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 Table of Contents    
Year : 2016  |  Volume : 6  |  Issue : 2  |  Page : 67-71
Perceived sources of stress among Palestinian dental students: A descriptive cross-sectional study

1 Department of Operative Dentistry, Al-Quds University, Jerusalem, Palestine
2 Department of Conservative Dentistry and Prosthodontics, The Arab American University, Jenin, Palestine

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Date of Web Publication11-Jan-2018


Background: Dental education can be implicated with higher perceived levels of stress among dental students owing to the fastidious facet of the clinical and didactic dental curricula.
Aim: The aim of the study was to identify the perceived sources of stress among dental students and to investigate specific stressors related to the gender and year of study.
Materials and Methods: The students from the 2nd to 5th year of the dental school of Al-Quds University, Palestine, were invited to participate in the study. The Dental Environment Stress-30 questionnaire survey instrument was employed to conduct the survey among the students. Descriptive, bivariate, and multivariate methods were used to examine the patterns of association between individual stressors, factor scores, and students' characteristics.
Results: One hundred and eighty-two students comprised the study's analytical sample, with two-thirds of those being female. A four-factor solution emerged and included “academic workload,” “clinical training,” “time constraints,” and “self-efficacy beliefs” factors. “Fear of failing a course or a year,” “examinations and grades,” and “lack of time for relaxation” were among the top individual-item stressors reported by students. Primary sources of stress in the dental students were an ambiguity in self-efficacy belief, workload, and performance pressure. Females reported higher perceived stress than males.
Conclusion: Increased workload, time constraints, and some aspects of clinical training were the top stressors among the Palestinian dental undergraduates. This study emphasizes the need to implement a positive learning environment by employing strategies to combat the high levels of stress prevalent in dental schools.

Keywords: Dental education, dental students, Palestine, perceived sources, stress

How to cite this article:
Rabi TH, Arandi NZ. Perceived sources of stress among Palestinian dental students: A descriptive cross-sectional study. J Educ Ethics Dent 2016;6:67-71

How to cite this URL:
Rabi TH, Arandi NZ. Perceived sources of stress among Palestinian dental students: A descriptive cross-sectional study. J Educ Ethics Dent [serial online] 2016 [cited 2021 Apr 19];6:67-71. Available from: https://www.jeed.in/text.asp?2016/6/2/67/223001

   Introduction Top

Health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.[1] The psychological well-being is an integral health component, which influences the ability to learn and achieve the maximum professional potential. Stress is a very broad term that has been used imprecisely to describe different psychological conditions. Among several stress definitions, Lazarus and Folkman distinguish predecessors of stress from consequences of stress and define psychological stress as “a particular relationship between the person and environment that is appraised by the person as taxing or exceeding his or her resources and endangering his or her well-being.”[2] Dental schools have an environment that is highly demanding, fastidious, and stressful. Contemporary curricula require students to obtain training in both theoretical and surgical aspects of dental care including performing treatments on patients to qualify as competent dental professionals. Stressors associated with dentistry include time and scheduling pressures, managing uncooperative patients, and highly technical and intensive nature of work. The resulting stress can lead to depression, anxiety, substance misuse, diminished work efficiency, and burnout.[3],[4],[5],[6] Although studies have been conducted to evaluate the perceived stress among dental students in the Western world, no studies have evaluated the same in Palestine. Hence, the aim of the current study was to identify the perceived sources of stress among dental students in Palestine and to investigate whether specific stressor was related to year of study or gender.

   Materials and Methods Top

The study was designed to be a descriptive cross-sectional qualitative study. It was carried out using a self-administered questionnaire among 2nd–5th year Bachelor of Dental Surgery students enrolled with the Al-Quds University, Palestine, during the academic year of 2013–2014. A total of 182 students participated in the study, of which 141 were females and 41 were males. The purpose of the study was addressed in advance, and student participation in the research was voluntary. The students were asked to complete the questionnaire before the commencement of lectures. Stress was measured using a modified Dental Environment Stress (DES) questionnaire consisting of thirty stress-related items. The survey instrument was based on the 38-item DES stressors inventory introduced by Garbee et al.[7] Subsequently, Westerman et al. introduced a modified 34-item version of the DES.[8] In 2005, Polychronopoulou and Divaris [9] further revised the instrument, introducing a 30-item version that was used subsequently in multinational [10],[11] and longitudinal studies [12] among dental students, as well as dental residents.[13],[14] The instrument contains thirty dental education environment stressor items that students are asked to classify on a scale according to their stress-provoking potential as 1: not stressful at all, 2: somewhat stressful, 3: quite stressful, and 4: very stressful. These items include stressors such as “examinations and grades,” “lack of time for relaxation,” “patients been late or not showing up for their appointments,” “lack of confidence to be a successful student,” and “difficulty of assigned class work.” Collected data were entered in the Microsoft Excel and further analyzed by Statistical Package for the Social Sciences version 17.0. Descriptive, bivariate, and multivariate methods were used to examine the patterns of association between individual stressors, factor scores, and students' characteristics. P value was set at < 0.05. For the examination of perceived sources of stress, we used mean item scores to rank the stressors in order of descending importance in each category.

   Results Top

A total of 182 students participated in the study, of which 141 were females and 41 were males. The demographic data of the study sample are presented in [Figure 1]. The thirty stress provoking factors were divided into seven categories for the purpose of presentation: Self-efficacy beliefs, faculty, and administration, workload, patient treatment, clinical training, performance pressure, and others. The detailed mean scores and mean ranks according to each category are illustrated in [Table 1], [Table 2], [Table 3]. The primary source of stress in the students was self-efficacy beliefs, assigned workload, and performance pressure [Table 1]. Among the self-efficacy beliefs, insecurity regarding the professional future (93.4%) was the most common stressor in 3rd-year student followed by failing the academic year (82.16%) in both 3rd-year and 4th-year students. The 5th-year students were most stressed about the fear of unemployment after graduation and lack of confidence about being successful candidate equally. When stressors related to workload were assessed, receiving criticism about assigned work was the most common in 3rd-year students (89.26%), lack of time for relaxation in the 4th year (91.25%), and difficulty with classwork and lack of time to do assigned work equally in 5th-year students (76.88%). It is noteworthy that female students were 45.65% more likely to perceive stress about “difficulty of classwork” than their male peers. Besides, females had higher stress scores in “fear of failing course” and in “laboratory and preclinical training” as well as in “learning of clinical procedures and protocols.”. It was also noted that the faculty and administration had a part to play, with increased stress scores correlating with “rules and regulations of the school” and “learning environment created by the faculty” [Table 2]. A noteworthy point is a majority of the students rated they had lesser time for relaxation, indicating time constraints due to dental education [Table 3]. The factor covariance matrix was used to denote correlations between the stressors, ranging from 0.31 to 0.42 (all P < 0.0005), indicating a high correlation between these factors [Table 4].
Figure 1: Demographic data of the dental students

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Table 1: Mean scores and mean ranks of the stressors in the performance pressure, workload and self-efficacy beliefs categories amongst the participating dental students (n=304)

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Table 2: Mean scores and mean ranks of the stressors in the clinical training, faculty and administration and patient treatment categories amongst the participating dental students (n=304)

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Table 3: Mean scores and mean ranks of the stressors in the others category amongst the participating dental students (n=304)

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Table 4: Covariance* matrix of the four dental environment stress 30-sp factors

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   Discussion Top

Stress can be metaphorically compared to a double-edged sword that can either stimulate and motivate the students to peak performance or reduce students to ineffectiveness. This study explores the stress-inducing factors among dental school students and supports the existing evidence in the literature. Primary sources of stress in the dental students were a self-efficacy belief, workload, and performance pressure. This is consistent with the findings of other studies. A recent systematic review has concluded that dental students experience considerable amounts of stress during their training. This stress is mainly due to the demanding nature of the training.[15] In addition, the study suggested adverse effects of elevated stress on students' health and well-being. Another systematic review confirmed that examination, grades, and clinical requirements were the main sources of stress for dental students.[16]

In the dental school in which the authors conducted the study, the 1st- and 2nd-year students basically study the biomedical didactics. Dental courses primarily begin from the 3rd year with the inclusion of preclinical laboratories; clinical exposure begins and continues through the 4th and 5th years of dental school. It was noted that there was a difference in dental student stress perception. This was related either to the phases of curriculum or associated individual and educational parameters. The causes of stress varied by year of the study with some overlaps. Students were most concerned with “self-efficacy beliefs” during the 2nd year. However, over a period of time, it decreased gradually through the 4th and 5th year. This may be attributed to the gain of confidence with progress in academic years. The 3rd-year students may be overloaded with high academic demands as they get introduced to clinical procedures and absence of early clinical exposure may incite anticipatory stress reactions with regard to upcoming encounter with clinical training. Stressors appear to be a significant concern for 4th-year students as they face difficulties in assessing their clinical work due to uncertainty about some aspects of their clinical competence. Moreover, it was seen that “lack of time for relaxation” in a 4th-year student may be attributed to the initiation of clinical training. This finding is consistent with various other studies, which showed students' stress from workload and clinical training increased as they progressed in their curriculum while stress from faculty and administration factors decreased.[17] A study conducted in the United States also described variations in sources of stress over time but within the 1st year of dental school.[18] Informal nature of social relationships in Greek dental schools helped the students interact comfortably with the faculty in a public dental school environment where there was a minimal financial commitment from students.[10]

Regarding the relationship between gender and perceived sources of stress, it was found that female reported higher percentages of stress in certain aspects of the educational process which includes lack of confidence to become a successful dentist, fear of failure, examination, and grades. These findings have been supported by many studies.[8],[18],[19],[20],[21] The reason for this may be attributed to the different patterns of response to stressful events. Sanders and Lushington, however, suggested that gender differences may be due to different patterns of psychological morbidity and because males are less expressive of their concerns.[20]

Dental education may develop stress which may lead to adverse consequences such as fatigue, mood alteration, sleep disturbances, the effect on performance, and headache. Stress reduction programs should be implemented to counter the ill effects of stress. This may include specific courses, stress reduction sessions, introduction to behavioral sciences, and faculty incorporated advising systems. A study by Muirhead and Locker found that social support from teachers, parents, or other students tended to have less stress on dental students.[10] Sugiura et al. concluded that regular exercise lowers stress and develops good human relationships.[22] Music and movies are also believed to have a soothing effect on the mind, thus enabling students to relax.

The limitation of this study is the cross-sectional nature of the data; to generalize the findings for a larger audience, longitudinal studies would be more acceptable. Probing into the origin of stressors, whether previously existed or developed during dental education, is essential to draw conclusions about the causal relationships between stress and dental education. Furthermore, it becomes vital to probe into the issue whether the associated stressors are generalizable to students of various other professional educations or only restricted to dental education.

   Conclusion Top

The study brings under the magnifying glass, the most common stressors in dental education - increased workload, performance pressure, and their self-efficacy beliefs. Students perceived different levels of stress in different years of study. Moreover, females reported higher levels of stress in certain areas of dental training. High rated stressors were prevalent in professional education and were related to diverse dental education settings. Hence, there arises a vehement need to implement a positive learning environment by employing strategies to combat the high levels of stress prevalent in dental schools. By identifying and curbing the menace of potential stressors in a learning environment, dental schools can help mold a better generation with better dentists.

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Conflicts of interest

There are no conflicts of interest.

   References Top

World Health Organization. Basic Documents. 39th ed. Geneva: WHO; 1992.  Back to cited text no. 1
Lazarus RS, Folkman S. Stress, Appraisal, and Coping. New York: Springer Publishing Company; 1984.  Back to cited text no. 2
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O'Mahony P, O'Brien S. Demographic, and social characteristics of university students attending a psychiatrist. Br J Psychiatry 1980;137:547-50.  Back to cited text no. 5
Gorter R, Freeman R, Hammen S, Murtomaa H, Blinkhorn A, Humphris G, et al. Psychological stress and health in undergraduate dental students: Fifth year outcomes compared with first year baseline results from five European dental schools. Eur J Dent Educ 2008;12:61-8.  Back to cited text no. 6
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Heath JR, Macfarlane TV, Umar MS. Perceived sources of stress in dental students. Dent Update 1999;26:94-8, 100.  Back to cited text no. 19
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Correspondence Address:
Dr. Tarek H Rabi
Al-Quds University, Jerusalem,
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jeed.jeed_12_16

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  [Figure 1]

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


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