EMHJ Vol.16 No.

4 2010

EasternMediterraneanHealthJournal LaRevuedeSantdelaMditerraneorientale

Burnout among clinical dental students at Jordanian universities

D.H. Badran,1 M.H. Al-Ali,2 R.B. Duaibis 2 and W.M. Amin2

: . 703 . . .
ABSTRACT Dentistry is a profession demanding physical and mental efforts as well as people contact, which can result in burnout. The level of burnout among 307 clinical dental students in 2 Jordanian universities was evaluated using the Maslach Burnout Inventory survey. Scores for the inventorys 3 subscales were calculated and the mean values for the students groups were computed separately. Dental students in both universities suffered high levels of emotional exhaustion and depersonalization. The dental students at the University of Jordan demonstrated a significantly higher level of emotional exhaustion than their counterparts at the Jordan University of Science and Technology.

Lpuisement professionnel chez les tudiants en dentisterie des universits jordaniennes RSUM La dentisterie est une profession qui demande des efforts physiques et mentaux et un contact avec le public qui peuvent conduire lpuisement professionnel. Le niveau dpuisement de 307 tudiants en dentisterie de deux universits jordaniennes a t valu laide de linventaire dpuisement professionnel de Maslach. Les scores obtenus pour les trois sous-chelles de linventaire ont t calculs et les valeurs moyennes pour les groupes dtudiants ont t dtermines sparment. Les tudiants en dentisterie des deux universits prsentaient des niveaux levs dpuisement motionnel et de dpersonnalisation. Les tudiants de luniversit de Jordanie ont montr un niveau dpuisement motionnel nettement suprieur celui de des tudiants de luniversit jordanienne des sciences et de la technologie.

Centre for Educational Development; 2Department of Prosthetic Dentistry, Faculty of Dentistry, University of Jordan, Amman, Jordan (Correspondence to W.M. Amin: profwala@gmail.com).
1

Received: 02/12/07; accepted: 13/02/08

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Introduction
Dentistry is a profession demanding physical and mental effort as well as personalcontact,whichcanresultina conditionknownasburnout.Burnout isdefinedasasyndromeofemotional exhaustion and cynicism that occurs frequentlyamongindividualswhodo people-workofsomekind[1].Itis characterizedby3keyaspects:emotional exhaustion (mental fatigue), depersonalization (psychological distancingfromothers)andreduced personalaccomplishment[2,3]. The rate of burnout among dentists and its effect on their lives have beenpreviouslyinvestigatedbymany researchers[412].Burnoutcanlead to early retirement and indifference to treatment outcomes and patients conditionsorneeds[4].Theaffected dentistalsotendstoavoidcontactwith people,includingcolleagues,patients, friendsorevenfamily.Burnoutthereforeobviouslyhasseriousdetrimental effectsontheprofessionaswellason society[3,6]. Manyresearchershavestudiedthe existenceofstressamongdentalstudents[2,712]andafewhavestudied theprevalenceofburnout[2,79,12]. Inastudyaimedattestingtherateof burnout among German dental studentsat3universities[3],therewere highscoresforburnoutregardlessof theeducationsystemused.Inaseparate study, emotional exhaustion among dentalstudentsat7Europeanschools was significantly higher than among medical students [2]. The perceived stressamongdentalstudentshadbeen attributed to factors such as fear of failure[7], the load of academic and clinicalwork[8,11],nonavailabilityin some colleges of materials for study andclinicaltraining[10]andperformancepressureandself-efficacybeliefs [12].Ithasbeenreportedthatstudents whodemonstratedhighlevelsofstress tendedtoshowlowergradesinclinical

competency and contextual understanding[9]. Theaimofthisstudywastodeterminethepresenceandlevelofburnout amongclinicaldentalstudentsatthe2 dentalsschoolsinJordan.

Methods
In Jordan, there are only 2 dental schools,theUniversityofJordan(UJ) andattheJordanUniversityofScience andTechnology(JUST),bothoffering abachelordegreeprogramme. Theextentofburnoutin307clinical dentalstudentswasassessedusingthe MaslachBurnoutInventoryHuman ServicesSurvey(MBI-HSS)[1].The inventorycomprises22items(phrases) measuring 3 subscales of burnout: emotional exhaustion (9 items), depersonalization(5items)andpersonal accomplishment(8items).Respondentsscoreitemsonascalefrom1to4 indicating how often they encounter theitem:1(never,rarelyorafewtimesa year);2(onceorafewtimesamonth); 3(onceorafewtimesaweek);4(daily). Ahighdegreeofburnoutisreflected byhighscoresontheemotionaland depersonalization subscales and low scoresonthepersonalaccomplishment subscaleandviceversa.The3subscales, though related, are independent and thereforethedegreeofburnoutisexpressedbythescoresofits3subscales ratherthanbyatotalscore. The MBI-HSS is an effective tool ofprovenreliabilityandvalidityindetectingthepresenceandassessingthe degreeofburnoutinhumanservices workers.TheEnglishversionoftheinventorywasusedsinceEnglishisthe teachinglanguageinboththeJordanian dentalschools. Theclinicalstudents(4thand5th year) of the dental schools at UJ (n =83andn=93respectively)andJUST (n=64and n=67respectively)were askedtocompletetheinventoryduring

alectureateachoftheuniversitiesduringthe2ndsemesterafterthemidterm examinations. The instructions were explainedthoroughlytothestudents bytheresearchers.Theresponseswere totally anonymous to ensure confidentiality.Priortothesurvey,students were briefed on the objectivesofthe survey and the impact it would have on planning their study curriculum; theresponseratewas100%.Students werealsoaskedtodouble-checktheir answerstoensurecompleteresponses. Thescoreforeachofthe3subscales wascalculatedforeachstudentfrom the sum of responses to the items in the subscale. Mean values were then calculatedforeachstudentgroupseparately.ShapiroWilktestofnormality indicatedthatthedatawerenotnormally distributed in many instances; consequently,nonparametricstatistical testswereusedtocomparetheresults ofthe4studentgroups.KruskalWallis 1-wayanalysisofvariance(ANOVA) basedonrankswasusedindeterminingwhetheranysignificantdifferences existed among the groups. Multiple comparisonsamongthegroupswere performedusingtheMannWhitney ranksumtest.Statisticalanalysiswas carried out using SPSS, version 14.0, with the level of significanceset at P <0.05.

Results
Theresponsesforthe4thand5thyear students of each university were describedintermsofmeanandstandard deviation(SD).Cut-offvaluesabove which a subscale score was deemed highwereobtainedbycorrectingthe valuesindicatedintheMBI-HSSscoringkeytocompensateforthedifference inscoringscale. FemalestudentsatUJhadsignificantlyhighermeanscoresonemotional exhaustion(P<0.05)thantheirmale counterpartsinboththe4thyear[mean
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EasternMediterraneanHealthJournal LaRevuedeSantdelaMditerraneorientale

score27.3(SD5.2)versus23.2(SD 4.6)]and5thyear[29.9(SD4.8)versus 26.7(SD5.5)].Nosignificantdifferenceswerefoundbetweenmalesand females of either university in depersonalizationorinpersonalachievement scores(Table1). Pairwisecomparisonsshowedthat the4thyearUJstudentsexhibitedsignificantlyhigherdegreesofburnoutin all3subscalesthantheir5thyearcounterparts(P<0.05).Ontheotherhand, nosignificantdifferenceswerefound between4thand5thyearstudentsat JUST.ComparisonsbetweentheuniversitiesshowedthatUJstudentshad significantlyhigherdegreesofemotionalexhaustionthantheircounterpartsat JUST(P<0.05)(Table2).

highdegreesofemotionalexhaustion. Inapreviousstudyitwasreportedthat only22%ofthesurveyedstudentsfrom 7 European dental schools had high degrees of emotional exhaustion [2]. The scores of emotional exhaustion determinedinthisstudywereextremely high,especiallythoseoftheUJstudents. Eventherelativelylowerscoresattained bytheJUSTstudentswerestillhigher thanthosereportedbytheEuropean study[2].Thecauseofthehighlevelsof emotionalexhaustionshownbytheJordaniandentalstudentsmayberelatedto thepressuresofstudying,examinations, competitionandfulfilmentoftheminimumclinicalrequirementsinaddition totheprimarycauseofdirectcontact withpatients.Furtherinvestigationsto determinethepossiblefactorsrelatedto thisproblemanditspossiblecausesare necessaryandofsignificantimportance. Discussion Comparisons betweenthe2denAlmost all of the students in the 4th tal faculties showed that UJ students and5thyearsinthe2dentalschools hadsignificantlyhigherscoresofemointhe2Jordanianuniversitiessuffered tionalexhaustionthanJUSTstudents.
Table 1 Scores on the 3 subscales of the Maslach Burnout InventoryHuman Services Survey for 4 student groups
Student group/sex Emotional exhaustion (max. score 36) Mean (SD) 4th year UJ Male Female All 5th year UJ Male Female All 4th year JUST Male Female All 5th year JUST Male Female All 20.8 (4.8) 22.7 (4.9) 21.0 (4.9) 7.5 (2.3) 7.3 (2.3) 7.6 (2.1) 24.9 (4.6) 26.3 (4.0) 24.9 (5.0) 20.8 (5.4) 22.7 (5.2) 21.8 (5.4) 6.4 (2.2) 7.2 (2.3) 6.9 (2.3) 26.1 (4.2) 26.5 (4.0) 26.0 (4.6) 26.7* (5.5) 29.9* (4.8) 29.0 (5.2) 8.1 (2.9) 8.2 (2.6) 8.1 (2.7) 23.6 (4.6) 22.6 (4.0) 22.9 (4.2) 23.2* (4.6) 27.3* (5.2) 26.1 (5.4) 7.0 (2.3) 7.0 (2.6) 7.0 (2.5) 26.7 (2.9) 25.2 (4.6) 25.6 (4.1) Depersonalization (max. score 20) Mean (SD) Personal achievement (max. score 32) Mean (SD)

*P < 0.05 between males and females of the same student group. SD = standard deviation; UJ = University of Jordan; JUST = Jordan University of Science and Technology.

Althoughtheclinicaltrainingscheme issimilarinbothuniversities,thereare somedifferenceswhichmaybefavourabletoJUSTstudents.Thedentalfacultiesofbothuniversitieshaveaclinical trainingsystemwhichobligesastudent to successfully complete a minimum amountofclinicalrequirementsinorder topassanyclinicalcourse.Nevertheless, theminimumclinicalrequirementsof UJdentalfacultyaregreaterintermsof quantityandvarietyofclinicaltasksthan thoseofJUSTfor4thor5thyearstudents(datanotpresented).Thiscould requiremorephysicalandmentaleffort bytheUJstudentscomparedwiththeir counterpartsatJUST.Inaddition,UJ studentshavetofindtheirownpatients duetotheabsenceofapatientrecords filingsystem.ThedentalfacultyofJUST, ontheotherhand,organizesthestudents patient records and distributes them accordingtothestudentsneeds.This increasedthenumberofpatientstheUJ studentshadtointeractwith(datanot presented), which consequently may haveincreasedtheemotionalexhaustionlevelinthosestudents. Clinicalsessionswerelongerandless frequentinJUSTdentalfaculty(data notpresented).Thus,UJstudentsmay havebeenmorestressedtryingtofinish theirproceduresintime.Furthermore, havingmoreclinicalsessionsperweek meansahigherlevelofpatientcontacts, whichinturnislikelytoincreasethe levelofemotionalexhaustion. Theavailabilityofthestaffduring the clinical sessions might also have played a role. In JUST, the staff-tostudent ratio was very favourable for boththelearningexperienceandthe studentsmentalhealth.Aseachclinical instructorhandlesfewerstudents,the studentreceivesalongertimeandbetterattentionfromthestaff.Moreover, JUSTprovidesanallieddentalsciences programmewhosestudentsassistthe clinicaldentalstudentsduringtheirsessions,putting4-handeddentistryinto practice.TheFacultyofDentistryatUJ

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Table 2 Significance of differences (MannWhitney rank sum test) among students for the 3 subscales of the Maslach Burnout InventoryHuman Services Survey
Compared groups, year and university P-value Emotional exhaustion Depersonalization Personal achievement

Conclusions and recommendations

Thefindingsofthisstudyindicatedthat dentalstudentsatJordanianuniversi4th UJ versus 5th UJ < 0.001 0.005 < 0.001 ties suffered considerable degrees of 4th JUST versus 5th JUST 0.466 0.105 0.305 burnout. Dental students as well as 4th UJ versus 4th JUST < 0.001 0.914 0.422 instructorsshouldbeinformedabout 5th UJ versus 5th JUST < 0.001 0.270 0.014 burnout and its elements to increase UJ = University of Jordan; JUST = Jordan University of Science and Technology. theirawarenessoftheproblem.Analyticalstudiestargetingstudentshealth andpsychologyshouldbecarriedout doesnotoffersuchprogrammes;this awarenessofsuchaproblemisimpera- regularlytodeterminethecausesand hasobligedthestudentsoftheUJto tivetoavoidfurtherdevelopmentofthe factors related to the high degree of findtheirownpatientsandtohandle probleminthefutureclinicalcareerof burnoutamongdentalstudents. thementirelybythemselves thestudents. Depersonalizationmaybethemost High scores of personal achievecriticalaspectofburnoutinahealthcare mentmeanmoreinvolvementwiththe Acknowledgements professionsuchasdentistry.Perceiv- patientsandmoresatisfactionwiththe ingthepatientasanimpersonalobject professionandconsequently,lowerde- The authors express their sincere ratherthanahumanbeingmightresult greesofburnout.Thelowermeanscores gratitudetothedentalstudentsofthe universities who participated in this indetrimentalnegligenceintreatment of personal achievement in 5th year surveyandtothedeansofthe2faculprocedures and disregard ofthe psystudentsatUJcomparedwith4thyear tiesfortheirinterestinthestudyand chologicalaspectsoftreatingpatients. studentsshouldbeviewedasanother forprovidingaccesstolectures.Special Inbothdentalschools5thyearstudents signofincreasingburnoutwhichwas thanksgotoMsIkramTamimiofthe hadsignificantlyhigherscoresof derelatedtoincreasedpatientcontactin CentreforEducationalDevelopment personalizationthan4thyearstudents. Nosignificantdifferenceswerefound termsoffrequencyandduration(data forherinvaluableassistanceintabulatbetween students of the 2 schools in notpresented).Thisscaleofburnout ingthedataandorganizingtheresults. thesameacademiclevel.Thesefindings isextremelyimportantandshouldbe Theauthorswouldalsoliketoexpress mightsuggestthatdepersonalizationin- closely monitored during the clinical theirthankstoDrHananJafarofthe creaseswithincreasedpatientcontact. trainingperiodofdentalstudentsand Faculty of Medicine and Dr Ammar Longitudinalstudiesarenecessaryto even after their graduation to ensure Kassab,internandresearchfellowatthe confirmthissuggestion,butincreasing thatfeelingsoflackofpersonalachieve- FacultyofDentistryfortheireffortsand thestudentsaswellastheinstructors menthavediminished. assistanceinconductingthesurvey.

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