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ORIGINAL ARTICLE
Year : 2021  |  Volume : 19  |  Issue : 2  |  Page : 122-128

Perceived sources of stress and coping strategies adopted by final year under graduate students at dental teaching institutes in Gujarat – A questionnaire survey


Department of Conservative Dentistry and Endodontics, AMC Dental College and Hospital, Ahmedabad, Gujarat, India

Date of Submission21-Mar-2020
Date of Decision31-May-2021
Date of Acceptance22-Jun-2021
Date of Web Publication2-Aug-2021

Correspondence Address:
Urvashi M Ujariya
AMC Dental College and Hospital, Bhalakia Mill Compound, Khokhra, Maninagar, Ahmedabad - 380 008, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaphd.jiaphd_33_20

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  Abstract 


Background: Dental schools are known to be highly demanding and stressful learning environments. The identification of the potential sources of stress is important in dental education programs to take various measures for preventing stress in the dental school environment. Aim: To assess stress perception and coping strategies adopted by final year undergraduates at dental teaching institutes in Gujarat. Materials and Methods: A questionnaire-based, cross-sectional study was conducted among final year students of dental institutions of Gujarat. The validated and translated questionnaire comprised the modified version of the dental environmental stress scale. A four-point Likert scale was used to record the responses from the participants. The participants were asked to fill a self-administered questionnaire about coping strategies. Data were analyzed using the Chi-square test. Results: Responses were received from 560 students. Out of 27 items, 22 items were reported to be stressful by more than 75% of the students. Six items were reported to be stressful by 100% of the students. Seven items were reported to be highly stressful among 27 items. Focus in problem, detachment, focus on positive, tension reduction, and keeping to self were the only significant predictors for total stress level. Conclusions: A contemporary dental school should address potential stress sources effectively. Strategies for stress management must be incorporated and evaluated on a timely basis in dental education to ensure the educational and professional well-being of dental undergraduates.

Keywords: Academic performance, clinical skills, coping strategies, dental students, learning environment, stress


How to cite this article:
Ujariya UM, Kothari AK, Bharatiya RP, Patel AR. Perceived sources of stress and coping strategies adopted by final year under graduate students at dental teaching institutes in Gujarat – A questionnaire survey. J Indian Assoc Public Health Dent 2021;19:122-8

How to cite this URL:
Ujariya UM, Kothari AK, Bharatiya RP, Patel AR. Perceived sources of stress and coping strategies adopted by final year under graduate students at dental teaching institutes in Gujarat – A questionnaire survey. J Indian Assoc Public Health Dent [serial online] 2021 [cited 2021 Nov 29];19:122-8. Available from: https://www.jiaphd.org/text.asp?2021/19/2/122/322863




  Introduction Top


Stress is defined as the pattern of specific and nonspecific responses an organism makes to stimulus events that disturb its equilibrium and tax or exceed its ability to cope.[1] Dentistry has been widely acknowledged as being associated with high levels of stress.[2] Dental students reported considerably more stress symptoms while studying, were more anxious, and showed higher levels of depression, obsessive-compulsive disorders, and interpersonal sensitivity than age-matched controls.[3]

This could be due to a multitude of factors including self-efficacy beliefs, assigned workload, and performance pressure. In addition, and importantly, dental students have been facing stress related to clinical sessions and patient management.

Published reports on the prevalence of stress in dental students exist for the Australia,[4] Canada,[5] Europe,[6] Fiji,[7] Germany,[8] Greece,[9] India,[2],[10],[11],[12] Japan,[13] Jordan,[14] Malaysia[15] Nigeria,[16] South Africa,[17] Turkey,[18],[19] and West Indies.[20]

There is a lack of literature concerning information on the prevalence of stress and coping mechanisms adopted by students in Gujarat. Hence, this study aims to evaluate the same by students affiliated to the eight dental colleges of Gujarat and North Gujarat University in the academic year 2017–2018.


  Materials and Methods Top


The study sample was derived from officially registered students of eight dental teaching institutions of Gujarat during the academic year 2017–2018. Ethical approval for performing the survey was availed from the institutional research board.

All participants took part in the study voluntarily, and no incentives were used for the respondents. Verbal consent was obtained from the respondents, and students present on the day of the survey were included. No attempt was made to trace the students who remained absent on the survey days. The confidentiality of the study participants was ensured by anonymous submissions. Students were asked to record the data regarding age and gender.

Stress was measured using a modified dental environment stress (DES) questionnaire which consisted of 27 questionnaires that are related to the clinical environment present in the Gujarat dental education system. The DES questionnaire was created by Garbee et al.[21] and was first used in 1980 to determine perceived sources of stress among dental students. DES was validated in Spanish by Fonseca et al.[22] This questionnaire has been modified and used in several studies worldwide to determine the degree of stress of the students who follow the career of dentistry.[2],[3],[6],[7],[9],[10],[11],[13],[14],[16],[18],[19],[20] The participants accessed the stressors on a four-point Likert scale ranked as, (1) not stressful, (2) slightly stressful, (3) moderately stressful, and (4) severely stressful. Categories of slightly stressful, moderately stressful, and severely stressful were combined to obtain the overall percentage of the students who felt certain factors were stressful.

Lazarus and Folkman's[23] model of coping was utilized as the theoretical framework for this study in question no. 28.

Statistical analysis

The collected data were organized as descriptive, and they included the student's age and gender. The data were analyzed and tabulated as percentage distribution [Table 1] and [Graph 1] and [Graph 2]. The mean score and standard deviation were tabulated for each of the measures under research [Table 2] and [Graph 3]. Statistical analysis was done after converting the completed questionnaire to a four-point Likert scale. The analysis was organized by assigning the values from 0 to 4 for each response on the Likert scale. The participants were asked to fill a self-administered questionnaire about coping strategies (Lazarus and Folkman's Model).
Table 1: Perceived level of stress reported by undergraduate dental students

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Table 2: The stressors with the highest mean score

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The data were analyzed using the Chi-square test using the Statistical Package for the Social Sciences statistical software (SPSS version 20 Inc., Chicago, IL, USA).

Regression analysis was performed in the present study to predict the stress (dependent variable) from various coping strategies (independent variables). Strategies with a significant impact on stress prediction were noticed.


  Results Top


A total of 560 students participated in the study (response rate: 86%). They were in the age group of 20–23 years with a mean age being 21.2 ± 0.7 years. Of total, 33.3% (187 students) were male and 66.6% (373 students) were female.

Out of 27 items, 22 items were reported to be stressful by more than 75% of the students. Six items (learning environment created by faculty, lack of time for relaxation, examination and grades, amount of assigned work, difficulty of course work, and responsibilities for comprehensive patients care were reported to be stressful by 100% of the students irrespective of the level of stress [Table 3] and [Graph 4].
Table 3: Six sources perceived to be stressful by all final year undergraduate students

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Patients not available at the prescribed time for treatment or examination (45.5%), unemployment fear (41.6%), learning environment created by faculty (38%), possibility to pursue postgraduation (35.2%), insecurity concerning dental career (35%), complementing graduation requirements (31.4%), and receiving criticism about work (31.3%) were reported to be highly stressful among 27 items [Table 4] and [Graph 5].
Table 4: Seven perceived sources with the highest level of stress

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Relationships with other members of the class, inconsistency of feedback on work among different instructors, difficulty in learning precision manual skills required in clinical and laboratory work, difficulty in managing difficult cases, and patients inability to complete prescribed care plan were found to be strategies with only quite or somewhat level of stress on Likert Scale.

[Table 5] presents the coping strategies used in stressful conditions and gender cross-tabulation. All coping strategies were more utilized by female participants than male participants except self-blame which was not believed as a stress alleviator by all participants.
Table 5: Coping strategy used in stressful conditions and gender cross-tabulation

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Regression analysis stated that focus in problem (B = ‒12.187, P < 0.00001), detachment (B = ‒4.684, P < 0.000462), focus on positive (B = ‒14.950, P < 0.00001), tension reduction (B = ‒10.453, P < 0.00001), and keeping to self (B = ‒8.038, P < 0.00001) coping strategies were the only and highly significant predictors for total stress level [Table 6].
Table 6: Regression analysis to predict stress from various coping strategies

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  Discussion Top


This study was conducted to assess the different sources of the stress perceived and coping strategies adopted by the final year dental undergraduate students in Dental Teaching Institutions in Gujarat.

In the advanced era of the 21st century, the education system improved a lot as well the society. Economy, as well as public-related services, approached to the higher level. Hence, some stressors from the DES scale were not tested as the responsible stressors for the development of stress in this study. Furthermore, Harikiran et al.[11] and Sekhon et al.[24] also reported these stressors to be less stressful in comparison with academic and clinical work-related stressors. These include financial problems, health-related issues, problems related to hostilities such as accommodation and food issues.

Among included items, learning environment created by faculty, lack of time for relaxation, examination and grades, amount of assigned work, difficulty of course work, and responsibilities for comprehensive patient care were reported to be stressful by 100% of the students. This suggests the curriculum of the final year reported to be lengthy and difficult because they have to take up exams in seven clinical participants at the end of the year (Revised Scheme 2-Dental Council of India Guidelines), while the students in the 1st 3 years of the undergraduate program have to appear for four subject exams only.

The result is in accordance with the study by Harikiran et al.[11] who also reported that stress causing factors reported by >85% of the students were mainly related to academic and clinical concerns. This finding is similar to the findings in Australia,[4] where the cumulative effect of performance pressure and the workload was thought to be the cause of higher stress levels in the clinical years. Similar concerns were reported in Jordan[14] and UK[25] where clinical students rated falling behind with requirements among their highest six stressors. Pau et al.[26] and Radcliffe and Lester[27] stated that the precise technical requirements of dentistry make the transition from preclinical to clinical all the more stressful.

Patient not available at the prescribed time for treatment or examination was reported to be highest stressful by students. This is because the students have to complete a particular amount of clinical work (patients) during their clinical posting. This may be due to the academic pattern where they are assessed based on their quantitative work done during the clinical term rather than qualitative work which they actually learned. The search of specific cases for the examination which should fulfil certain criteria is also a difficult task for students.

Fear of unemployment and insecurity concerning dental career after graduation were among the highest stressors for students; the reason may be the present trend of dental education in India where larger numbers of dentists passing out from dental institutions each year. Higher competition still exists to gain a job abroad or to achieve admission for postgraduate studies.

Complementing graduation requirements was also among the highest stressors. This may be due to the academic pattern that emphasizes scoring the marks and passing the exams rather than the process of actual learning.

Criticism from clinical supervisors in front of patients appears to be an issue for dental students worldwide[7] which is in accordance with this study.

In this study, all the stressful situations (be it slight, moderate, or severe) were clubbed together to obtain a binomial variable regarding the presence or absence of the stress. Even if the “slightly stressful” situations are mainly due to physiologic reasons, the same cannot be discounted. Stress as perceived by the student, irrespective of the degree of stress, does contribute to the overall stress.

Stress can be managed by either decreasing the number of stressors or by increasing students coping skills about stress. Increasing students' ability to cope with stress is also important.

Coping is a complex process. Lazarus and Folkman[23] identified eight coping strategies believed to be used by individuals in stressful situations. These eight subscales include problem-focused coping, wishful thinking, detachment, seeking social interactions; focusing on the positive, self-blame, tension reduction, and keeping to oneself. These eight subscales separate into two types of coping strategies to change either the environment (problem-focused) or the meaning of the event (emotion-focused or palliative) directly.[28]

In the present study, among the coping strategies adopted focus on problem, detachment, focus on positive, tension reduction, and keeping to self were the only and highly significant predictors for total stress level. Wishful thinking and seeking social support were found to have a less significant impact on the level of stress reduction. Moreover, self-blame has not been adopted by any of the students as a stress alleviator.

Students' stressful and coping experiences are complex. A wide variety of sources are responsible for experiencing stress at work, some of which fall within their control, and others, such as regulations, fall completely outside their control. The coping mechanisms which are likely to be useful in one set of circumstances are unlikely to be helpful in another. It is paramount that these factors are taken into account in any coping strategies designed to alleviate stress in dental students. The things that may need to be addressed are the feedback and advisory systems for students, time management, and choosing realistic goals. Online stress management programs which are more easily accessible and more cost-effective than traditional programs can be incorporated. Moreover, overall wellness should be emphasized by discussing the importance of sleep, diet, exercise, and other stress relievers such as music, yoga, and meditation.


  Conclusions Top


Patients not available at the prescribed time for treatment or examination, unemployment fear, learning environment created by faculty, insecurity concerning dental career, complementing graduation requirements, and receiving criticism about work are the stressors with the highest level of stress perception among dental students of Gujarat.

There have been very few intervention studies that accessed the efficacy of different coping strategies on the reduction of stress level in dental students. Some important factors that need to be addressed should include techniques to keep students within their comfort zone, to broaden the zone by increasing psychological resilience, and encouraging emotional support offered by colleagues. Evaluation for identifying and abolishing triggers of stressors arising during clinical environment at regular intervals may be helpful to make learning joyful.

Acknowledgment

The authors would like to thank Dr. Dolly Patel (Dean, AMC Dental College and Hospital) for her continuous support related to this survey. Author would also express their sincere gratitude toward Dr. Mayank Patel (Assistant Professor, PSM Department, AMC MET Medical College) for carrying out the statistical analysis.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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