Burnout among Undergraduate Dental Students at a Public Academic Institution in Lahore, Pakistan

 

Shamta Sufia1                   BDS, MSc, PhD


Waqas Latif2                     MSc

 

ABSTRACT:

Emotional, mental and psychological health influence academic performance. A stressful environment leads to impaired academic functioning and adds to student apprehension and anxiety, and thus, burnout. Burnout is ‘a syndrome that occurs frequently among individuals who do ‘people-work’ of some kind’. Initially studied among human service professionals e.g. nurses, doctors and teachers etc. attention lately has been on student burnout especially in medical and dental sciences.

OBJECTIVE: The study was undertaken to verify the presence of burnout in undergraduate students of dentistry at a public sector dental institute.

METHODOLOGY: two hundred and seventy five students from a public sector college of dentistry participated by filling The Maslach Burnout Inventory.

RESULTS: Moderate to high levels of emotional exhaustion is experienced by majority of students and so is feeling of depersonalization in their final year. Older aged students and those in their final year of training experienced burnout.

CONCLUSIONS: Burnout is experienced by students of dentistry in the public sector dental institute.

KEYWORDS: Burnout, Dental Students, Dental Education, Maslach Burnout Inventory.

HOW TO CITE: Sufia S, Latif W. Burnout among Undergraduate Dental Students at a Public Academic Institution in Karachi, Pakistan. J Pak Dent Assoc 2016; 25(4): 131-36

Received: 23 June 2016, Accepted: 12 December 2016

INTRODUCTION

In Pakistan, the eligibility for a student to take admission into the professional dental education starts after higher secondary school or equivalent 12 years of school education. Students either enter a public sector dental institution or may go to a private dental college. Students in the public sector institutions have varied backgrounds. They come from all regions of the country. The program constitutes four years of structured training during which subjects related to medicine and dentistry are taught. Basic dental sciences are introduced during the initial years along with the basic medical sciences. Preclinical laboratory work is an essential part of the training program during the first two years. Training is quite intense, both academically and clinically. Students over the four year course and especially  in the entry year are introduced to concepts to which there is no previous exposure. At the same time, students of dentistry have to cope with an entirely different and new environment. This occurs mostly for students who leave the safe and secure environments of their homes. The new concepts and the academic pressure to excel in studies put a lot of stress on students. All together students have to keep pace with academics, laboratory work and clinical service. Hence, they may experience exhaustion or burnout.

Burnout is ‘a syndrome of emotional exhaustion, cynicism and detachment, and feelings of ineffectiveness and lack of accomplishment that occurs frequently among individuals who do ‘people-work’ of some kind1 . Burnout was initially found among human service professionals in constant interaction with people e.g. nurses, doctors and teachers etc. and in those with interpersonal relationship between caregiver and the recipient of care2,3. Burnout is characterized by three key aspects: emotional exhaustion (EH) explained as the mental fatigue, depersonalization or cynicism (DP) which is the psychological distancing from others, and reduced personal accomplishment (PA)4 .Burnout is slow and insidious which makes a person incapable to work effectively at personal or professional level.

It is well known that emotional, mental and psychological health influence academic performance. A stressful environment leads to impaired academic functioning and adds to student apprehension and anxiety, and thus, burnout. In addition to the academic demands, a change in comfort level due to changed social and family environment, culture, loss of familiarity, contribute to the stress felt by students. Financial responsibilities, social pressures and expectations add to the stress level as does the fear of failure. Uncertainties about future life after graduation also lead to production of burnout. Academic and clinical work load, unavailability of materials for study and clinical training, performance pressure, self-efficacy beliefs are assumed to lead to burnout5.

Recently, attention has been focused on student burnout especially in medical and dental sciences. The effect of burnout is high levels of stress which tends in lower grades for clinical competency and contextual understanding. High scores of burnout among medical and dental students have been reported in literature4-6. Emotional exhaustion among dental students has been found to be significantly higher than the reported scores of medical students4 which may affect as high as 85% of college students on a daily basis.

The purpose of this study was to verify the presence of burnout in undergraduate students of dentistry at a public sector dental institute. No previous information is available on the level of burnout among students of dentistry in Pakistan even though studies addressing burnout among dental professionals are available. This was felt important because dysfunctional coping and mismatch can, in the long run, have serious detrimental effects on the profession as well as on the society. Early detection of burnout is imperative because of its work related implications. It is essential to take effective measures to control burnout in order to avoid the long term adversarial effects on medical and dental practice. Prevention strategies and measures can be introduced when very early symptoms appear.

METHODOLOGY

English version of The Maslach Burnout Inventory – Student Survey (MBI-SS), was used to assess the Burnout syndrome. The inventory is an effective tool of proven reliability and validity in detecting the presence, and assessing the degree of burnout. The MBI-SS is a selfassessment, seven-point Likert-type scale, with categories ranging from “never” to “every day”. The instrument consists of 15 questions, which are divided into three dimensions, emotional exhaustion (EH) with 5 items, Cynicism (C) with 4 items and Professional Efficacy (PE) with 6 items. Scores on each scale are added and interpreted as follows. Emotional exhaustion is considered high if the scores is more than 14, medium when score ranges between 10-14 and low for 0-9 score. Cynicism scores ranging between 0-1 are considered low, 2-6 taken as moderate and > 6 was considered high. On the other hand, professional efficacy was considered low when the scores were greater than 27, moderate for 23-27, and considered high when the score was less than 23.

This survey was done ensuring that the students did not have tests or assessments during the week of implementation of survey. All students present for lecture at a given day were distributed a copy of the inventory after taking free verbal consent. The instructions were explained thoroughly to the students. The response was anonymous to ensure confidentiality. To characterize this study’s population,socio-demographic information on gender, age, year of the course, who the student lives with was also collected. Students were given 15 minutes to complete the questionnaire. All questionnaires with completed information were included for analysis.

The data were organized and analysed for all study variables using the program Statistical Package for Social Sciences (Version 17.0, SPSS Inc., Chicago, Illinois, USA). The age of the students was dichotomised since a lot of variation existed in ages of students in all years of training for meaningful analysis. Similarly, the variable “with whom student lives with” was also dichotomised to be analysed meaningfully as very few lived independently or with people other than their own families. The total score for each of the three subscales was calculated by the sum of responses to the items in the subscale. Mean values were then calculated for each subscale. Chi square test for associations was performed for age, gender, and who the student lived with. Independent t-test for difference in means was performed for age, gender, who student lived with as independent variables while for year in training ANOVA with post hoc Tukey’s test was performed. The level of significance for decision making was 5%.

RESULTS

Out of 276, a total of 225 forms were received, yielding an overall response rate of 81.5%. The least response was from within the third year of which only 58.3% completed the survey form which had no missing data. Distribution of students according to sex, mean age and age range, response rate in respective year of training are given in Table 1. The mean burnout scores with standard deviation (SD) for subscales was as follows; EH: 12.36 (SD. 5.77), DP :6.88 (SD 5.09), reduced PA: 24.29 (SD. 6.29).

Table 2 demonstrates the percentage of student burnout for subscales “Emotional exhaustion”, “Depersonalization”, and “Low professional efficacy”. High levels of EH and DP were reported for more than two third of the students as was low professional efficacy (Table 2). Statistically significant difference in the proportion of high EH and DP was observed among relatively older students. High EH was also seen among students in their final year of studies. No significant difference in low PA was observed between the sub-groups (Table 3). Table 4 shows mean difference in burnout scales in relation to age, gender, whom student lives with, and year of training.

DISCUSSION

Burnout is said to be a gradual and cumulative process which if overlooked can have detrimental effects and can get worse over time7. The physical, mental and social implication of burnout has put it in the category of the many public health problems8. Burnout and stress can put a person at risk of developing a number of medical problems such as insomnia, headache, cardiovascular and gastrointestinal problems, backache, chronic fatigue and palm sweating9.

Individuals affected with burnout also have higher levels of depression, obsessive-compulsive disorders, and interpersonal sensitivity than age-matched norms10. Unexplained anger, irritability, exhaustion, apathy, hopelessness, detachment, poor performance and lack of productivity may be some of the early signs. Their psychosocial implication puts it into an important work related problem requiring early recognition and address. A study by Ghali & Awooda revealed that more than half of the students suffering from high levels of emotional exhaustion7. Burnout remains high in dental students during the pre-clinical and clinical years10. Camposet al.8 in their study report almost 2/5th of students suffer from burnout. The exhaustion scores were reportedly higher for first and third year students8. In contrast, the present study observed burnout in more than 2/3rd of the sample which is much higher than that reported previously. In the present study, however, scores were highest for exhaustion and depersonalization. Students in the current study demonstrated high emotional exhaustion especially affecting the fourth year students. This may be because fourth year students have clinical assignments where they work on the patients in the limited space of the oral cavity. They also have to work hard for completion of their assigned clinical service quota. The constant worry to carry out and complete the assignments during the time period of rotation during academic year may be adding to their stress levels. Exhaustion is considered the first level of burnout according to Maslach’s model. Emotional exhaustion may be the result of disparities between input and the rewards, in the case of current study, timely and successful accomplishment of clinical cases in a limited time span. The students during this period have to face a number of problems such as unavailability of materials, interruptions in power supply, competition for allocation of patients etc. (unreported student responses not a part of study). Similarly, a high level of cynicism was also observed. Among students cynicism has been said to reflect insecurities in treating and dealing with patients11. Past studies have focused on clinical years for presence of burnout among dental students. Among many stress factors identified, humiliating attitudes of instructors in front of patients and display of displeasure with the procedures have been reported12. Behaviour of staff with students was also reported to create stress among students in past research. Another cause of burnout reported by students is insufficient time between exams12. Considering the high burnout rate in this particular group of students in public sector dental institution, it is suggested that further investigation are carried out for exploring the reasons for burnout.

Dental students experience a lot of distress which has been reported in the past, too13. This nervousness and stress levels remain high for dental students as compared to other fields14,15. The current study observed a higher burnout among female students. Polychronopoulou and Divarisalso reported gender based differences with a higher stress among female students9. The stress and burnout continues beyond undergraduate years and seems to progress after graduation among females during their post graduate training courses16.

In accordance with the findings of Martinez et al. and Carlotto et al.17,18 a high burnout (EH)was seen in first year students although this was less than that reported for the fourth year students, but also higher than for students in their second or third year of training. A similarly high emotional exhaustion among first year dental students has been reported by Humphris et al.4 who reported 22% first year students affected. The scores for low professional efficacy showed burnout among the first year students as compared to other years.Carlotto et al. and Martinez et al.17,18 also found this relation, stating that the lower the course year, the greater the emotional exhaustion, cynicism in education and lower sense of professional efficacy. This difference may have resulted from new entrants undergoing unfamiliar and very demanding courses offered during the first year in addition to the demands of training in laboratory procedures. Study by Gorter et al. concluded that student’s increasingly develop emotional exhaustion and distress from first year through their final year19. In contrast, the present study observed higher levels of burnout in first year and fourth year students whereas the difference in burnout between the two clinical years (third and fourth year) was not significant. Progressive nature of burnout suggested by Gorter et al .was not observed.

Similar to findings of Ghali and Awooda there was no significant difference between the means scored of EE, PA and DP among males and females students7 . Low professional efficacy although did not achieve statistical significance, was observed in a higher number of younger aged students, in females, people living at homes or independently and in students in their first year of dental school.

Dentistry has been related to a stressful and a challenging field. Professional burnout may also lead to other problems such as depressive symptoms20. A significant relationship has been observed between burnout and depression, and between depression and suicidal ideation among dental students10. Professional burnout may start very early when students are expected to learn professional skills in addition to volume of medically and dentally related knowledge9. Although no direct association between burnout and suicidal ideation has been found, with the high prevalence of burnout in the current sample, it is quite possible that burnout may lead to depression and pose a risk of suicidal tendencies in these students. Professional burnout can be a good indicator of inability in achievement of professional and academic excellence17. Poor performance by students during the training period may result in higher burnout, too. .Lack of self-esteem and self-confidence, and inability to rectify mistakes or manage educational demands are a product of burnout in students12. Personality factors also determine level of burnout among medical and allied health professionals22,23 and may even protect against the risk of developing burnout24.

Although the results cannot be generalized to all students of dentistry in Pakistan, we conclude that burnout is quite prevalent. Further studies are required at a much broader level and appropriate measures should be taken to monitor the burnout among dental students.


1 Assistant Professor, Community & Preventive Dentistry Department, de’Montmorency College of Dentistry, Lahore
2 University of Health Sciences, Lahore
Corresponding author: “Dr. Shamta Sufia” < ssufia@yahoo.com >