CLINICAL REVIEW

 

Managing stress in the dental environment

 

 

S Naidoo

BDS (Lon), LDS.RCS (Eng), MDPH (Lon), DDPH.RCS (Eng), MChD (Comm Dent), PhD (US), PG Dip! Int Research Ethics (UCT), DSc (UWC). Senior Professor and Principal Specialist, Faculty of Dentistry, University of the western Cape, department of Community dentistry, Private Bag X1, Tygerberg 7505. e-mail: suenaidoo@uwc.ac.za

 

 

Stress is defined as "an imbalance between a perceived demand (stressor) and a person's perceived ability to cope with, or to meet, that demand".¹ It is well known that dentists are subject to a variety of stress-related physical and emotional problems. In dental practice it may include the difficulties in managing anxious children, or dealing with "neurotic", difficult or uncompliant adults. Stress may also take the form of personal insult if dentists are regarded as incompetent when compared with their peers, or are seen as insensitive, inconsiderate and inferior to doctors. Attempting to stay on schedule in a busy dental practice is a chronic source of stress. Not receiving commensurate payment for their services, anxiety about the future and long working hours may also act as stressors.² Stress is not good for health! It is well known that stress and poor stress management increase susceptibility and vulnerability to ill health including cardiovascular disease, ulcers, colitis, hypertension, lower back pain, eye strain, marital disharmony, alcoholism, drug addiction, mental depression and even suicide.³ How does stress manifest in the practice? It may result in absenteeism, increased incident rate, inter-personal aggression, poor quality control, low productivity, high aggression, low productivity, high turnover, reduced morale, complaints and litigation.

The key stressors in dentistry are

(i) running behind schedule;

(ii) causing pain;

(iii) heavy workloads;

(iv) late patients and

(v) anxious patients.⁴

So what can dentists do to deal with stress, to find ways to deal with it and leave them more in control, less anxious and ultimately, less stressed? Can you avoid the stressor? Can you minimise the stressor? Can you handle the stressor differently? A professional person needs to act in a way which is seen as being appropriate and proper by both their patients and professional colleagues. By adopting a positive attitude to both work and life, the treatment and management of patients can be seen to be caring and non-judgemental. Often inappropriate comments by professional colleagues that may suggest a lack of integrity, inferior abilities or stature are unethical and best avoided as they can quickly cause an emotional fall out and anger that may become destructive.⁵ The triggers for such disputes are often professional rivalry, jealousy, wounded pride, a financial/business dispute and resentment which can sometimes result in inappropriate comments being made about a professional colleague. When dealing with stress, strategies that help to express feelings, particularly negative ones such as anger and sadness, are helpful. Professional disputes can be acrimonious, and they demand a high level of ethical awareness and restraint. With regard to anger particularly, it is more effective to talk one's anger than to act it out. There is less chance of losing control, hurting others and possibly endangering friendships, or more importantly perhaps, losing patients.² Other outlets might also include relaxation exercises, participation in sport, or listening to music.⁶

Having good social support networks is important to acquire opinions or assistance in times of need. This support could be from family members or friends, or others who may have specialised knowledge or training in the service professions, such as doctors, or psychologists and fellow dentists and colleagues. They will offer an ear and useful feedback that is appropriate to the problem at hand.⁷ When one uses past experience to deal with a current problem it can make it easier to predict an expected outcome. As one gains life experience, one becomes more adept at using this knowledge in a variety of different ways and in different situations. To the experienced dentist, the notion of "I've seen cases like this before and have dealt with them successfully" offers the confidence to predict that a current problem case will be also be successfully dealt with. However, when there is a loss of predictability, for example in unfamiliar situations, or a situation one is not equipped to manage, there is an increase in anxiety and stress levels. Unpredictable situations make stressors more stressful, and often one cannot predict nor influence subsequent events that will allow one to assume control. The only possible area for the exercise of control is the belief that one is in control and this is the key to self-management and effective problem-solving behaviour.⁷

While it is useful to be optimistic when facing difficult issues, it is also important to acknowledge the possibility that things may not improve and that one needs to be imaginative, creative and courageous in finding new and innovative ways of dealing with difficult situations.⁶ Some authors have been more philosophical in their approach to stress management.⁸ The notion of a life purpose can be as original, individualised and as innovative as we choose to make it. It may include finding ways to stimulate and develop personal growth, committing ourselves to a sincerely spiritual and religious life, aligning ourselves with a deeply-felt political cause, or making a lifetime commitment to the arts such as literature, music or painting. However, when it comes to issues of flexibility and adaptability, throughout a lifespan there are numerous milestones to be negotiated as each age demands new learning, new behaviour, and new roles that carry with them the obligation and readiness to meet the expectations society has of us as health professionals.

One learns to assume appropriate work and professional roles, so that we can become independent and reliable members of society, while simultaneously offering a service to the community. The pressure to keep up with the unrelenting stream of new information and the daily demands of modern dental practice is a constant challenge to the intellectual flexibility and adaptability of health professionals. These attributes may well be expressed through continued professional education and the acquisition of new knowledge. Dentists are encouraged to take communication skills training (including interviewing and listening skills) as well as financial and business management courses. In addition, the acquisition of skills that would assist in the management of fearful patients, as well as specific stress-relieving procedures such as relaxation, hypnosis, and desensitisation cognitive coping skills will be useful to alleviate potential stress.⁹

Being 'sad, mad, glad and bad' are some basic emotions, and in essence refers to sorrow, anger, joy and fear/anxiety. They can readily command our attention, undermine our sense of control and subvert our rationality.¹⁰ However, if one is sensitive or attuned to one's feelings and what causes them to be triggered, then one can deal with such reactions more effectively. In this regard, self-awareness is the key and by recognising emotions as they happen and adjusting them accordingly, insight and understanding can be achieved. This is more so when handling negative feelings, where it may be possible to convert aggressiveness into assertiveness, thus making it easier to regain and maintain self-control. Handling feelings so that they are appropriate is an ability that relies on self-awareness.⁷ One of the ways to manage the negative feelings that cause stress is to express them, but such expression needs to be verbal, not acted out. Mastering the skill of self-control allows a bounce back from setbacks, and shows social adeptness and personal effectiveness.

Managing and building good professional and patient relationships are important to avoid stressful conditions and environments. There are many strategies to achieve this including improving skills at conflict resolution, negotiating disagreements, greater assertion and skills in the art of communicating.¹⁰ Empathy, an understanding of how others feel, or having the ability to see the world through their eyes, is a fundamental people-skill. It is perhaps, the most important quality by which the dentist's personal appeal and professional expertise are measured. In addition, good networking and relationship-building rests on an empathetic approach to dental care and, in the eyes of an anxious patient, you, the dentist, are actually responding to their unspoken need for nurturing and emotional support. It is probably the single most important "practice-builder" apart from clinical expertise and good diagnostic ability. It is a quality worth cultivating, not only to allay patient anxiety, but to boost self-confidence.⁷

 

CONCLUDING REMARKS

Dentists are prone to professional burnout, anxiety disorders and clinical depression. While the root causes, stress and stressful situations, can never be totally eliminated from clinical practice, they must be reduced to avoid the many stress-related physical and emotional problems. The key to managing stress successfully is to first recognize and understand its causes. Once those have been identified and understood, preventive steps can be taken. People perceive and react differently to stress and a stressor for one person may not be a stressor for another. Choosing and implementing an approach or combination of approaches is crucial for effective stress management. Some of the preventive measures that could minimise the stress of dental practice are as follows (adapted from Lang, 2007):¹¹

• Improve the working environment in the surgery;

• Avoid isolation and share problems with fellow practitioners;

• Work sensible hours and make time each day for a leisurely break;

• Take time off whenever the pressures of practice start to build;

• Learn how to better handle patient anxiety and hostility;

• Attend courses on stress management, and improving communication skills;

• Adopt a programme of regular physical exercise;

• Be kind to yourself and less critical and demanding of your efforts.

 

References

1. Cox T, MacKay CJ. A psychological model of occupational stress. Paper presented at a Medical Research Council Meeting, Mental Health in Industry. London, 1976.         [ Links ]

2. Brand AA, Chalmers BE. Individual perceptions of stress by dentists. SADJ 1992; 47: 355-9.         [ Links ]

3. Alexander RE. Stress-related suicide by dentists and other health care workers: fact or folklore? JADA 2001; 132:786-94.         [ Links ]

4. Moore R, Bradsgaard I. Dentists' perceived stress and its relation to perceptions about anxious patients. Community Dent Oral Epidemiol. 2001; 29(1):73-80.         [ Links ]

5. Ethics, values and the law. Booklet 11: Relating to colleagues. Dental Protection Limited, 2009.         [ Links ]

6. Sapolsky RM. Why Zebras don't get ulcers - a guide to stress, stress-related diseases and coping. W.H. Freeman and Com pany, New York, 1994.         [ Links ]

7. Brand AA, Naidoo S. Dealing with stress. SADJ 2003; 58 (3): 115-20.         [ Links ]

8. Kobassa S. Stressful life events, personality and health: An inquiry into hardiness. Journal of Personality and Social Psychology 1979; 3: 1-11.         [ Links ]

9. Moller AT, Spannenberg JJ. Stress and coping among South African dentists in private practice. SADJ 1996; 51: 347-57.         [ Links ]

10. Goleman D. Emotional Intelligence - Why it can matter more than IQ. Bloomsbury Publishing Plc. Soho Square, London, 1996.         [ Links ]

11. Lang R. Stress In Dentistry - It could kill you! Oral Health Journal 2007; 8: 23        [ Links ]