reported significantly higher social stress scores than single students (p = 0.005). Only 4 dental students (2.3%) had children. Stress and Academic Year Table 3 shows the mean stress scores according to academic year with item adjustments made for academic and total stress scores. Third-year students had the highest mean adjusted total stress score. Third-year students also had higher clinic-related stress scores than fourth-year students (p < 0.001). There was no statistical difference between academic years in terms of school-entry debt (p = 0.29), expected debt on graduation (p = 0.09) or social stress scores (p = 0.51). Stress and Predental Education Most students (82.3%) majored in biology or a health science. Approximately 13% of students majored in a 323c non-life-sciences subject, such as music, mathematics or commerce. Approximately 5% of students studied psychology at the undergraduate level. No significant differences in stress were found between students who studied biology/health sciences and non-life-sciences subjects (Table 4). Students completed a mean of 3.78 years (SD = 0.80 years) of predental university education. Students who had completed more years of predental education had lower mean adjusted academic, clinicrelated stress and adjusted total stress scores than those with less predental education, but the difference was not significant. As expected, students with more years of predental education had higher dental school entry debt (p = 0.006) and expected graduating debt (p = 0.005) than those with fewer years. Stress and Student Debt Students with higher expected graduating debts had higher adjusted academic stress (p = 0.008) and adjusted total stress scores (p = 0.02). Students with higher student debt on entering dental school also had higher social stress scores (p = 0.02). Stress and Living Arrangement Among the respondents, 31% resided with their parents during term time, 30.4% shared accommodation JCDA • www.cda-adc.ca/jcda • May 2007, Vol. 73, No. 4 • ––– Student Perception of Stress ––– Table 4 Stress scores according to predental education university major Undergraduate major Mean clinic-related stress score (SD) Mean social stress score (SD) Mean adjusted total stress score (SD) Biology/health science 66.41 (14.4) 24.88 (4.8) 4.32 (2.6) 124.80 (25.5) Non-life science 68.49 (16.7) 25.43 (5.7) 4.22 (2.8) 126.36 (31.5) 0.49 0.82 0.86 0.77 p value a Mean adjusted academic stress score (SD) a Student’s t test. Table 5 Stress scores according to term-time living arrangement Living arrangement Parents Mean adjusted academic stress score (SD) Mean clinic-related stress score (SD) Mean social stress score (SD)a Mean adjusted total stress score (SD) 72.37 (14.6) 26.55 (3.8) 4.02 (2.5) Family member 60.63 (10.7) 23.00 (3.0) 5.83 (2.6) 121.02 (18.5) Partner/spouse 64.68 (15.9) 23.63 (5.5) 5.70 (2.5) 125.43 (29.4) Roommate 64.92 (13.9) 24.04 (4.7) 4.44 (2.9) 121.90 (26.2) Alone 64.20 (14.3) 25.92 (6.4) 3.35 (1.9) 118.05 (26.5) 0.02 0.31 0.007 0.06 p valueb 133.71 (24.6) SD = standard deviation. a According to Bonferroni post-hoc test for mean social stress, roommates experienced more stress than those living alone (p = 0.008). b 1-way ANOVA. with roommates, 21.1% lived alone, 14% lived with their partner or spouse and 3.5% resided with other family members. Table 5 shows the mean stress scores according to term-time abode. The lowest mean adjusted total stress score was found among students living alone and the highest among those residing with their parents. Students living with parents also had the highest mean adjusted academic stress score and the highest dental school entry debt. Students residing with roommates had significantly higher social stress scores than students living alone (p = 0.008). Student Finances and Living Arrangement Students residing in the parental home had the highest dental school entry debt (mean = $14,339.62, SD = $25,614.52) whereas students living alone had the lowest entry debt (mean = $6,666.67, SD = $10,370.29). Students residing with roommates reported the highest expected graduating debt (mean = $105,750.00, SD = $56 869.95). Discussion This most recent study of dental student stress in Canada raises several key issues; however, these results �������� cannot be extrapolated to other Canadian dental schools. A further limitation of this study is the suboptimal response rate of 62% and the fact that the sample was marginally overrepresented by female students. Previous studies have found that female dental students report higher levels of stress than male dental students.7,17 Nevertheless, the results are consistent with international studies rating examinations and grades as the highest academic stressor. However, the mean stress score for “Examination and grades” in this study (3.43, SD = 0.89) was higher than the mean scores reported in previous studies.18,19 Third-year students had the highest total stress scores. This confirms anecdotal evidence that the third year (with the onset of patient care) may be a critical period in dental school training, and students may require additional academic support at this time. The lack of overall gender differences may be a reflection of the growing number of female students entering the dental��������� program� (35 male and 29 female entrants in 2002) and that 53.6% of all Doctor of Dental Surgery students in the faculty are female. Inconsistent feedback from instructors was cited as the most significant clinic-related stressor. The use of part-time clinicians (with different clinical backgrounds) as demonstrators will invariably result in inconsistencies. 20 The school introduced a Faculty Development/ Calibration Educational Series in June 2003 in recognition of this problem. However, the extent of student JCDA • www.cda-adc.ca/jcda ����� �� • May 2007, Vol. 73, No. 4 • 323d ––– Muirhead ––– reports on conflicting teaching highlights the need for further consensus training for dental instructors. This is the first study to date to explore the relation between dental student stress and student finances; student debt was associated with high academic, social and total stress scores. Findings also������������������������������ emphasize�������������������� the high levels of debt incurred during dental training. The mean dental school entry debt of $10,970.80 ����������������������������������� and expected graduating debt of $97,185.30 represent an eightfold and fourfold increase, respectively, over reported 1993–1994 levels.13 The increase in graduating student debt can be partly explained by the increase in dental school tuition fee since deregulation. Dentistry remains the most costly Canadian professional program,11 and the Canadian Dental Association continues to petition the federal government to increase dental school funding to offset the need to increase student fees further.21 The finding that students living with their parents had higher stress scores than those in other living arrangements contrasts with previous studies.15 However, previous studies did not consider student debt as a potential stressor. In this study, students living with their parents had significantly higher dental school entry debts. This supports the theory that students with higher debts tend to reside with parents to avoid the cost of housing. Dental school entry debt could explain the elevated stress levels reported by students living at home. However, the relation between high stress and living with parents remained significant even after adjusting for dental school entry and expected graduating debts, suggesting that other factors may be involved, such as caring for elderly parents or dealing with family illness or separation or divorce. The adverse effects of student stress on psychological well-being are well documented, 22 and w������������������ e did not explore this area in our study. Further �������������������������������� research should incorporate standardized measures of psychological disturbance (i.e., the Brief Symptom Inventory or General Health Questionnaire) for a more detailed assessment of psychological well-being and its relation to dental school stress. Conclusion This study identifies debt as a dental student stressor and ��������������������������������������������������� emphasizes the need to address this issue. It also highlights the necessity for faculty instructor training and����������������������������������������������������� the need to provide extra academic support to thirdyear students to alleviate dental school stress. Further �������� studies should include assessing relations among stress, academic performance and psychological well-being. a THE AUTHORS Dr. Muirhead is a PhD student at the University of Toronto and a CIHR Strategic Training Fellow in Cell Signaling and Mucosal Inflammation and Pain (STP-53877). 323e Dr. Locker is a professor in community dentistry and associate dean of graduate and postgraduate studies at the faculty of dentistry, University of Toronto, and the director of the Community Dental Health Services Research Unit. Correspondence to: Dr. Vanessa Muirhead, Faculty of Dentistry, University of Toronto, 124 Edward St., Toronto, ON M5G 1G6. The authors have no declared financial interests. This article has been peer reviewed. References 1. 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