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Occupational Medicine Advance Access originally published online on February 22, 2008
Occupational Medicine 2008 58(4):275-281; doi:10.1093/occmed/kqn014
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© The Author 2008. Published by Oxford University Press on behalf of the Society of Occupational Medicine. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org

Job stressors of New Zealand dentists and their coping strategies

K. M. S. Ayers1, W. M. Thomson1, J. T. Newton2 and A. M. Rich1

1 Department of Oral Sciences, Faculty of Dentistry, University of Otago, Dunedin, New Zealand
2 Department of Oral Health Services Research and Dental Public Health, King's College London School of Dentistry, King's College London, UK

Correspondence to: K. M. S. Ayers, Department of Oral Sciences, Faculty of Dentistry, University of Otago, PO Box 647, Dunedin, New Zealand. e-mail: katie.ayers{at}mac.com


   Abstract
Top
 Abstract
Introduction
 Methods
 Results
 Discussion
 Conflicts of interest
 References
 
Background Dentistry is understood to be a stressful profession. Although there has been recent research about stress and dentistry in the UK and the Netherlands, little is known about the job stressors and coping strategies of New Zealand dentists.

Aim To investigate job stressors and coping strategies among New Zealand dentists.

Methods A nationwide postal survey of a representative sample of 700 dentists.

Results The response rate was 65%. The most commonly reported stressors were treating difficult children (52%), constant time pressure (48%) and maintaining high levels of concentration (43%). The strategies most utilized for managing work-related stress included interactions with people (78%), sports (64%) and forgetting about work (59%). Dentists who had graduated overseas reported more sources of stress than New Zealand graduates. There were differences in the strategies used by male and female practitioners to manage stress.

Conclusions There is considerable variation in the number of stressors experienced by dentists. Overseas-qualified dentists appear to be under more stress than New Zealand-trained dentists and may need greater professional support. Dentists should be encouraged to make greater use of active coping strategies.

Keywords      dentists; burnout; occupational health; stress; stressors; stress management


   Introduction
Top
 Abstract
 Introduction
Methods
 Results
 Discussion
 Conflicts of interest
 References
 
Dentistry is perceived as a stressful profession [1–3]. Several models of stress exist, such as the classic model by Cox, which suggests that stress is an imbalance between an individual's demands and ability [3]. High levels of stress can lead to physical or mental health problems [1,2], and high levels of work-related stress have been linked to poor working relationships and low job satisfaction [4]. Furthermore, the quality of care provided may also be affected [5].

Cross-sectional studies indicate that >10% of dentists experience high levels of ‘burnout’, a possible long-term consequence of occupational stress [6–8]. Dentists with a high burnout risk have poorer health and more unhealthy behaviours than their less-stressed peers [9]. Furthermore, stress-related disorders are a common cause of early retirement among dentists [10].

Research findings on the health and well-being of dentists are conflicting [11]. It has been suggested that dentistry generates more stress than any other profession and that job-related factors explain almost half of the overall stress in a dentist's life [5]. However, the personality traits common to those who choose to practise dentistry may also play a role [2]. Little comparison has been made of the stress experienced by dentists and that encountered by other professionals [12].

It has been suggested that dentists lack awareness and knowledge about managing their stress [13,14]. However, before developing interventions to manage and prevent stress among dentists, the job-related stressors and existing coping strategies need to be determined [12]. The most common stressors reported include time-related pressures, heavy workloads, financial concerns, anxious/difficult patients, the causing of pain, staff problems, equipment breakdowns, defective materials, poor working conditions, medical emergencies in the surgery and the routine nature of the job [4,5,13,15]. Some stressors appear to be linked to the type of health system in which dentists work and the way in which they are remunerated.

There is a lack of information on stress levels among dentists in New Zealand. Therefore, the aim of this study was to investigate job stressors, coping strategies and their associations among New Zealand dentists. This will assist in determining the need for interventions to manage and prevent stress among dentists.


   Methods
Top
 Abstract
 Introduction
 Methods
Results
 Discussion
 Conflicts of interest
 References
 
A nationwide postal survey of 700 general dental practitioners was undertaken between April and July 2006. The sample was randomly selected from the 2005 New Zealand Dental Register [with permission from the Dental Council of New Zealand (DCNZ)]. The study was approved by the University of Otago Ethics Committee. Participation incentives were offered in the form of prize draws sponsored by dental supply companies. The questionnaire was posted with a covering letter explaining the study's purpose, and a prepaid envelope was included for returning completed forms. A second wave of forms was sent to the 354 non-responder dentists after 1 month.

Data collected included respondents' socio-demographic and practice characteristics, together with information on factors causing stress in dentistry and coping strategies. A modified form of the inventory devised by Cooper et al. [4] was used to obtain information about job stressors. It consisted of 33 items within the following seven scales: time pressures, financial stressors, patient-related stressors, staff and technical problems, the nature of work and concerns about the future. Respondents were asked to rate those stressors in terms of the frequency with which they usually experienced them. The response options were as follows: ‘never’, ‘seldom’, ‘sometimes’, ‘often’, ‘frequently’ and ‘all the time’. Similar versions of this questionnaire have been used widely in dental research [4,5,15,16]. For reporting purposes, respondents were grouped by gender, year of graduation (pre-1970, 1970–79, 1980–89, 1990–99 and 2000+) and site of practice (major city, provincial city and other).

The survey responses were entered into an electronic database, and then analysed using the Statistical Package for the Social Sciences (SPSS; Version 11 for Mac OS X; http://www.spss.com). Associations between categorical variables were tested for statistical significance using the Chi-square test, with the alpha level set at 0.05.


   Results
Top
 Abstract
 Introduction
 Methods
 Results
Discussion
 Conflicts of interest
 References
 
Of the original random sample of 700 general dental practitioners, 23 were outside the sampling frame, either because they were retired, deceased, or because their questionnaires had been returned due to incorrect address details. The 437 questionnaires returned from the remaining 677 dentists gave a response rate of 65%. Comparison of the characteristics of the responders with the practising dentists in New Zealand (using the DCNZ Dentist's Register) showed that there were no significant differences, with the Register data falling within the 95% confidence intervals for all the survey estimates (Table 1).


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  		Table 1. Comparison of respondents' socio-demographic and degree characteristics with those of the actively practising New Zealand dental profession as a whole (data are percentages)

 
There were 329 male (75%) and 108 female respondents (25%). The mean age of male respondents was 48.2 (SD 12.1) and of females was 38.8 (SD 8.4). In all, 146 (44%) males had graduated prior to 1980, 105 (32%) graduated between 1980 and 1989 and the remaining 78 (24%) had graduated in 1990 or later. Only 14 females (13%) had graduated prior to 1980, 36 (33%) had graduated in the 1980s and over half (58, 54%) graduated in 1990 or later (P < 0.001). More male (281, 85%) than female (77, 71%) dentists were New Zealand graduates (P < 0.001). There were no significant differences in practice setting by gender, but a larger proportion of male (180, 55%) than female (34, 31.8%) dentists had a typical weekly patient load of 58 patients or more (P < 0.001), with 58 patients per week being the median. There were no differences in the typical patient load of New Zealand- and overseas-trained dentists.

There was considerable variation in the number of stressors that dentists experienced frequently or all the time, with the number per dentist ranging from 0 to 31 (mean = 7.0, SD = 6.2). Of all participants, 215 (49%) experienced 5 or fewer sources of stress frequently or all the time, while 22 individuals reported experiencing 20 or more stressors frequently or all the time. The mean number of such stressors was 6.4 (SD 5.6) among New Zealand graduates and 9.7 (SD 7.8) among overseas-qualified dentists (P < 0.05). A higher proportion of the latter reported experiencing eight or more stressors frequently or all the time (39, 49%) than New Zealand graduates (126, 38%, P < 0.05).

The frequency with which the various stressors were reported as occurring ‘very often’ or all the time is presented in Table 2. The most commonly reported stressors were treating difficult children, constant time pressure and maintaining high levels of concentration. The least frequent stressors were feeling isolated, perceived problems with colleagues and the possibility of contracting a viral infection.


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  		Table 2. Frequency of stressors reported very often or all the time among general dental practitioners

 
For a number of stressors, there were no significant differences by gender, graduating cohort, practice setting, country of graduation or weekly workload in the number of respondents reporting them very often or all the time. These included the following: seeing more patients for income reasons, rising costs, perceived problems with colleagues, actually making mistakes, working with children and treating difficult children.

There were no significant differences between male and female respondents in the frequency of reporting any of the job stressors, except for maintaining high levels of concentration (46 and 35%, respectively; P = 0.05) and causing pain (35 and 24%, respectively; P < 0.05). A higher proportion of male respondents reported working with children as a stressor very often or all the time, but this failed to reach statistical significance (34 and 27%, respectively).

The only stressors which reached statistical significance with respect to the weekly workload of dentists (<58 versus ≥58 patients) were as follows: concerns about the supply of dentists (22, 11% and 36, 18%, respectively), continuing professional development requirements (22, 11% and 37, 18%, respectively) and the ability to sell the practice in the future (37, 18% and 55, 27%, respectively).

There were only five stressors that differed significantly in reported frequency by graduating cohort. These are presented in Table 3. Fewer dentists who had graduated prior to 1970 reported feeling stressed by constant time pressure than those who had graduated later (P < 0.05), while those who had graduated between 1980 and 1999 reported having difficulty finding time for family and friends more often than their colleagues (P < 0.05). Those in the oldest and youngest groups reported being stressed by coping with difficult patients more often than those in the other age groups (P < 0.05). The elder dentists were also the most concerned about their ability to sell their practice in the future (P < 0.001).


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  		Table 3. Number reporting job stressors very often or all the time by graduating cohort

 
In Table 4, the number of respondents reporting job stressors very often or all the time is presented by practice setting. More dentists from provincial cities than those in major cities or small towns were concerned about lack of patient appreciation and the possibility of making mistakes (P < 0.05). Dentists in major cities reported being more frequently stressed by unsatisfactory auxiliary help than other dentists (P < 0.05), while those in the small towns were more frequently concerned about the supply of dentists (P < 0.001) and their ability to sell their practice in the future (P < 0.01) than their colleagues in the towns and cities.


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  		Table 4. Number reporting job stressors very often or all the time by practice setting

 
Further comparison between New Zealand- versus overseas-trained dentists demonstrated that, for most potential stressors, more overseas- than New Zealand-trained dentists reported experiencing them frequently or all the time. The only exceptions were treating difficult children, concerns about the supply of dentists and the ability to sell the practice in future. These data are presented in Table 5.


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  		Table 5. Number reporting job stressors very often or all the time by country of primary dental qualification

 
The most commonly used strategies for coping with stress are presented in Table 6. The most frequently used three were interactions with people, sports and forgetting about work. The least commonly used strategies were smoking (4%), recreational drugs (3%) and prescribed drugs (3%). Fifteen males (5%) but no females reported that they smoked to deal with stress (P < 0.05). A higher proportion of males than females reported using both recreational drugs and prescribed drugs to deal with stress, but this did not reach statistical significance. More male than female respondents reported using alcohol or sports to manage stress, while a higher proportion of female dentists reported that they spent money or interacted with people. Changing the work environment was a strategy used by more males (83, 26%) than females (17, 16%). Dentists who had graduated within the previous 16 years were less likely than other age groups to report using alcohol. There was a gradient towards increasing proportions of dentists that reported spending money was used as a stress-coping strategy by higher proportions of more recent graduates. A similar gradient was observed with respect to ‘interactions with people’, but this failed to reach statistical significance. Fewer dentists practising in provincial cities (than in major cities or other areas) reported interactions with people as a strategy for dealing with job-related stress. The strategies used by overseas- and New Zealand-trained dentists were similar, except that a higher proportion of New Zealand graduates consumed alcohol, played sport or engaged in hobbies. Fewer busier dentists (those who treated, on average, at least 58 patients per week) identified interactions with people or ‘changing relationship with patient/staff’ as strategies for dealing with job-related stress.


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  		Table 6. Strategies most commonly used for coping with stress by demographic and practising characteristics (brackets contain percentages)

 

   Discussion
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
Conflicts of interest
 References
 
This study found that there was considerable variation in the number of stressors experienced by dentists and that overseas-qualified practitioners reported experiencing more stressors frequently or all the time than those trained in New Zealand. There were differences in the strategies that male and female dentists use to manage stress.

There were some limitations to our study, mainly due to its cross-sectional nature. The response rate of 65% was not ideal, but is typical of this type of study [16,17]. It is not possible to determine precisely how the respondent dentists differed from the non-responders. However, comparison of the socio-demographic characteristics of our sample with all (non-specialist) dentists on the Dental Register confirmed that there were no statistically significant differences with respect to gender, age or source of the primary dental qualification (Table 1). Thus, it is possible to generalize the findings of our study to all New Zealand dentists (assuming that the two groups do not differ with respect to any other characteristics).

There was a variable degree of item non-response (i.e. failure to answer particular questions). It is assumed that this did not materially affect the findings. Cross-sectional studies are not able to demonstrate cause and effect, merely associations between variables. Although there are a number of more recent stress measures used in the literature, we chose a modified version of that used by Cooper et al. [4] to allow comparison with previous work involving dentists.

There was considerable variation in the number of stressors experienced by dentists ‘frequently’ or ‘all the time’, with approximately half of respondents experiencing ≤5, but 5% experiencing ≥20. The most important stressors (treating difficult children, constant time pressure, maintaining high levels of concentration, coping with difficult patients and treating extremely nervous patients) were similar to those found in previously reported studies [4,5,15,18,19]. Newton et al. [16] suggested that paediatric dentists might be more stressed than other specialists, and Humphris and Peacock [18] proposed that treating children is the primary reason for the UK community dental service being so stressful. Time- and income-related stressors are reported to be high for dentists working in the National Health Service [15], where there is a perceived need to work quickly in order to generate sufficient income. In the current study, time pressure was a principal source of stress for dentists, but this may have related to scheduling and running on time, rather than treating as many patients as possible. Dentists in this study appear less concerned about the future than has been reported previously [20].

The most commonly reported stressors did not vary much between dentists, with no significant differences by demographic or practising characteristics in the reported frequency of being stressed by treating difficult children. Constant time pressure varied only by graduating cohort and maintaining high levels of concentration only by gender. In comparison, the ‘ability to sell practice in future’ varied by gender, graduating cohort, practice setting and weekly workload. It is possible that confounding factors are responsible for this, as male, older and rural dentists may treat more patients per week and be more likely to own their own practice. Finding time for family and friends appeared to be more of an issue for dentists who had graduated between 1980 and 1999 (presumably those with pre-school- or school-aged children). Similarly, Moller and Spangenberg [12] reported that difficulty in finding time for family and friends was more of a problem for younger dentists.

Although a medical emergency in the dental surgery has been found to be one of the most highly ranking stressors in the UK [4,15,18], only 15% of dentists in our study reported that this was a stressor very often or all the time. This may reflect a difference in the wording of the questionnaires used; Cooper et al. [4] used a five-point Likert-type scale ranging from ‘no stress’ to ‘a great deal of stress’, whereas we used a similar scale labelled ‘never’ to ‘all the time’. Although a medical emergency would be one of the greatest potential sources of stress, it does not occur commonly, and many dentists may not have experienced such an event.

A larger proportion of overseas-qualified dentists reported frequently experiencing many of the individual stressors. For example, although ‘feeling isolated’ was one of the least commonly reported stressors overall, a larger proportion of overseas- than New Zealand-trained dentists reported feeling isolated (P < 0.001). These dentists may need greater professional support, as professional isolation may put dentists at greater risk. It has also been suggested that the New Zealand population can be hard on practitioners from overseas [21]. Perhaps the public (and the dental profession) need their awareness raised with respect to the valuable role that these dentists play in the community.

Although overseas-trained dentists had a similar patient load to New Zealand dental graduates, a larger proportion of them reported that they were regularly stressed by factors such as long working hours, finding time for family and friends, earning enough money to meet lifestyle needs and cancellations or failed appointments. It is of some concern that overseas-qualified dentists experience higher levels of job-related stress. It is not clear whether there are differences in the perceptions of stressors between the groups or whether these dentists are subject to more sources of stress. New immigrant dentists may have extra sources of stress beyond the workplace (such as family remaining overseas, the challenges of settling into a new country and culture and language difficulties). It is likely that a combination of factors is responsible and these warrant further investigation.

Consistent with reports from previous studies [22,23], dentists tended not to apply active coping strategies for stress management. The gender differences were not unexpected with males more likely to report using sports and alcohol as strategies to relieve stress and female dentists preferring to interact with people and spend money. That >25% of respondents reported using alcohol to relieve stress is a matter of concern. It is likely that more consume alcohol, without identifying this as a means of managing stress. Other authors have reported worrying use of alcohol by dentists [9,12,24,25]. Conversely, Myers and Myers [5] reported that, although >90% of dentists in their sample consumed alcohol regularly, the mean weekly consumption was low. The finding that smoking and drug use were not frequently reported as stress-reducing strategies is consistent with the findings of other studies [12].

There is considerable variation in the number of stressors experienced by dentists. Overseas-qualified dentists appear to be under more stress than New Zealand-trained dentists. These individuals may need increased professional support. Dentists should be encouraged to make greater use of active coping strategies. Further research is indicated to determine why overseas-trained dentists appear to have more job-related stress and to identify interventions that could be used to decrease stress among dentists.


Key points
  • The most commonly reported stressors in New Zealand dentists were treating difficult children, constant time pressure and maintaining high levels of concentration.
  • Overseas-trained dentists reported more sources of stress than local graduates.
  • There are differences in the strategies used by male and female practitioners to manage stress.

 


   Conflicts of interest
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Conflicts of interest
References
 
None declared.


   Acknowledgements
 
The authors would like to thank Oral-B and Henry Schein Regional for sponsoring prizes as an incentive for participation in the study. We also thank the dentists for taking the time to accurately and honestly complete the questionnaire. Debbie Chi and Rumi Lee are thanked for their assistance with the survey.


   References
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Conflicts of interest
 References
 

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  5. Myers HL, Myers LB. ‘It’s difficult being a dentist': stress and health in the general dental practitioner. Br Dent J (2004) 197:89–93.[CrossRef][Web of Science][Medline]

  6. Gorter RC, Albrecht G, Hoogstraten J, Eijkman MAJ. Professional burnout among Dutch dentists. Community Dent Oral Epidemiol (1999) 27:109–116.[CrossRef][Web of Science][Medline]

  7. Osbourne D, Croucher R. Levels of burnout in general dental practitioners in the South-East of England. Br Dent J (1994) 117:372–377.

  8. Croucher R, Osbourne D, Marcenes W, Sheiham A. Burnout and issues of the work environment reported by general dental practitioners in the United Kingdom. Community Dent Health (1998) 15:40–43.[Medline]

  9. Gorter RC, Eijkman MAJ, Hoogstraten J. Burnout and health among Dutch dentists. Eur J Oral Sci (2000) 108:261–267.[CrossRef][Web of Science][Medline]

  10. Freeman R, Main JRR, Burke FJT. Occupational stress and dentistry: theory and practice. Part I recognition. Br Dent J (1995) 178:214–217.[CrossRef][Web of Science][Medline]

  11. Joffe H. Dentistry on the couch. Aust Dent J (1996) 41:206–210.[Web of Science][Medline]

  12. Moller AT, Spangenberg JJ. Stress and coping amongst South African dentists. J Dent Assoc S Afr (1996) 51:347–357.[Medline]

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  18. Humphris GM, Peacock L. Occupational stress and job satisfaction in the community dental service of North Wales: a pilot study. Community Dent Health (1992) 10:73–82.

  19. Hastings A. Stress in dental practice. J Am Soc Psychosom Dent Med (1982) 29:111–120.[Medline]

  20. Humphris GM, Cooper CL. New stressors for GDPs in the past ten years: a qualitative study. Br Dent J (1998) 185:404–406.[CrossRef][Web of Science][Medline]

  21. Crum D. Just a few thoughts. Riskwise New Zealand (Dental Protection Newsletter) (2007) 8:2.

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  23. Alexander RE. Stress-related suicide by dentists and other healthcare workers. Fact or folklore? J Am Dent Assoc (2001) 132:786–794.[Abstract/Free Full Text]

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