Articles, Dentistry

Stressing out

This article reports on some of the results of a survey of UK salaried primary care dentists that took place in summer 2013 focusing on levels of job stressfulness and the sources of work-related stress.

In summer 2013, the BDA (British Dental Association) undertook a national survey of community and salaried primary dental care services to provide evidence for its submission to the Review Body on Doctors’ and Dentists’ Remuneration (DDRB) to support pay claims for dentists in the UK. The BDA presents written and oral evidence to the DDRB to help it keep up-to-date on recruitment, retention, motivation and changes in practice expenses in dentistry. Evidence is submitted on behalf of dentists in England, Scotland, Wales and Northern Ireland in general dental practice and the salaried primary dental care service. 

As well as collecting evidence on levels and sources of stress, the survey sought to identify what motivates salaried primary care dentists, gauge levels of morale and well-being, and assess the current state of salaried primary care services. The survey was administered online to 1,351 BDA members and valid responses were received from 499 dentists employed in salaried primary care, community or special care dental services. 

The measure of work-related stress used in this survey

A single-item measure of self-reported stress has been widely applied in UK population surveys, such as the Health and Safety Executive’s Psychosocial Working Conditions Survey (HSE, 2012) and the Scottish Health Survey (2010, 2012). We modified the measure used in these surveys for use in our own survey of salaried primary care dentists. We asked them: ‘How do you find your current work as a dentist?’ Responses were recorded using a five-point Likert scale ranging from ‘not at all stressful’ through to ‘extremely stressful’. In studies using a single-item approach such as HSE (2012), ‘very stressful’ and ‘extremely stressful’ have been used as a threshold to identify those with ‘high work-related stress’ or ‘high job stress’ (HSE, 2012; Houdmont et al, 2010). We followed this approach in our own analysis.

Stress among salaried primary care dentists

High levels of self-reported stress at work are a concern because they are linked to mental well-being more generally (Smith et al, 2000). In the BDA’s 2013 survey of salaried primary care dentists, the prevalence of high job stressfulness among salaried primary care dentists was estimated to be 37% (N=180) (Figure 1) (following Smith et al (2000) and HSE (2012) responses that fall in the categories of ‘very’ or ‘extremely’ stressful are used as a broad indicator of job stressfulness). This compares with estimates of 15% for British workers more generally according to a national survey undertaken by the Health and Safety Executive (HSE, 2012). That is, salaried primary care dentists are more than twice as likely to report high levels of job stressfulness by comparison with all employees.

In addition, the survey found that salaried primary care dentists working for providers in England were more likely than those in other UK countries to report high levels of job stressfulness (40%, compared with 27% for salaried dentists in Wales, Scotland and Northern Ireland combined). 

Figure 1: Levels of self-reported job stressfulness among salaried primary care dentists in the UK (Base all respondents; N=486; Missing=13)

 

Sources of work-related stress among salaried primary care dentists

Those respondents who said they experienced some stress in relation to their work as dentists were asked an open question about the sources of this stress, with 431 responding to this question. A simple thematic analysis of this data was then undertaken to identify the sources of work-related stress described in their accounts. Table 1 shows the results of this analysis. The most commonly identified sources of work-related stress were:

  • Time constraints or pressures, with 27% identifying this as a source of stress
  • Challenging patients – for example, patient or carer expectations, anxious patients (26%)
  • Management – for example, poor quality management, managerial expectations, lack of support (21%)
  • Administrative duties and other non-clinical responsibilities (14%)
  • Workload – for example, too much work, work-life balance, working late (13%)
  • Staffing issues – this includes staff shortages (where there are insufficient numbers of staff employed by the service) and understaffing (where staff are temporarily absent or unavailable, for example, due to illness) (12%).

Providing care for patients with complex health needs can sometimes be stressful in itself, but it was clear from the BDA’s research that there are a number of service-level factors and aspects of the role that exacerbate this stress. For example, salaried primary care dentists are required to meet high levels of demand and maintain high standards of care while often receiving little support in poorly resourced and unstable services.

Working with special-care patients and the nature of the treatments provided was one of the most commonly identified sources of stress among salaried primary care dentists. From Table 1, it is clear that the stress experienced when treating patients and managing their care is exacerbated by unrealistic targets and high numbers of patient referrals.

The capacity of services to cope with high levels of patient demand is affected by a number of service-level factors, including: service instability; financial constraints; understaffing and other staffing problems; staff shortages and other staffing problems; inadequate equipment or systems that do not work properly. Constraints on service capacity in the face of high patient demand mean that dentists’ workloads are bound to increase and the tension between ‘clinical time’ and the time required to complete administrative tasks becomes more acute. Being overburdened with administrative tasks and having to cover gaps in staffing, further erode the amount of time available for patient care.

This combination of high patient demand, limited service capacity, and a high administrative burden means that dentists sometimes struggle to find the time required to perform their principal role: treating patients. Where the quality of management is poor and managerial or administrative support is inadequate, then the capacity of dentists to respond to and cope with these pressures may be eroded further.

It is this conjunction of factors that may explain why dentists working in salaried primary care and community dental services are at a much higher risk of reporting high levels of work-related stress by comparison with UK workers more generally.

 

Conclusion

The results from our survey show how salaried primary care dentists often feel caught between conflicting sets of demands on their time and the expectations of patients, managers and the organisations they work in.

The capacity of salaried primary care dentists to perform their role and meet these expectations are sometimes undermined by a number of factors that may put them at a greater risk of high levels of work-related stress. These factors include: poor quality management; conflict or lack of cooperation between staff; job insecurity or poor working conditions; lack of support from colleagues or managers; lack of administrative or technical support. 

How dentists respond and cope with work-related stress and how much support they are able to call upon when they are under pressure may determine whether such stress translates into more negative consequences for their work and personal wellbeing.

The results reported here point to a number of measures, which may help to reduce the risk of high levels of work-related stress among salaried dentists. For example:

  • The healthcare providers and services employing salaried primary care dentists need to identify the main triggers for job stress among their clinical staff and develop strategies for preventing and effectively managing stress at work. This means promoting a greater awareness of work-related stress and its causes, and introducing measures to promote mental well-being at work
  • Many salaried primary care dentists in our study alluded to poor quality management or demanding targets as common sources of stress. Salaried primary care dentists must be able to call on effective and supportive management to assist them in managing the demands placed upon them
  • It is critical that salaried primary care dentists have sufficient clinical time to provide patients with the best possible care – this means not over-burdening salaried primary care dentists with administrative tasks that compete with clinical time
  • Service-level targets and managerial expectations should be realistic. How they impact on individual dentists and the care they provide needs to be considered carefully by service managers and commissioners
  • Adequate funding and resources must be available to ensure that high quality dental care is provided to all patients referred into salaried primary dental care services. There needs to be sufficient staffing to meet the level of demand for these services and to ensure that an individual dentist’s workload does not become excessive. 

For a list of references contact julian.english@fmc.co.uk.

 

Dr Martin Kemp is research manager at the British Dental Association, and Henry Edwards is a BDA research analyst.

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