|Year : 2013 | Volume
| Issue : 2 | Page : 64-70
Clinical anxiety among final year dental students: The trainers and students perspectives
A Obarisiagbon1, Clement C Azodo2, JO Omoaregba3, BO James3
1 Department of Oral and Maxillofacial Surgery, University of Benin Teaching Hospital, Benin City, Edo State, Nigeria
2 Department of Periodontics, University of Benin, Benin City, Edo State, Nigeria
3 Department of Clinical Services, Federal Neuropsychiatric Hospital, Uselu, Benin City, Edo State, Nigeria
|Date of Web Publication||19-Jul-2013|
Clement C Azodo
Department of Periodontics, New Dental Complex, University of Benin Teaching Hospital, P.M.B. 1111 Ugbowo, Benin City, Edo State
Background: The dental clinical setting, which is a significant learning environment for undergraduate dental students, may induce anxiety, which may adversely affect the clinical performance. The purpose of this cross-sectional study was to determine the factors provoking clinical anxiety in dental students from the trainers and students perspectives. Materials and Methods: This cross-sectional study was conducted among 6 th (final) year dental students of University of Benin and their clinical trainers between January and March 2012 using the 38-item modified Moss and McManus clinical anxiety questionnaire. Results: Of the 67 participants, 32 (47.8%) were 6 th year dental students while 35 (52.2%) were clinical trainers. According to the students, the top clinical anxiety provoking situations were inability to meet requirements before exams, inability to pass the final exams, dealing with psychiatric patients, coping with uncooperative children, getting infected by patients, fracturing a tooth during extraction, extracting the wrong tooth, discovering calculus by the supervisor after scaling, accidental pulp exposure, inadvertently hurting patients and using the high speed hand piece. There existed concordance on the top two clinical anxiety provoking situations reported by the students and their clinical trainers. However, measuring blood pressure, taking pulse, presenting in the clinic, handling a syncopal attack, and accidental pulp exposure were statistically significant contrasting clinical anxiety provoking situations from dental students and trainers perspectives. Conclusion: Data from this study revealed that clinical trainers share largely the same perspectives with the dental students on the clinical anxiety provoking situations with slight variations. Fostering a supportive learning environment conducive to dental student learning by strengthen efforts to minimize clinical anxiety is a necessity.
Keywords: Clinical anxiety, dental students, trainers
|How to cite this article:|
Obarisiagbon A, Azodo CC, Omoaregba J O, James B O. Clinical anxiety among final year dental students: The trainers and students perspectives. Sahel Med J 2013;16:64-70
|How to cite this URL:|
Obarisiagbon A, Azodo CC, Omoaregba J O, James B O. Clinical anxiety among final year dental students: The trainers and students perspectives. Sahel Med J [serial online] 2013 [cited 2019 Dec 15];16:64-70. Available from: http://www.smjonline.org/text.asp?2013/16/2/64/115263
| Introduction|| |
Anxiety, which is a multisystem response to a perceived threat or danger, reflects a combination of biochemical changes in the body, the patient's personal history and memory, and the social situation.  A large portion of human anxiety is produced by anticipation of future events attesting that stressful transitory events in life with associated uncertainty contribute to distress and anxiety most times. Anxiety especially, if it is chronic and prolonged, exerts adverse effects on drive, career aspiration, work and school performance and also leads to states of depression,  increased alcohol consumption  and attempted suicide.  Studies have documented anxiety as one of the factors that leads to reduced examination performance. 
Medical school is a time of significant psychological distress with inadvertent negative effect on students' mental health, with a high frequency of depression, anxiety, and stress in the medical students.  The transition from pre-clinical to clinical stages of medical education with challenges in relating to trainers, paraprofessionals, and patients and also added to these are the performance of procedures on patients is known to precipitate anxiety otherwise termed: "Clinical anxiety" in this study.
Several studies have been carried out to ascertain the anxiety provoking situations in the medical and nursing students, but only a few in dental students. Moss and McManus (1992)  investigated the anxieties of new clinical medical students about half of the total clinical situations elicited moderate to severe anxiety state among the participants. Gender variation in the development of anxiety among medical students from pre-clinical to clinical stages of their education was documented by Greenfield et al.  in which females reported significantly higher number of anxiety provoking clinical situations. In the study by Greenfield et al.  females scored situations involving interactions with consultants significantly higher than other situations while males ranked clinical situations involving intimate contact with patients significantly higher.
Anxiety in clinical situations is anticipated due to the recognition of dental training world-wide including Nigeria as stressful and stressors emanating from relationship, environment, and training. ,,, The act of rendering treatment under supervision, which is significantly different from procedures on phantom heads and fulfillment of clinical requirements pose great challenges to dental students. The only retrieved study among dental students was conducted at the University of Otago  and findings showed that the general clinical situations associated with highest levels of anxiety were felt for getting diagnoses wrong, hurting patients, dealing with medical emergencies, and getting infected. The prospect of surgical procedures temporomandibular joint problems and failed local analgesia were specific situations that resulted in heightened anxiety among the students. The anxiety level reported by the act of giving inferior alveolar nerve block and dealing with poor oral hygiene was significantly associated with year of study with the lower class showing greater anxiety. The identification of clinical anxiety as potential impedances to quality training and performance among dental students reinforced the need for evaluating the clinical anxiety among dental students from students and trainers perspectives and modeling ways to ameliorate it. However, the reviewed study among dental students was conducted in a country with demographics and a dentistry curriculum different from developing countries. The lack of information from the trainers on the perceived anxiety provoking situations among dental students in the study also preclude the evaluation of disparity and similarities and the ability to make an informed recommendation geared toward alleviating anxiety and improving overall training. The objective of this study was to determine the clinical anxiety provoking factors among dental students from the trainers and students perspectives.
| Materials and Methods|| |
This study was conducted among the final year dental students of University of Benin, Benin, City, Nigeria between January and March, 2012. All final year dental students of the school were included because of the small size of the study population and the lack of baseline data on clinical anxiety among dental students in Nigeria. However, students absent from class during the period of the study were excluded. The trainers, which are comprised of consultants and resident doctors (senior registrars and registrars) in the clinic, were involved in this study to gather information on the areas they perceived as greatest sources of anxiety among students. The tool of data collection was a self-administered questionnaire, hand delivered at the end of the students' introductory posting in which they do not have direct therapeutic relationship with patients, but are exposed via observation to the level of skill they're required to acquire before taking the final examinations. This questionnaire was a modification of the one designed by Moss and McManus (1992).  The questionnaire contained 38 questions with 20 questions from the original document and 18 questions added to cover dental specific perceived sources of anxiety. The situations were assessed using a 4-point Likert scale from "not anxious," "slightly anxious," "fairly anxious" to "very anxious." For the purpose of analysis, responses were scored 1 for not anxious, 2 for slightly anxious, 3 for fairly anxious, and 4 for very anxious. Demographic variables such as age and gender were also collected. The same questionnaire with modification on the instruction was administered by the lead researcher to the trainers. Participation in the study was voluntary, and no incentive was offered. Verbal informed consent was obtained prior to participation in the study. Ethical approval was obtained from University of Benin Teaching Hospital Ethics and Research Committee. The data were summarized using the descriptive statistics and comparisons made using the Chi-square from the Statistical Package for the Social Sciences version 17.0. Level of significance was set at P < 0.05.
| Results|| |
Of the 67 participants, 32 (47.8%) were 6 th year dental students while 35 (52.2%) were clinical trainers. Age range of the dental students was between 20 years and 30 years, and their mean age was 25.13 years. A total 18 (56.2%) of the dental students were aged 20-25 years while the remaining 14 (43.8%) were 26-30 years of age. A total of 28 (80.0%) and 7 (20.0%) of the clinical trainers were males and females respectively while 18 (56.3%) and 14 (43.8%) of the students were males and females respectively. Inability to pass the final exams and inability to meet the clinical requirements for the examination were the top two anxiety provoking situations from both the students' and trainers' perspective [Figure 1]. There was a statistically significant difference between students and trainers with respect to taking pulse (P = 0.021) and measuring blood pressure (P = 0.005) [Figure 2]. There was a statistically significant difference in mean score for accidental pulp exposure with the trainers scoring higher (0.042) [Figure 3]. The trainers rated all situations related to diagnosis as more anxiety provoking than the students; Making diagnosis (2.26 vs. 2.13), telling patients that diagnosis is not known (2.31 vs. 2.09), getting diagnosis wrong (2.83 vs. 2.43), unable to defend diagnosis (3.06 vs. 2.94).
|Figure 3: Deficiencies and error in treatment related situations among the participants|
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Assessment of communication and health team interaction among the participants revealed the following rating of trainer versus students on the anxiety provoking situations; Joining theatre team (1.91 vs. 1.63), interaction with nurses (1.51 vs. 1.22), communication with elderly (2.11 vs. 2.34), and talking with patients (1.43 vs. 1.09). Strikingly, students expressed a greater tendency to be anxious while talking with elderly patients and this was strengthened by the trainers' perspective on the situation.
Students were more likely to be anxious about managing psychiatric patients and uncooperative children. Statistically, significant difference exists between both groups regarding helping in a faint episode (P = 0.001) [Figure 4].
In comparing gender difference in anxiety provoking situation from trainers perspective revealed that administering local anesthesia was statistically significant (P = 0.010) with the mean scores as 2.46 ± 1.04 for male trainers and 3.57 ± 0.53 for female trainers. In comparing gender difference in anxiety provoking situation from students' perspectives revealed statistically significant difference in 6 out of the 38 studied situations. They include poor radiograph development (P = 0.046) males (2.44 ± 0.92) versus females (3.07 ± 0.73), treating children (P = 0.002) males (2.00 ± 0.84) versus females (3.07 ± 0.92), using extraction forcep (P = 0.001) males (2.93 ± 0.73) versus females (1.78 ± 0.81), arresting post-operative bleeding (P = 0.022) males (2.93 ± 0.83) versus females (2.17 ± 0.92), and inadvertently hurting patient (P = 0.013) males (2.33 ± 1.08) versus females (3.36 ± 1.08) [Table 1].
|Table 1: Gender differences in anxiety provoking situations from trainers and students perspectives|
Click here to view
| Discussion|| |
According to the students, the top clinical anxiety provoking situations were inability to meet requirements before exams, inability to pass the final exams, dealing with psychiatric patients, coping with uncooperative children, getting infected by patients, fracturing a tooth during extraction, extracting the wrong tooth, discovering calculus by the supervisor after scaling, accidental pulp exposure, inadvertently hurting patients, and using the high speed hand piece.
There existed concordance on the top two clinical anxiety provoking situations which were the inability to pass the final exams and meet the clinical requirements for the examination reported by the students and their clinical trainers. These may be due to the inability to predict of academic activity as a result of industrial actions of workers in university and the fact that these students have spent quite sometime in the university. Ignorance, poverty and poor oral health awareness with attendant low likelihood of dental seeking attention in the midst of reasonable population limits the chances of meeting clinical requirements. Dental students sometimes pay for dental procedures of patient in order to meet these requirements from anecdotal reports. The failure to meet clinical requirement, which is one requirement for qualification for the examination disqualifies one from participating the examination thereby explaining its ranking as the top second clinical anxiety provoking situations.
The management of uncooperative children and psychiatric patients are the equally fourth clinical anxiety provoking situations. These may be linked to the difficulty and undue stress in managing the duo as these groups of patients needs a lot of patience despite the strife to meet clinical requirement. The low interest in pediatric dentistry among dental students  with the lowest grand mean knowledge and skills for pediatric dentistry resident dental surgeons in Nigeria  explains why the dental care of uncooperative child provokes high anxiety. This also implies laying emphasis on the clinical psychology, which will facilitate interest in care of uncooperative with the minimal anxiety. Overall the top five clinical anxiety provoking situations in this study contrasted with the findings among New Zealand dental students by Kieser and Herbison, (2000). 
The possibility of dental professional getting infected by patients during the care delivery procedures varies according the type and prevalence of the infection, percutaneous and mucocutaneous exposure and the dose exposure of blood and blood products. The high prevalence of human immunodeficiency virus (HIV) infection in Nigeria, percutaneous exposures among dental professional cum significant prevalence of HIV infection in the dental health-care settings may be the reason for reporting increasing clinical anxiety in consideration getting infected by patients.
The fracturing of tooth during extraction, which may be due to inability to get adequate apical thrust and apply proper extraction force emanating from lack of confidence may have positioned tooth fracture during extraction among the top clinical anxiety provoking situations. Extracting wrong tooth with prevalence of 13%,  which is a medical error with medico-legal implications  may explain it relevance as the third precipitate clinical anxiety provoking situations. The anxiety was from this situation, extracting wrong tooth was significantly lower in males (2.94 ± 1.11) versus females (3.79 ± 0.80). The noted higher anxiety score among female students than male students in sensitive investigation such as radiograph development and act of treatment related situations such as treating children, using extraction forcep and arresting post-operative bleeding gives clues to why females pay to more attention to details thereby lessening their committal of medical error than males. The significantly lower anxiety score among male students (2.33 ± 1.08) than female students (3.36 ± 1.08) in inadvertently hurting patient situation may also be a contributory explanation. Females aspire to prevent medial errors as previous study reported that female medical trainees were more likely than male medical trainees to feel guilty, get angry at themselves and felt afraid of losing confidence if they made an error. 
Identification of calculus especially subgingival calculus is more difficult in comparison with supragingival calculus due to non-visibility when patient opens the mouth, and the difficulty in mastering the use of hand instrument in the removal of calculus during scaling may have triggered the student into reporting discovering calculus by the supervisor after scaling as a top clinical anxiety provoking situations.
Accidental pulp exposure during dental care changes the treatment plan to simple restoration to endodontic treatment, which is burdened with poorer prognosis. The ranking of accidental pulp exposure as a top clinical anxiety provoking situations may be explained by the high clinical anxiety provocation with use the high speed hand piece, which is used for restorative procedures. The dental care procedures are performed in the oral cavity with difficulty from mobile muscular organ tongue, saliva as fluid, size of mouth opening, and extensive pad of fat. The dominant presentation of dental patients with pain coupled with fear and the sensitivity of the oral cavity to injury may have propelled the students into reporting inadvertently hurting patients as top clinical anxiety provoking situation anxiety. The inexperience and low confidence in effective oral care procedure delivery may be contributory.
Measurement of blood pressure, taking pulse, clinical presentation, helps in a faint episode and accidental pulp exposure were statistically significant contrasting clinical anxiety provoking situations from dental students and trainers perspectives. The trainer rated clinical case presentation (2.97 vs. 2.34), pulse taking (1.51 vs. 1.16), blood pressure measurement (1.54 vs. 1.16), helping in a faint (3.46 vs. 2.59), and pulp exposure (3.43 vs. 2.97) as significant higher than students. This can be explained by the fact that trainers rated all situations related to diagnosis as more anxiety provoking than the students. The inherent belief among trainers about lower level of knowledge among students and attempting to ensure proper diagnosis will however, constitute unnecessary stress among trainer because their perception differs significantly from the student perspective.
Students expressed more tendencies to be anxious while communication with elderly patients, and this is strengthened by the trainers' perspective about the situation. The peculiarity of respect and high esteem mode of care for elderly in Nigeria society and culture may tend to pressure students into identifying it as anxiety provoking situation. This contrasted with findings among New Zealand dental students where dealing with elderly constitute one of the least anxiety provoking situations. 
In comparing gender difference in anxiety provoking situation from trainers perspective revealed that administering local anesthesia was statistically significant (P = 0.010) with the mean scores as 2.46 ± 1.04 for male trainers and 3.57 ± 0.53 for female trainers. The challenges of administering local anesthesia among students with attendant complications may explain why female trainer posited it as higher anxiety provoking situation among dental students than male trainers.
| Conclusion|| |
Data from this study revealed clinical trainer share the predominantly same perspective with the dental students on the clinical anxiety provoking situations with minute variations. There need to strengthen efforts to minimize clinical anxiety hereby creating a supportive learning environment.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
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