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  • Research note
  • Open Access

Perceived causes of stress among a group of western Canadian dental students

BMC Research Notes201710:714

https://doi.org/10.1186/s13104-017-2979-9

  • Received: 22 March 2017
  • Accepted: 22 November 2017
  • Published:

Abstract

Objective

The demanding nature of dental education, both academically and clinically, results in higher levels of perceived stress among its students. The aim of this study was to determine how dental students at the College of Dentistry, University of Saskatchewan perceived stress. During the 2013–2014 academic year, all students were asked to complete a modified dental environmental survey (DES).

Results

Of the 111 students enrolled at the College that year 92 completed the survey (response rate = 83%). In general, female students reported higher stress levels than males. Higher stress levels were associated with living away from home, concerns about manual dexterity and the transition from pre-clinical to clinical studies. Additionally, students who enter dental school with higher debt loads (> 100,000) report high stress levels relating to finances. This study found that financial and clinical workloads result in high stress levels among dental students.

Keywords

  • Stress
  • Dental education
  • Dental students

Introduction

The Canadian Mental Health Association (CMHA) defines stress as “the body’s response to a real or perceived threat […] [however], most of the threats people face today […] are usually problems that people have to work through” [1]. They go on to state that stress can be both helpful (in terms of motivating people towards problem or task completion) or unhelpful, which is some instances can be associated with problem or task avoidance and physical symptoms (e.g., increased heart rate, sweating, headaches and sleeping difficulties) [1]. Often associated with major life events (i.e., entering a professional school, changing jobs) responses reflect a person’s perception about their ability to handle the situation. Dental education, like other health professional programs, is considered to be demanding both, academically and clinically and is associated with higher levels of stress among students [2]. The literature has shown that stress among dental students is associated with emotional exhaustion, burnout, decreased productivity and lower academic success (lower GPA) [24]. Common stressors include marital status, gender, academic year, personality type, clinical training and financial burden [57]. Al-Saleh et al. [7] reported that among Saudi dental students, stress levels peaked during the latter years of dental training and were associated with the availability of patients, treatment compliance and supervisor feedback. While there are common stressors (i.e., clinical training, patient treatment and supervisor feedback) identified in the literature, prevalence and impact on student stress levels varies and appears to be related to the teaching institution [6]. In light of these variations and the scarcity of Canadian data on this topic, this study attempted to ascertain sources of perceived stress in undergraduate dental students at the University of Saskatchewan, College of Dentistry.

Main text

Materials and methods

All undergraduate dental students enrolled in the Doctor of Dental Medicine (DMD) program at the College of Dentistry, University of Saskatchewan, located in western Canada, were invited to participate in the study. Data collection occurred between January and February 2014, thus allowing for the completion of one semester. This study received ethical approval from the Behaviorial Research Ethics Board (REB), University of Saskatchewan (BEH #12-122). Written informed consent was obtained prior to data collection. Paper-based surveys (see Additional file 1) were administered to all years by a College staff member to ensure anonymity. A modified version of the dental environmental stress (DES) questionnaire, and a 10-item Perceived Stress Scale questionnaire (PSS-10) were used [8]. Both instruments are widely accepted, and have proven to be effective tools to quantify stress levels. Data were collected regarding demographics and motivation for choosing a dental career, analysis was completed using SPSS version 24 (SPSS Inc., Armonk, NY: IBM Corp.). Descriptive statistics were used to describe the study and outcome variables. Internal consistency of the questionnaire was assessed by calculating Cronbach’s alpha. A Kruskal–Wallis test [9] was employed to determine significant differences between year of study, gender, marital status, grade point average, ethnicity, and debt load and debt interest payment. The level of significance was set at p < 0.05.

Results

The reliability of the questionnaire with all items (49) was 0.959, which indicated significant internal consistency (see Additional file 2). Scale 1 contained 10 items referring to social-related stress (Cronbach’s alpha for internal consistency between the items was 0.802); scale 2 (7 items) dealt with financial related stress (Cronbach’s alpha = 0.902); scale 3 (11 items) related to clinical-related stress (Cronbach’s alpha = 0.851); and the fourth scale (21 items) represented academic-related stress (Cronbach’s alpha = 0.934). The adequacy of items under each of the factors was also assessed by calculating the range of Cronbach’s alpha values.

At the time the study was completed, the College of Dentistry had 111 students enrolled in all years, with a response rate of 83 percent the survey is representative of the student body. The dental student cohort at the College of Dentistry at the time of the study was mostly male (56.5%). Respondents were representative of each academic year of the dental program (see Additional file 3). The majority of respondents were between 23 and 25 years of age (55.4%) and reported being never married or single (66.3%). Of interest is that almost 58 percent reported having a current debt load of greater than $100,000 (CDN).

Table 1 shows that when comparing between each academic years statistical differences in stress levels were seen for: socially related stressors (living away from home); clinical related stressors (concern about manual dexterity and clinical skills, the transition from pre- clinical to clinical studies); and academic related stressors (communication with faculty or staff, fear of failing a course/year, confidence about own decision making, and student’s input into College decision-making) were significantly different (p < 0.05). Among first year dental students, the highest mean DES score was attributed to fear over failing a course or year (mean DES = 4.36; SD 1.07). This level of fear decreased as students progressed through their education, with fourth year students reporting considerably lower levels (mean DES = 2.16, SD 1.71). Additionally, social-related stressors (for all years) such as, a lack of time for relaxation and the lack of holiday time account for mean DES scores of 3.42 and 2.84 respectively. Table 2 looked at the role of gender and marital status on mean DES scores. Female dental students reported higher stress levels (mean DES: female = 1.84; males = 1.21, p < 0.05) for family demands and lack of holiday time (mean DES: females = 3.25; males = 2.51, p < 0.05) when compared to their male counterparts. Dental students who reported being married or common law, also reported higher stress levels than their single counterparts when discussing financial responsibilities, specifically pertaining to tuition costs (mean DES: 3.79 versus 3.06, p < 0.05) and size of current debt load (mean DES: 3.79 versus 2.97, p < 0.05). The role of gender was highlighted with female students reporting statistically higher stress levels pertaining to the social demands of family and the lack of holiday hours compared to their male counterparts (mean DES: 1.84 versus 1.21 and 3.25 versus 2.51 respectively). However, the overall lack of gender differences suggests that gender does not play a large role in student’s stress levels. This trend can also be seen when looking at marital status. Slightly higher levels of stress were reported among students who were married or common law in terms of tuition costs (mean DES: 3.79 versus 3.06) and current debt load (mean DES: 3.79 versus 2.97).
Table 1

Mean dental environmental stress (DES) questionnaire scores and comparison among 4 years

Category

Stressor

DES overall

DES by year

Sig. level

Year 1 (2016)

Year 2 (2015)

Year 3 (2014)

Year 4 (2013)

Mean (SD)

Mean (SD)

Mean (SD)

Mean (SD)

Mean (SD)

Social-related stress

Living away from home

0.92 (1.14)

1.14 (0.96)

1.13 (1.25)

1.00 (1.38)

0.35 (0.61)

0.039*

Accommodations not being conducive for studying

1.77 (1.59)

2.04 (1.57)

2.00 (1.17)

1.44 (1.63)

1.65 (1.90)

0.292

Difficulty in making friends

0.62 (0.89)

0.74 (1.10)

0.78 (0.94)

0.56 (0.82)

0.42 (0.61)

0.720

Romantic relationships

1.63 (1.45)

1.59 (1.26)

1.50 (1.41)

1.81 (1.75)

1.53 (1.31)

0.973

Lack of time for relaxation

3.42 (1.33)

3.24 (1.13)

3.55 (1.43)

3.81 (1.39)

2.95 (1.27)

0.109

Lack of holiday time compared to other students

2.84 (1.39)

2.96 (1.10)

2.90 (1.55)

2.63 (1.64)

2.89 (1.24)

0.893

Social demands-family

1.49 (1.32)

1.18 (1.10)

1.37 (1.07)

1.92 (1.69)

1.39 (1.14)

0.531

Social demands-friends

1.65 (1.19)

1.80 (0.91)

1.63 (1.12)

1.70 (1.54)

1.39 (1.04)

0.562

Personal physical health

1.97 (1.62)

1.60 (1.61)

1.60 (1.70)

2.62 (1.79)

1.95 (1.08)

0.088

Physical health of others-significant other/family

1.51 (1.40)

1.18 (1.05)

1.47 (1.59)

2.14 (1.58)

1.13 (1.15)

0.145

Financial-related stress

Financial responsibilities-living expenses

2.33 (1.50)

2.32 (1.49)

2.05 (1.87)

2.52 (1.45)

2.37 (1.21)

0.757

Financial responsibilities-disposable income

2.18 (1.58)

2.38 (1.47)

1.71 (1.72)

2.39 (1.67)

2.11 (1.49)

0.499

Financial responsibilities-tuition costs

3.29 (1.46)

3.42 (1.35)

3.35 (1.49)

3.44 (1.45)

2.84 (1.61)

0.593

Financial responsibilities-transportation

1.62 (1.28)

1.35 (1.03)

1.33 (1.14)

1.88 (1.37)

1.84 (1.50)

0.404

Financial responsibilities-size of current debt load

3.23 (1.60)

3.00 (1.62)

3.21 (1.62)

3.42 (1.58)

3.26 (1.69)

0.793

Financial responsibilities-size of future debt load

3.36 (1.59)

3.42 (1.47)

3.28 (1.60)

3.38 (1.67)

3.32 (1.73)

0.979

Financial responsibilities-interest payments on debt

2.81 (1.61)

2.50 (1.44)

2.83 (1.65)

3.12 (1.61)

2.74 (1.82)

0.531

Clinical-related stress

Concern about manual dexterity and clinical skills

1.68 (1.39)

2.44 (1.26)

1.40 (1.31)

1.67 (1.49)

1.05 (1.10)

0.003*

Transition from pre-clinical to clinical studies

1.17 (1.44)

2.68 (1.17)

1.89 (1.66)

3.00 (1.41)

1.90 (1.25)

0.017*

Completing clinical requirements

2.84 (1.48)

2.93 (1.33)

2.90 (1.33)

3.19 (1.62)

2.21 (1.44)

0.149

Clinical grading

2.36 (1.35)

3.00 (1.36)

2.05 (1.36)

2.37 (1.33)

2.20 (1.32)

0.236

Differences in opinions of clinical faculty and staff regarding clinical decision-making and treatment

2.88 (1.39)

3.05 (1.60)

2.75 (1.29)

3.19 (1.36)

2.42 (1.26)

0.237

Supply of patients

2.86 (1.47)

2.14 (1.21)

2.84 (1.38)

3.33 (1.47)

2.50 (1.54)

0.159

Patient communication and management

2.27 (1.47)

2.00 (1.15)

2.45 (1.54)

2.33 (1.44)

2.15 (1.63)

0.899

Confidence in own clinical decision-making

1.77 (1.13)

2.57 (0.94)

1.45 (0.99)

1.81 (1.21)

1.45 (1.05)

0.009*

Adequacy of clinical supervision

2.04 (1.38)

1.92 (1.31)

1.60 (0.99)

2.41 (1.50)

2.05 (1.54)

0.415

Patients attending scheduled appointments

2.57 (1.61)

2.00 (1.15)

2.60 (1.82)

2.89 (1.62)

2.30 (1.52)

0.557

Occupational/health hazards

1.41 (1.37)

1.27 (1.03)

1.15 (1.35)

1.81 (1.52)

1.25 (1.37)

0.292

Academic-related stress

Conducive teaching environment

2.31 (1.37)

1.88 (1.48)

2.79 (1.27)

2.44 (1.28)

2.21 (1.36)

0.100

Criticism of academic and/or clinical work

2.78 (1.38)

3.04 (1.46)

3.15 (1.35)

2.74 (1.40)

2.00 (1.00)

0.064

Approachability of faculty/staff

2.16 (1.45)

1.76 (1.45)

2.85 (1.39)

2.15 (1.35)

2.00 (1.53)

0.068

Communication with faculty/staff

2.27 (1.41)

1.76 (1.42)

2.95 (1.22)

2.41 (1.47)

2.05 (1.27)

0.023*

Rules/regulations of college

2.62 (1.61)

2.32 (1.75)

2.85 (1.56)

2.89 (1.60)

2.37 (1.50)

0.481

Expectation versus reality of dental school

3.29 (1.50)

3.40 (1.38)

3.25 (1.71)

3.56 (1.34)

2.79 (1.62)

0.453

Amount of course work

3.28 (1.30)

3.40 (0.82)

3.20 (1.24)

3.59 (1.39)

2.80 (1.64)

0.306

Difficulty of course work

2.67 (1.33)

3.08 (0.95)

2.90 (1.52)

2.56 (1.28)

2.10 (1.45)

0.088

Time available for learning

3.32 (1.31)

3.48 (1.05)

3.55 (1.28)

3.56 (1.28)

2.55 (1.47)

0.051*

Fear of not being able to catch up if falling behind in course work

3.03 (1.44)

3.28 (1.14)

3.40 (1.43)

3.26 (1.48)

2.00 (1.37)

0.008*

Fear of failing a course or year

3.68 (1.50)

4.36 (1.07)

4.15 (1.09)

3.78 (1.22)

2.16 (1.71)

< 0.001*

Competition for grades

1.96 (1.58)

2.36 (1.75)

2.11 (1.52)

1.93 (1.41)

1.35 (1.56)

0.170

Uncertainty about future dental career

2.01 (1.48)

2.40 (1.58)

2.05 (1.61)

1.74 (1.16)

1.84 (1.61)

0.469

Examinations

3.05 (1.39)

3.00 (0.98)

3.00 (1.59)

3.56 (1.40)

2.50 (1.47)

0.107

Lack of input into dental college decision-making

2.48 (1.61)

1.72 (1.49)

3.15 (1.56)

2.68 (1.57)

2.50 (1.57)

0.026*

Clinical time allotted in curriculum

2.24 (1.32)

2.41 (1.28)

2.40 (1.09)

2.41 (1.55)

1.70 (1.17)

0.176

The language of teaching

1.03 (1.12)

1.21 (1.21)

1.06 (1.16)

0.96 (1.10)

0.89 (1.05)

0.842

Knowledge transfer of information, methods and materials

1.63 (1.21)

1.54 (1.18)

1.80 (1.20)

1.69 (1.32)

1.50 (1.19)

0.867

The amount of material

2.60 (1.41)

2.88 (1.13)

2.45 (1.15)

2.89 (1.60)

2.00 (1.59)

0.108

The difficulty of material

1.97 (1.20)

2.20 (0.82)

2.05 (1.05)

2.04 (1.48)

1.50 (1.28)

0.152

Reference and information resources

1.33 (1.17)

1.14 (0.89)

1.32 (1.06)

1.48 (1.42)

1.35 (1.23)

0.934

* Statistically significant at p < 0.05

Table 2

Mean dental environmental stress (DES) questionnaire scores and comparison among gender and marital status

Category

Stressor

DES by gender

Sig. level

DES by marital status

Sig. level

Male

Female

Other

Married/common-law

Mean (SD)

Mean (SD)

Mean (SD)

Mean (SD)

Social-related stress

Living away from home

0.78 (1.01)

1.13 (1.29)

0.216

0.92 (1.08)

0.92 (1.26)

0.781

Accommodations not being conducive for studying

1.65 (1.52)

1.94 (1.68)

0.451

1.70 (1.55)

1.92 (1.69)

0.633

Difficulty in making friends

0.56 (0.92)

0.70 (0.84)

0.236

0.63 (0.87)

0.62 (0.94)

0.906

Romantic relationships

1.80 (1.56)

1.42 (1.31)

0.261

2.14 (1.46)

0.61 (0.74)

< 0.001*

Lack of time for relaxation

3.33 (1.31)

3.53 (1.36)

0.471

3.35 (1.34)

3.55 (1.30)

0.533

Lack of holiday time compared to other students

2.51 (1.42)

3.25 (1.26)

0.015*

2.68 (1.43)

3.17 (1.26)

0.127

Social demands-family

1.21 (1.16)

1.84 (1.44)

0.036*

1.30 (1.26)

1.86 (1.38)

0.055

Social demands-friends

1.48 (1.15)

1.87 (1.22)

0.158

1.68 (1.20)

1.59 (1.18)

0.677

Personal physical health

1.74 (1.35)

2.25 (1.89)

0.311

2.11 (1.61)

1.66 (1.63)

0.160

Physical health of others-significant other/family

1.20 (1.11)

1.91 (1.65)

0.084

1.53 (1.40)

1.46 (1.43)

0.793

Financial-related stress

Financial responsibilities-living expenses

2.20 (1.41)

2.50 (1.61)

0.449

2.12 (1.47)

2.79 (1.47)

0.055

Financial responsibilities-disposable income

2.10 (1.56)

2.29 (1.62)

0.652

2.02 (1.58)

2.52 (1.55)

0.165

Financial responsibilities-tuition costs

3.12 (1.45)

3.51 (1.47)

0.178

3.06 (1.52)

3.79 (1.20)

0.035*

Financial responsibilities-transportation

1.54 (1.27)

1.71 (1.29)

0.535

1.53 (1.18)

1.81 (1.47)

0.510

Financial responsibilities-size of current debt load

3.15 (1.58)

3.33 (1.64)

0.515

2.97 (1.64)

3.79 (1.40)

0.025*

Financial responsibilities-size of future debt load

3.23 (1.59)

3.51 (1.60)

0.345

3.14 (1.64)

3.82 (1.39)

0.063

Financial responsibilities-interest payments on debt

2.70 (1.56)

2.95 (1.68)

0.511

2.58 (1.60)

3.29 (1.56)

0.068

Clinical-related stress

Concern about manual dexterity and clinical skills

1.52 (1.39)

1.90 (1.37)

0.138

1.84 (1.46)

1.37 (1.19)

0.152

Transition from pre-clinical to clinical studies

2.20 (1.37)

2.76 (1.50)

0.072

2.37 (1.44)

2.57 (1.48)

0.475

Completing clinical requirements

2.53 (1.53)

3.22 (1.33)

0.059

2.75 (1.44)

3.04 (1.56)

0.386

Clinical grading

2.20 (1.36)

2.57 (1.33)

0.151

2.40 (1.31)

2.29 (1.46)

0.834

Differences in opinions of clinical faculty and staff regarding clinical decision-making and treatment

2.71 (1.43)

3.11 (1.33)

0.222

2.88 (1.28)

2.89 (1.62)

0.877

Supply of patients

2.56 (1.45)

3.21 (1.45)

0.061

2.85 (1.46)

2.88 (1.53)

0.851

Patient communication and management

2.17 (1.39)

2.40 (1.56)

0.521

2.20 (1.38)

2.41 (1.62)

0.681

Confidence in own clinical decision-making

1.73 (1.19)

1.81 (1.06)

0.608

1.77 (1.12)

1.75 (1.17)

0.807

Adequacy of clinical supervision

1.84 (1.46)

2.29 (1.25)

0.065

2.00 (1.37)

2.11 (1.42)

0.661

Patients attending scheduled appointments

2.15 (1.46)

3.06 (1.67)

0.018*

2.57 (1.64)

2.56 (1.60)

0.973

Occupational/health hazards

1.25 (1.24)

1.59 (1.50)

0.360

1.42 (1.35)

1.39 (1.42)

0.820

Academic-related stress

Conducive teaching environment

2.12 (1.29)

2.56 (1.45)

0.169

2.13 (1.35)

2.69 (1.36)

0.098

Criticism of academic and/or clinical work

2.59 (1.34)

3.00 (1.41)

0.185

2.89 (1.38)

2.54 (1.37)

0.230

Approachability of faculty/staff

2.02 (1.39)

2.35 (1.53)

0.360

2.10 (1.50)

2.30 (1.37)

0.405

Communication with faculty/staff

2.04 (1.37)

2.55 (1.43)

0.087

2.17 (1.49)

2.47 (1.25)

0.273

Rules/regulations of College

2.69 (1.59)

2.53 (1.65)

0.616

2.70 (1.59)

2.43 (1.65)

0.447

Expectation versus reality of dental school

3.08 (1.67)

3.55 (1.22)

0.248

3.16 (1.55)

3.53 (1.38)

0.299

Amount of course work

3.06 (1.38)

3.58 (1.15)

0.060

3.26 (1.27)

3.33 (1.40)

0.592

Difficulty of course work

2.50 (1.38)

2.90 (1.24)

0.167

2.55 (1.28)

2.93 (1.41)

0.146

Time available for learning

3.19 (1.44)

3.48 (1.11)

0.412

3.29 (1.28)

3.37 (1.38)

0.716

Fear of not being able to catch up if falling behind in course work

2.80 (1.47)

3.33 (1.37)

0.100

3.00 (1.39)

3.10 (1.56)

0.659

Fear of failing a course or year

3.57 (1.49)

3.83 (1.52)

0.248

3.62 (1.52)

3.80 (1.47)

0.581

Competition for grades

2.00 (1.53)

1.90 (1.67)

0.650

2.06 (1.50)

1.72 (1.75)

0.206

Uncertainty about future dental career

1.86 (1.61)

2.21 (1.28)

0.173

1.87 (1.41)

2.31 (1.61)

0.240

Examinations

2.71 (1.37)

3.50 (1.30)

0.008*

2.95 (1.34)

3.28 (1.51)

0.247

Lack of input into dental college decision-making

2.22 (1.50)

2.82 (1.70)

0.084

2.33 (1.50)

2.77 (1.79)

0.237

Clinical time allotted in curriculum

2.26 (1.36)

2.21 (1.30)

0.821

2.18 (1.25)

2.36 (1.47)

0.701

The language of teaching

1.02 (1.06)

1.05 (1.21)

0.909

1.10 (1.15)

0.89 (1.05)

0.450

Knowledge transfer of information, methods and materials

1.63 (1.23)

1.64 (1.20)

0.943

1.67 (1.31)

1.55 (0.98)

0.947

The amount of material

2.38 (1.46)

2.88 (1.32)

0.108

2.68 (1.40)

2.43 (1.45)

0.397

The difficulty of material

1.83 (1.11)

2.15 (1.29)

0.288

1.95 (1.21)

2.00 (1.20)

0.819

Reference and information resources

1.28 (1.16)

1.39 (1.20)

0.619

1.32 (1.20)

1.36 (1.13)

0.729

* Statistically significant at p < 0.05

Table 3 illustrates the role of current debt load on student stress levels, significantly higher levels of stress were reported among students incurring a current debt load of greater than $100,000 dollars. This trend was also seen in those reporting a debt related interest payment of greater than $500 dollars.
Table 3

Mean dental environmental stress (DES) questionnaire scores and comparison among debt load and debt interest payment

Category

Stressor

DES by debt load

Sig. level

DES by debt interest payment

Sig. level

≤ $100,000

> $100,000

$0–500

> $500

Mean (SD)

Mean (SD)

Mean (SD)

Mean (SD)

Social-related stress

Living away from home

1.34 (1.32)

0.67 (0.95)

0.008*

0.90 (1.14)

1.00 (1.19)

0.722

Accommodations not being conducive for studying

1.77 (1.55)

1.81 (1.62)

0.973

1.81 (1.60)

1.71 (1.54)

0.880

Difficulty in making friends

0.65 (0.85)

0.60 (0.93)

0.654

0.64 (0.94)

0.53 (0.64)

0.947

Romantic relationships

1.82 (1.53)

1.51 (1.42)

0.310

1.68 (1.45)

1.43 (1.55)

0.460

Lack of time for relaxation

3.45 (1.31)

3.38 (1.36)

0.863

3.39 (1.35)

3.53 (1.25)

0.763

Lack of holiday time compared to other students

2.76 (1.34)

2.87 (1.44)

0.745

2.75 (1.40)

3.20 (1.37)

0.291

Social demands-family

1.17 (1.01)

1.73 (1.48)

0.119

1.32 (1.14)

2.33 (1.80)

0.043*

Social demands-friends

1.54 (1.12)

1.73 (1.25)

0.608

1.55 (1.12)

2.13 (1.46)

0.117

Personal physical health

1.92 (1.67)

2.02 (1.62)

0.728

1.84 (1.61)

2.67 (1.59)

0.058

Physical health of others-significant other/family

1.19 (1.26)

1.83 (1.47)

0.047*

1.41 (1.39)

2.00 (1.36)

0.099

Financial-related stress

Financial responsibilities-living expenses

1.68 (1.32)

2.77 (1.48)

0.001*

2.17 (1.50)

3.13 (1.30)

0.013*

Financial responsibilities-disposable income

1.68 (1.53)

2.55 (1.54)

0.014*

1.98 (1.57)

3.07 (1.39)

0.011*

Financial responsibilities-tuition costs

3.00 (1.47)

3.52 (1.43)

0.097

3.24 (1.47)

3.60 (1.45)

0.360

Financial responsibilities-transportation

1.51 (1.28)

1.73 (1.27)

0.363

1.47 (1.15)

2.40 (1.55)

0.024*

Financial responsibilities-size of current debt load

2.47 (1.78)

3.77 (1.23)

0.001*

3.07 (1.62)

4.13 (1.12)

0.015*

Financial responsibilities-size of future debt load

2.76 (1.81)

3.75 (1.33)

0.011*

3.20 (1.63)

4.13 (1.25)

0.030*

Financial responsibilities-interest payments on debt

2.18 (1.59)

3.25 (1.49)

0.004*

2.59 (1.60)

3.93 (1.16)

0.030*

Clinical-related stress

Concern about manual dexterity and clinical skills

1.82 (1.27)

1.58 (1.49)

0.226

1.79 (1.44)

1.19 (1.11)

0.135

Transition from pre-clinical to clinical studies

2.49 (1.50)

2.42 (1.42)

0.880

2.52 (1.41)

2.13 (1.59)

0.227

Completing clinical requirements

2.68 (1.25)

2.98 (1.60)

0.294

2.89 (1.38)

2.75 (1.84)

0.811

Clinical grading

2.23 (1.19)

2.44 (1.46)

0.573

2.31 (1.26)

2.56 (1.75)

0.665

Differences in opinions of clinical faculty and staff regarding clinical decision-making and treatment

2.82 (1.45)

2.94 (1.38)

0.800

2.91 (1.40)

2.81 (1.42)

0.859

Supply of patients

2.96 (1.45)

2.80 (1.50)

0.662

2.90 (1.40)

2.73 (1.79)

0.797

Patient communication and management

2.79 (1.52)

1.98 (1.36)

0.022*

2.34 (1.48)

2.00 (1.41)

0.401

Confidence in own clinical decision-making

2.00 (1.34)

1.64 (0.98)

0.286

1.82 (1.16)

1.60 (1.06)

0.757

Adequacy of clinical supervision

2.00 (1.49)

2.08 (1.33)

0.703

2.11 (1.38)

1.80 (1.42)

0.367

Patients attending scheduled appointments

2.68 (1.72)

2.50 (1.56)

0.609

2.61 (1.64)

2.40 (1.55)

0.661

Occupational/health hazards

1.57 (1.52)

1.32 (1.28)

0.616

1.50 (1.41)

1.06 (1.18)

0.246

Academic-related stress

Conducive teaching environment

2.08 (1.34)

2.48 (1.39)

0.173

2.30 (1.42)

2.40 (1.18)

0.563

Criticism of academic and/or clinical work

2.92 (1.40)

2.66 (1.38)

0.399

2.84 (1.41)

2.38 (1.19)

0.267

Approachability of faculty/staff

1.87 (1.38)

2.37 (1.49)

0.148

2.12 (1.47)

2.31 (1.45)

0.604

Communication with faculty/staff

1.95 (1.45)

2.50 (1.36)

0.089

2.27 (1.45)

2.25 (1.29)

0.952

Rules/regulations of College

2.16 (1.46)

2.94 (1.66)

0.031*

2.58 (1.58)

2.75 (1.84)

0.796

Expectation versus reality of dental school

2.95 (1.47)

3.50 (1.49)

0.070

3.22 (1.48)

3.50 (1.59)

0.430

Amount of course work

3.34 (1.12)

3.25 (1.44)

0.964

3.32 (1.23)

3.13 (1.67)

0.855

Difficulty of course work

2.87 (1.23)

2.53 (1.39)

0.276

2.68 (1.29)

2.63 (1.59)

0.957

Time available for learning

3.53 (1.25)

3.17 (1.35)

0.219

3.43 (1.25)

2.81 (1.51)

0.136

Fear of not being able to catch up if falling behind in course work

3.16 (1.40)

2.94 (1.49)

0.536

3.11 (1.38)

2.69 (1.74)

0.421

Fear of failing a course or year

3.79 (1.28)

3.58 (1.65)

0.898

3.74 (1.45)

3.31 (1.70)

0.285

Competition for grades

2.00 (1.49)

1.94 (1.67)

0.786

1.95 (1.58)

2.06 (1.69)

0.809

Uncertainty about future dental career

1.76 (1.38)

2.14 (1.49)

0.250

1.92 (1.41)

2.25 (1.65)

0.475

Examinations

2.95 (1.35)

3.12 (1.44)

0.494

3.11 (1.35)

2.75 (1.61)

0.453

Lack of input into dental college decision-making

2.00 (1.45)

2.85 (1.64)

0.016*

2.51 (1.63)

2.44 (1.55)

0.957

Clinical time allotted in curriculum

2.36 (1.19)

2.18 (1.41)

0.448

2.18 (1.28)

2.60 (1.50)

0.302

The language of teaching

1.00 (1.09)

1.08 (1.15)

0.761

0.97 (1.14)

1.38 (1.02)

0.097

Knowledge transfer of information, methods and materials

1.59 (1.17)

1.67 (1.26)

0.850

1.60 (1.19)

1.81 (1.38)

0.616

The amount of material

2.82 (1.25)

2.18 (1.09)

0.161

2.64 (1.36)

2.44 (1.71)

0.479

The difficulty of material

2.18 (1.09)

1.81 (1.27)

0.071

1.93 (1.13)

2.13 (1.54)

0.842

Reference and information resources

1.56 (1.34)

1.20 (1.02)

0.247

1.32 (1.19)

1.44 (1.09)

0.563

* Statistically significant at p < 0.05

Discussion

This study presents current data on the role of student stress in dental education, and importantly presents data from western Canada, specifically the prairies. As the survey was conducted at the College of Dentistry, University of Saskatchewn the results cannot be generalized to all Canadian dental schools. High stress levels reported due to lack of time for relaxation among students at the University of Saskatchewan (means DES = 3.42) is consistent with Muirhead [10], who reported a mean DES of 3.14 for students at another Canadian dental school. Contextually, the University of Saskatchewan, begins classes in mid-August and continues until April or May (depending on year of program), the longer academic term coupled with the understanding that dental education places demands above and beyond the normal school hours, the findings are consistent with the literature [11]. Also consistent with the literature is the finding that clinical-related stressors, in particular those dealing with the transition from pre-clinical to clinical work, (i.e., clinical grading, patient supply and communication) are highest among 3rd year dental students (mean DES ranges from 2.33 to 3.33). Thus re-iterating the belief that the aforementioned transition marks an integral and stressful time in a student’s dental education [12, 13]. High levels of stress were associated with differing opinions of clinical faculty and staff regarding decision making and treatment (mean DES scores ranged from 3.05 in 1st year to 2.42 in 4th year). Clinical faculty is largely comprised of practicing or newly retired clinicians willing to provide their time, and thus bring differing experiences and backgrounds [14]. Currently, the College of Dentistry has no formalized program to calibrate clinical faculty, as some other dental institutions do. The high levels of stress attributed to this lack of clarity from faculty highlights the need for a calibration program to be implemented, potentially mitigating some stress levels among the students. Additionally, the incorporation of stress management strategies (i.e., mindfulness, therapy dogs) during high stress times (e.g., examination periods) should be explored by dental educators.

This study found that when looking at financial-related stressors, significant differences were seen between those with smaller debt loads (≤ $100,000) and those carrying larger debt loads (≥ $100,000), in all categories except tuition costs. Of interest is that higher stress due to living away from home was seen among those with lower debt loads (mean DES score of 1.34) compared to those with larger debts, while students living with their parents had significantly higher dental school entry debts. Similar findings were reported among Canadian dental students in Toronto, Canada [10]. This is important as the Financial Consumer Agency of Canada reported that tuition for the 2013–14 academic year rose 3.3 percent over the previous year and was expected to increase further from the reported Canadian average of $5772.00 [15]. When looking at the costs of dental education from 2010/11 to 2014/15 average tuition costs rose from $15,062.00 to $18,187.00 per year [16]. It is not surprising then, that students with higher existing debt loads and interest payments had significantly higher self-reported stress levels relating to finances. Discussions around debt loads and costs of tuition are important, especially when post-secondary institutions are faced with increased operating costs and funding reductions.

Conclusions

The findings of this study are consistent with the literature, which states that financial and clinical workloads result in high stress levels among dental students. Dental educators must be cognizant of their responsibility to ensure that students, especially at the beginning of their education, have realistic expectations pertaining to issues such as workloads and costs of education. Of equal importance, all faculty especially clinical instructors, should be educated on grading systems and calibrated to help mitigate student stress as it pertains to faculty-student interactions. From a policy perspective, a formalized onboarding program for faculty and staff is recommended prior to interacting with students.

Limitations

This study was conducted at a single Canadian dental education institution (University of Saskatchewan) and the results cannot be generalized to other Canadian dental education institutions. However, the data was representative of the students enrolled at the College of Dentistry as evidenced by the high response rate. The findings represent the first time data on student stress was reported for a dental education institution located in western Canada thus providing insight for educators into student stress levels. Further research is needed to determine if similar results would be reported by dental students across Canada.

Abbreviations

DES: 

dental environment survey

CMHA: 

Canadian Mental Health Association

GPA: 

grade point average

DMD: 

Doctor of Medicine in Dentistry

PSS-10: 

Perceived Stress Scale 10

SPSS: 

statistical Package for the Social Sciences

Declarations

Authors’ contributions

AH contributed to the secondary literature search, the writing and editing of the manuscript. JH contributed to the initial literature search, the initial drafts of the ‘introduction’ and ‘methods’ sections of the manuscript and supervised the collection of data. CK provided assistance with data analysis and interpretation. GU contributed to the study conception and data collection. All authors read and approved the final manuscript.

Acknowledgements

The authors wish to thank Simon-Hannes Haimanot, Saud Ahmad, Adam Abdo, and all participants who were students at the College of Dentistry, University of Saskatchewan at the time of study.

Competing interests

The authors declare that they have no competing interests.

Availability of data and materials

The data generated and analyzed in this study are not publicly available as further analysis is ongoing. Data are available from the corresponding author on reasonable request.

Consent for publication

Not applicable.

Ethics approval and consent to participate

Ethics approval was obtained from the University of Saskatchewan, Behavioral Research Ethics Board (Beh-REB), Reference Number # 12-122. All participants provided their free and written, informed consent.

Funding

Minimal funding was provided by the College of Dentistry, as the survey pertained to a student led research initiative.

Publisher’s Note

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Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Authors’ Affiliations

(1)
College of Dentistry, University of Saskatchewan, 105 Wiggins Rd, Saskatoon, SK, S7N 5E4, Canada
(2)
Canadian Centre for Health and Safety in Agriculture-CCHSA, University of Saskatchewan, Saskatoon, SK, S7N 2Z4, Canada

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Copyright

© The Author(s) 2017

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