Stress and Burnout Assessment Among Post Graduate Dental Students

Key Message :

Postgraduate dental program is a specialized course which can be quite challenging physically and mentally. Stress and burnout are detrimental to the learning process. So it is important to identify the domains of maximum stress and burnout and come up with efficient strategies to tackle it.

Introduction :

Dental education is a highly demanding and challenging course placing heavy demands on the mental resources of students making them vulnerable to high levels of stress. Stress describes external demands (physical and mental) on an individual's physical and psychological wellbeing.¹ Some dose of stress is beneficial and acts as a driving force for improved performance, but the persistence of long term stress can be debilitating.

Studies have shown that in comparison to the general population, dental students have been reported to experience increased levels of anxiety and depression at times approaching levels seen in general medical patients judged psychiatrically ill. ²A study conducted comparing chronic stress between medical and dental students concluded that chronic stress was more pronounced among dental students.³

Post graduate training in dental science is a complex educational experience. The residents of all specialties are expected to train clinically, complete research assignments and participate in teaching programme. Apart from this, long working hours, additional strain of financial issues, family obligations and future employment uncertainty add to substantial stress circumstances.⁴ As many studies show that stress and anxiety are predictors of academic and clinical performance it becomes all the more important to assess the stress levels.^5,6

This study aimed to evaluate the mental health of postgraduate students in a dental college in India specifically with respect to stress and burnout. This adds to the knowledge base from the findings from similar studies in other countries - Switzerland ⁷, United Kingdom ⁸, Spain⁹ and Greece¹⁰. We are not aware of any similar studies among postgraduate dental students in the Indian population.

Subjects and Methods :

All postgraduate dental students enrolled in the MDS program of a dental college in India in the year 2011-2013 comprised the target population and were requested to participate in the study ( n= 126) . The study sample included residents in six departments: Conservative dentistry and Endodontics, Orthodontics, Oral and Maxillofacial surgery, Pedodontics, Periodontics, Prosthodontics , Oral medicine and radiology and Oral pathology. The MDS program is a 36 month programme which when successfully completed leads to a Masters degree in Dental Surgery (MDS) specific to each department. Stress and burnout were separately evaluated. To measure perceived stress, a modified version of the Graduate Dental Environment Stress (GDES30) scale was used.¹¹ The participants were administered a questionnaire in English language. Postgraduate students were invited to complete the questionnaires with pen or pencil and completion required approximately 20 minutes. The questionnaire was anonymous and participation was voluntary.

The questionnaire basically consisted of 30 statements pertaining to various sources of stress perceived by the dental postgraduates on a daily basis. The statements were to be rated on a 4 point likert scale as 1: “not stressful at all”, 2: “somewhat stressful”,3 “quite stressful”,4: “very stressful” .

To quantify burnout the 22-item Maslach Burnout Inventory (MBI) (Maslach et al., 1996) was employed, as used in previous investigations to measure burnout.^7,8,11 This questionnaire is a modification of the list of stressor items listed by Garbee and colleagues in 1980.¹² The three dimensions of burnout that were measured by this 22 point scale were Emotional Exhaustion (EE; nine items), Depersonalization (DP; five items) and Personal Accomplishment (PA; eight items). Participants were asked to rank these items on a seven-point Likert scale where 0 means “never”, 1: “a few times a year”,2: “monthly” ,3: “a few times a month” ,4: “weekly” , 5: “a few times a week” and 6 : “everyday”. The subscale score thresholds that were recommended by the MBI manual were used to identify individuals who met the criteria of burnout “cases”– EE: > 26, DP: > 12, and PA: < 32. 13

Summary statistics (proportions, mean and standard deviation) were used to summarize the responses to the thirty stress items, as well as the participants' demographic information. Subsequently, overall mean GDES30 and MBI subscale scores were computed .Cronbach's alpha was computed for the GDES as a measure of its internal consistency , proportions of burnout “cases” were calculated among the entire sample of residents and stratified according to year of study (first, second, and third) , age and gender

Results :

Out of the 126 postgraduates contacted, 82 completed the stress survey questionnaire and 72 completed the burnout questionnaire .The Cronbach's alpha was 0.876 for the stress questionnaire. Respondents had a mean age of 27 and were balanced in terms of age and gender. The specialty distribution of the respondents and the year of study are depicted in Table I.

The mean overall score was GDES30 was 2.28(SD=0.09), the vast majority of answers were in range between 2 (somewhat stressful) and 3 (quite stressful). Distribution of individual responses to the thirty statements , as well as mean scores and ranking of the stress factors are given in Table II. Top three stressors overall among the Postgraduate students was examinations and assessments, lack of time for leisure activities ,and insecurity regarding professional future. Meeting research requirements, financial issues and amount of assigned reading material were the next three factors for stress. There was no significant difference in the perceived stress among the three years. However multiple linear regression analysis indicated that stress due to fear of failure while treating complex cases, and difficulty of communication with patients was maximum in the first year postgraduates and decreased with subsequent years .Overall females had slightly higher stress rates than males which was significantly higher in terms of response to stress induced by amount of assigned readings, difficulty of assigned readings, examinations/assessments, learning clinical/surgical techniques, and lack of leave and holiday days allowed. The mean score of perceived stress was higher in the younger age group (2.31 vs 2.23). With regard to burnout 21% of respondents were “cases of burnout” in the emotional exhaustion component, Table III the proportion was higher for depersonalization (29%) while personal accomplishment was lowest with 54% of the postgraduates burnout cases with inadequate sense of personal accomplishment. There was however no significant difference in burnout cases among the three years of postgraduates.

Discussion :

The study found moderate to high levels of stress and burnout faced by post graduates students in their three years of training. The overall stress score being 2.28 was higher among this study group of dental postgraduates when compared to a similar study on Greek dental residents (2.1)⁷

“Examinations and assessment” “lack of time for leisure activities” and “insecurity regarding professional future” were top stressors among the study group. This is not surprising considering the meticulous and strict nature of the course. The stress of examination and assessment can be attributed to the competitive nature of the course, and the fear of failing the course requirement. Previous findings of similar studies rank “lack of leisure time” and “completing graduation requirements” the highest stressors.^14,15,16 Our data did not reveal stress and burnout to be linked to the study year, unlike studies conducted in European dental residents.^9,17 This could be explained on two grounds. First, the timing of the survey corresponded to almost ten months from the beginning of the academic year. Hence, the students in the first year would have had significant exposure to the professional environment and its attendant mental demands including facing the taxing clinical workload. There is a possibility that although the course burden increases with the year, the coping skills may also be improve with time. This could also be the reason that burnout is consistently higher in the lower age group (< 26years) .There is also the limitation of limited sample size. In any case, it must be acknowledged that the typically small size of all studies in the field, limits their between-subgroups inferential potential.⁹ Increased stress of communication with patients among first year postgraduates can be justified, because India has a multi linguistic population .The setting of the study is a dental college situated at the border of two states with the population speaking various dialects. Gender has been considered to be an important factor in influencing the extent of psychological symptoms. The female students in our study had a higher level of stress relative to their male counterparts. There is higher female stress in many studies conducted among dental and medical professionals.^{2,18,19,20,21} This could be attributed to socio cultural differences, different psychological attributes related to coping skills and vulnerability to life events.^5,22,23

Our study revealed high levels of burnout among the postgraduates with more than 54% of the postgraduates feeling low Personal Accomplishment and 29% feeling burnout with Depersonalization , and 21 % Emotionally Exhausted. This burnout is much higher than burnout values obtained from postgraduates in European dental schools.⁹ The current study set up is a dental college offering completely free dental care to all the patients irrespective of the dental care required. This is similar to most government dental hospitals where patient dental care is almost always free or at minimal cost. Such a scenario leads to an immense case load which is handled by the postgraduate dental students. A disproportion between the numbers of patients to the post graduate students can lead to quicker burnout, and more stress.

Limitations of the study

The limitations of our study are limitations inherent in the methodology i.e. a chance of misinterpretation of questions and lack of response could not be controlled. The cross-sectional approach to interpretation of stress across three years , the difference in the number of postgraduates from different subjects participating in the study are limiting factors to an accurate assessment.

Conclusion :

Our study reveals high levels of stress and burnout among post graduate dental students, which must not be overlooked. There is a need to come up with an effective strategy in the postgraduate curriculum to tackle stress and burnout .Regulating bodies for dental education should take initiatives to provide financial security and future job prospects for the students, policies to update the examination systems and make it relatively less stressful should be looked into. Addressing issues that may arise in the educational setting will help improve the academic environment and lead to superior professional training.