Perceived causes of stress among a group of western Canadian dental students
Hayes et al. BMC Res Notes
Perceived causes of stress among a group of western Canadian dental students
Alyssa Hayes 0
Jay N. Hoover 0
Chandima P. Karunanayake 1
Gerald S. Uswak 0
0 College of Dentistry, University of Saskatchewan , 105 Wiggins Rd, Saskatoon, SK S7N 5E4 , Canada
1 Canadian Centre for Health and Safety in Agriculture-CCHSA, University of Saskatchewan , Saskatoon, SK S7N 2Z4 , Canada
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.
Stress; Dental education; Dental students
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” [
]. 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) [
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 [
]. The literature has shown that stress
among dental students is associated with emotional
exhaustion, burnout, decreased productivity and lower
academic success (lower GPA) [
]. Common stressors
include marital status, gender, academic year,
personality type, clinical training and financial burden [
Al-Saleh et al. [
] 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
]. 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.
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 [
]. 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 [
] 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.
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
clinicalrelated 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
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 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.
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 [
], who reported a mean DES
Mean dental environmental stress (DES) questionnaire scores and comparison among 4 years
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
]. 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 [
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 [
]. 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 [
]. 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 [
Mean dental environmental stress (DES) questionnaire scores and comparison among gender and marital status
Fear of not being able to catch up if 2.80 (1.47) 3.33 (1.37) 0.100
falling behind in course work
Fear of failing a course or year 3.57 (1.49) 3.83 (1.52) 0.248
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 [
]. 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.
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.
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.
Additional file 1. Dental Environment Stress Survey.
Additional file 2. Reliability of stress factors (subscales) of DES
Additional file 3. Socio-demographic characteristics of the participants.
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.
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.
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.
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
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.
Minimal funding was provided by the College of Dentistry, as the survey
pertained to a student led research initiative.
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
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