The greatest difficulty we encountered when evaluating stress levels in dental students was the wide range of potentially stressful sources or stressors.31 In this study, we measured potentials sources of stress in Dominican students pursuing courses with clinical practica, as previous studies concluded that factors causing dental students significant stress were relationships with patients, administrative and support staff, as well as the professors of the clinical practica.21,28,29,32-35 Authors like Alhajj et al9 and Alzahem et al2 have added that stress levels increase progressively the farther along a student is in the program. In this study, students in their 12th term demonstrated the highest stress levels, obtaining significant values for items referencing proximity to end of program, final exams, increased interaction with patients, and teaching and admin staff,29,30 insecurity about the job market, lack of confidence in future as a dentist without professor supervision, and even doubts as to their true calling. Abu-Ghazaleh et al have highlighted the importance of family expectations with regard to academic success.8 Other studies11-14,16,20 yet have stated that clinical requirements are significant stressors. The present study did not take this item into account, as it was not part of the clinical evaluation. As for increased uncertainty and insecurity,34 students may very well experience anticipatory anxiety because of it, although it generally tends to subside with experience.36,37 Other authors have found that anticipatory anxiety sets in in the third term, when students are first exposed to patients. 11,12,16,18,20,23,35,38,39 With regard to sex, our data shows greater stress levels in women, with significant differences for certain items (Table 3). As for the bibliography reviewed, women, as a rule, demonstrated greater values across varying scales.4,19,20 However, a number of studies8,9 posit that this could in fact be cultural in nature, claiming that women in the populations studied are more likely to be open about their feelings, whereas men are more likely to bottle up their emotions when faced with challenges.9 Conversely, other authors claim that,12,29,30 generally speaking, men present greater stress levels, while Inquimbert et al affirmed in 2017 that there are no significant differences between the sexes.17
When analyzing the total mean value of each specific item in the present study, we found that the exams item obtained the highest score (M: 4.44, S.D.: 0.652). Table 2. Generally speaking, evaluations can provoke intense stress levels in students and require a high level of responsiveness,22,40-43 given that they must pass said exams to complete the terms and program. These results coincide with numerous works published in the literature that establish that exams and evaluations are among the top five most stressful factors faced by students.2,3,8,9,11,14,16-18 Grades alone may also generate stress, as there is generally a fair amount of competition associated with them.44
The item with the second-highest score in our research was fear of failing, which may be linked to poor test results, carrying out a clinical procedure incorrectly or facing the consequences of said error, as well as clashes with parents.3 These results coincide with other studies that have placed this element among the top five most stressful factors faced by dental students.9,18,20,34
Professors play a key role in ensuring the quality of treatments patients receive and alleviating any discomfort they may suffer.45 Some students believe that professors are, at times, a source of considerable stress,2 as they receive contradictory instructions from them when treating patients. 9,11 This leads to lowered self-esteem in students when required to make clinical decisions, and increased mental distress.46 Students observe that their professors are not consistent in their ways, and that their requests are not always reasonable. As a result of this, students may adopt a passive attitude, and attempt to fly below the radar. This may compromise students’ progress, as obtaining passing grades becomes their only focus.21 In response to this, Muirhead and Locker concluded that it would be helpful to train clinical staff and attempt to unify evaluation criteria to minimize this source of stress.39 Conversely, authors like Fonseca et al13 and Ersan et al12 believe varying staff criteria and the environment created by clinical professors to be irrelevant as a source of stress in students.
In the vast majority of surveys, there is no allusion made to the fact that variables are correlated using factor analysis, and that groups may have been established in an arbitrary way. In our survey, factor analysis followed by VARIMAX enabled us to group together and score the sources of stress across ten dimensions, which, however, could not explain 100% of the stress generated (as with Sanders and Lushington,46 also using VARIMAX). This occurs because stress is a multidimensional concept with variables acting independently in each individual. Yet we can affirm that the academic factor is the most relevant stressor, as reflected in other studies.22,35,40,41,47,48
That being said, this factor is not exclusive, as it interacts with others. If a student fails his or her exams, he or she will not pass their courses, will have to face their parents and professors after a failing grade, and may have subsequent personal problems (daily life factor), as described by Yap et al.40
Furthermore, the atmosphere in the clinic item is essential to distinguishing the first period from the second, and reflects the transition from basic sciences to clinical sciences.47 The fact that the responsibilities associated with patient management scored higher in our sample than the opinions that patients may have regarding the treatments received suggests that what actually causes stress among dental students is carrying out treatments, not patient management per se. Students’ inexperience and professors’ high expectations may increase treatment-related stress.
The primary obstacle we encountered during this study was the potential subjective nature of the responses given. In order to validate the tools applied here, we suggest carrying out a multicentric study in all of the dental schools in the Dominican Republic.