Journal of0ccupationaland Organizational Psycbology (1973), 66, 153-162 Printed in Great Britain 153 0 1973 The British Psychological Society

Occupational stress, life stress and mental health among dentists

M. Robin DiMatteo" Department of Psycbology, University of Califrnia, Riverside, CA 722521 -0426, USA and

Social Policy Department, RAND, Santa Monica, CA

Daniel A. Shugars Scbool of Dentistry, University of North Carolina and The Pew Healtb Profusions Program

Ron D. Hays Social Policy Department, RAND, Santa Monica, CA

This study examined the prediction of occupational sttess, general life stress and mental health among 108 randomly sampled dentists who completed mail-survey question- naires at two points in time. In multiple regression analyses, the outcome variables were the dentists' self-reported general life stress, dental practice-related stress and mental health. Predictors were locus of control, non-verbal expressiveness, age, gender, income, hours worked per year, social desirability response set, and baseline measures of occupa- tional stress and satisfaction with 10 aspects of dental practice: s t a g income; profes- sional relations; professional time; delivery of care; patient relations; practice manage- ment; personal time; professional environment; and respect received as a dentist. Both dental practice-related stress and general life stress were predicted by baseline occupa- tional stress, by feelings of lack of respect for practicing dentistry, and by dissatisfaction with the amount of professional time available to improve clinical skills. Poorer mental health was predicted by baseline occupational stress, by perceived lack of respect for practicing dentistry, and by feelings of having too little personal time.

Prompted by a decline in dental school applicants, a rise in dental school closures and con- cerns about rising malpractice suits, declining patient loads, declining income, dentists' well-being, and the care provided to patients, interest has developed in recent years in the study of dentists' job satisfaction and occupational stress (LaRocco, Tetrick & Meder, 1989; Shugars, DiMatteo, Hays & Cretin, 1990; Shugars, Hays, DiMatteo, Cretin & Johnson, 1991). Most studies on this topic suggest that dentists do experience a good deal of stress and may be more emotionally vulnerable than people in general and other health professionals in particular (Ayer & Moretti, 1985; Cecchini, 1985; Coster, Carstens & Harris, 1987; LaRocco et aL, 1989; Mallinger, Brousseau & Cooper, 1978; Wall & Ayer,

*Requests for reprints should be addressed to M. Robin DiMatteo at the University of Californin, Riverside.

154 M . R. DiMatteo, D. A. Sbrigars and R. D. Hays

1984). Dentists appear to have higher blood pressure than the national average (Cutright, Carpenter, Tsaknis & Lyon, 1977) and recent concerns about contracting or transmitting the HIV virus on the job may have added to the pressures of dental practice (Kunzel & Sadowsky, 1991). It is important to determine the sources of dentists’ stress because unre- lieved pressures may drive away potential entrants to the profession, impair job perfor- mance of practicing dentists, and even cause some dentists to leave the profession altogether (Department of Health and Human Services, 1988).

Researchers have begun to explore the factors that contribute to stress in the dental profession. Lack of contact with other dentists and long work days as well as physical dis- comforts (such as back pain), financial pressures, heavy workloads and lack of free time have been proposed as important factors (Coster et af., 1987; Eccles & Powell, 1967; Litchfield, 1989). People management problems, difficult patients and conflicts with staff have also been found to be important determinants of dentists’ stress levels (Brand & Chalmers, 1987; Burns, 1986; Cooper, Mallinger & Kahn, 1978). Dentists’ perceptions of and attitudes about their jobs and their beliefs that negative views of dentistry are held by the wider society also appear to contribute to the aetiology of dentists’ stress (Coster et al., 1787; Katz, 1987).

In a recent study using multivariate predictive models, Cooper, Watts, Baglioni, Jr & Kelly (1988) found that the most consistent predictors of poorer mental health among a random sample of dentists in England, Scotland, Wales and Northern Ireland were time demands and complexities of scheduling, their belief that they are perceived negatively by their patients and income-related pressures. Job dissatisfaction was related to beliefs in patients’ negative perceptions, to time and scheduling difficulties and to staff and tech- nical problems, The study was cross-sectional, however, and prediction of stress and men- tal health over time was therefore not possible.

The present study extends work on predictors of dentists’ stress to examine the role of multiple dimensions of dentists’ perceptions of their work in affecting their levels of occu- pational stress, general life stress and mental health. The effects of characteristics of the dentists, including their age, gender, number of hours worked per year and income level, as well as theoretically important individual difference variables (non-verbal expressive- ness and locus of control), are also assessed. Measures of stress are available at two points in time, making it possible to take account of previous occupational stress in predicting both general and dental practice-related stress and mental health. Measures with estab- lished reliability and validity are used, and the data are from a stratified random sample of dentists in California.

Method

Subjects

In December of 1989 (with follow-up to non-respondents in January of 1990), a questionnaire (Wave One) was sent to 558 general dentists randomly selected from a list ofall dentists licensed in the State ofCalifornia. A systematic stratified sampling technique was employed to obtain a sample distributed geographically, thus avoiding oversampling in rural areas and undersampling in urban Standard Metropolitan Statistical Areas. A total of 408 dentists responded to the Wave One survey. The questionnaire asked respondents to indicate if they would be willing to be contacted again with another short questionnaire-202 respondents indicated such willingness, and Wave Two questionnaires were sent to 162 of them six months later, in June 1990 (the

Dentists’ stress and mental health 155

other 40, randomly selected, provided data for test-retest reliability of the measures used in Wave One). A total of 113 responses were received, of which 108 constituted completed questionnaires.

Measures Wave One questionnaires, which took about 15 minutes to complete, requested information about the den- tist’s age, gender, income level, average number of hours worked per week and average number of weeks worked per year (which were multiplied to indicate number of hours worked per year) and total number of auxiliaries in the office. Questionnaires also included the Dentist Satisfaction Survey (DSS), a 54-item instru- ment with 10 subscales of satisfaction with various facets of dental practice: the delivery of quality care; pro- fessional environment (primarily malpractice); relationships with patients; availability of personal time; practice management (of the business aspects of practice); income; professional relations (primarily regarding the quality and number of specialists available for referral); professional time (for improvement of clinical skills and consultation with colleagues); respect received (and prestige) as a dentist; and work conditions with office staff. The DSS contains an additional subscale measuring dentists’ feelings that practicing dentistry is stressful for them, and this subscale constituted the b,aseline measure of occupational stress. The DSS and its psychometric properties are described in detail elsewhere (Shugars, DiMatteo, Hays & Cretin, 1990).

Wave Two questionnaires, filled out approximately six months later, conrained six measures and took about 17 minutes to complete. Genwal fqe stress was measured by 10 items of the Perceived Stress Scale (Cohen, Kamarck & Mermelstein, 1983), a measure of the degree to which situations in a person’s life are appraised as stressful. The full 14-item scale has average internal consistency reliability of .85 (Cohen & Williamson, 1988). The 10-item measure used in this study had alpha reliability of .88 in the present sample, and in a separate sample of 96 undergraduate students demonstrated a correlation of r = .98 with the full 14-item scale. Several versions of the Perceived Stress Scale correlate significantly with life-events, depressive and physical symptomatology, use of health services and social anxiety. Dental stress was measured by the 15-item Dental Stress Scale (Katz, 1987), measuring dentists’ feelings of stress specifically in their work environment. The reported alpha reliability of the scale is .84. The RAND Mental Health Index (MHI-5) is a five-item self- report measure of aspects of mental health functioning including anxiety, depression and general positive affect (Berwick, Murphy, Goldman, Ware, Barsky & Weinstein, 1991; Stewart, Hays & Ware, 1988). High scores indicate positive well-being and low scores reflect psychological distress. The scale has been validated extensively and has high internal consistency reliability (alpha 38) (Stewart et a!., 1988). The LOCUJ of Controf Scale (LOC) assesses the degree to which one feels control over his or her destiny and outcomes, or whether such control lies in the hands of others or of fate (Rotter, 1966). The internal consistency reliability of this 29-item scale was .70 in a sample of US college students (Rotter, 1966) and high scores indicate an external locus of control. Locus of control was examined here because previous research has suggested that job stress may be inversely related to individuals’ feelings that they are in control of their outcomes (Frost & Wilson, 1983; St-Yves, Freeston, Godbout, Poulin, St-Amand & Verret, 1989). The Aflectiue Communication Test (ACT) (Friedman, Prince, Riggio & DiMatteo, 1980) is a 13-item scale assessing self-reported non-verbal expres- siveness. Ir has internal consistency reliability of .77 and test-retest reliability (over a two-month time span) of .90 (in a sample of US college students). This measure was included because in previous research physicians who scored higher on the ACT were found to be more popular with their patients (that is, had more patients who had chosen them to be their physicians) (DiMatteo, Hays & Prince, 1986). It was expected that non-ver- bally expressive dentists would have better relationships with their patients and, in turn, less job stress. Social Desirability ResponseSet (SDRS) was assessed with a five-item short form of the Marlowe-Crowne Scale (Hays, Hayashi &Stewart, 1989) in order to control for respondents’ need for social approval and tendency to respond to the questionnaire in a socially acceptable but invalid manner. Internal consistency reliability of .68 and test-retest reliability of .75 have been obtained.

Statistical procedures Means, standard deviations and alpha internal consistency reliability were computed for variables at each wave for the longitudinal sample of 108 dentists. Because the study’s goal was to determine the extent to which the various measured constructs affected respondents’ general life stress, dental practice stress and mental health, these outcomes measured at Wave Two were regressed on the demographic variables, 10 DSS scores and the DSS scale ofoccupational stress, all measured at Wave One. The outcome measures were also regressed

156 M . R. DiMatteo, D. A. Shrqars and R. D. Hays on the two scales measured at Wave Two that were expected to be theoretically important to occupational and life stress and mental health: locus of control and affective communication. We included social desirability response set as a covariatc in our models to adjust for any possibility that the dentists might minimize their self-reporred stress level in order to appear socially acceptable. A two-step process using stepwise mulcjple regression was performed. First, each dependent variable was regressed on the DSS and the LOC and ACT scales, with age, hours worked per year, reported income level, gender of the dentist, stress at Wave One and social desirability response set forced into the regression equations. In all cases, the four demographic vari- ables and social desirability were not significant, whereas stress at Wave One was significant. Next, the regres- sion analysis was rerun, forcing only stress at Wave One and social desirability response set into the equations and allowing all the other variables to enter in stepwise fashion usingp < .05 as the criterion for entry. The final models based on this second step are reported below.

Results

Comparisons were made between the characteristics of the longitudinal (Wave Two respondents) sample and the Wave One only sample and the non-respondents in the orig- inal survey at Wave One on the following variables: age, gender of dentists, hoursfweek and weekdyear in practice, yearly income level, overall satisfaction with dentistry and occupational stress measured at baseline (Wave One). Wave One and Two respondents were significantly younger than the original non-respondents. Wave Two respondents worked significantly fewer hours per week but significantly more weeks per year and earned somewhat lower income than Wave One only respondents. No other mean or percentage differences were significant, indicating that the groups were basically quite similar.

Comparisons were made between the scores obtained by the Wave Two sample and nor- mative data for the RAND Mental Health Index (MHI-5) and the Perceived Stress Scale. The dentists in the present sample had MHI-5 scores almost identical to those of large samples of non-dental providers (McGlynn, 1988) and general medical patients (Stewart et al., 1988; Stewart, Ware, Sherbourne & Wells, 1992), and significantly higher scores than patients with HIV infection (Berry, Bozzette, Hays, Stewart, Kanouse & the ACTG 081 Study Group, 1991). The dentists' scores on general life stress were significantly lower than those of college students and smoking cessation patients (Cohen et al., 1983), but were identical to those of samples of individuals in their mid-forties and older, and with incomes over $25,000 per year (Cohen & Williamson, 1988).

Internal consistency reliability for the 10 subscales plus the baseline measure of occupa- tional stress from the DSS ranged from .73 to .94 for this sample. The ACT, General Life Stress, MHI-5 and Dental Stress Index had high internal consistency (.76 to .88), but alpha reliabilities of locus of control and social desirability response set were just under .60.

Table 1 contains the intercorrelations among all of the measures employed in the mul- tiple regression equations presented below. Note that correlations among the Wave Two criterion measures of stress and poorer mental health (reversed MHI-5) were as follows: dental stress with general life stress (r = .57), dental stress with poorer mental health (r = .54), and general life stress with poorer mental health ( r = .78) (all) < .OOl).

The final predictive models based on stepwise multiple regression are presented in Tables 2 and 3. Age, hours worked per year, reported income level, gender of dentist, social desirability response set, satisfaction with other job facets, locus of control and non-verbal expressiveness did not have significant effects on the stress or mental health measures in these multiple regression models in which SDRS and Wave One stress were forced in.

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158 M . R. DiMatteo, 0. A. Shqars and R. D. Hays Table 2 . Dental Stress Scale regressed on job satisfaction facets and previous stress level

Predictor Zero-order Standardized Adjusted Increment variable correlation beta F . R2 in R2 Stress at Wave One .32** .16 5.50** .09 .09 Respecdprestige - .5 5" -.42** 15.83** .33 .24 Professional time - .44** -.25* 14.51** .37 .04

NoreJ. Stepwise multiple regression results are reported. Overall model F (4, 88) = 14.5 1; p < .001 (with SDRS included in this model but n.s.). Age, hours worked per year, reported income level, gender of dentist, satisfaction with other job facets, locus of control and non-verbal expressiveness did not have significant effects on scores on the dental stress scale in this multiple regression model. Age, hours worked per year, reported income level and gender of the dentist were forced into previous regressions, but produced no significant effects.

*p < .os; * p < .001.

Table 3. Poorer mental health (emotional distress: reversed MH-5) regressed on job satisfaction facets and previous stress level

~

Predictor Zero-order Standardized Adjusted Increment variable correlation beta F R2 in R2 Stress at Wave One .33** .13 5.07" .08 .08 Respecdprestige - .52** - .43** 13.68" 2 9 .2 1 Personal time -.34** -.21* 12.08" .32 .03

*p < .05; **p < .01. Nofes. Stepwise multiple regression results are reported. Overall model I: (4, 90) = 12.08;p < .001 (with SDRS included in this model but n.s.). Age, hours worked per year, reported income level, gender of dentist, satisfaction with other job facets, locus of control and non-verbal expressiveness did not have Significant effects on poorer mental health (presence of dysfunctional affect) in this multiple regression model. Age, hours worked per year, reported income level and gender of the dentist were forced into previous regressions, but produced no significant effects.

Age, hours worked per year, reported income level and gender of the dentist had been forced into previous regressions, but produced no significant effects. In Table 2, dental stress (at Wave Two) was significantly predicted by previous occupational stress (the DSS subscale measured at Wave One), by feelings of not receiving enough respect as a dentist, and by dissatisfaction with the amount of professional time available for clinical develop- ment and interaction with colleagues. Although the correlation of dental stress with gen- eral life stress was only .57, prediction of the latter (results not shown) resulted in precisely the same model as prediction of the former. Table 3 presents the model for den- tists' emotional distress (poorer mental health: the reversed MHI-5) which is predicted by previous occupational stress, dissatisfaction with the amount of respect received as a den- tist, and feelings of not having enough personal time.

Discussion

The present study contributes to our understanding of the sources of occupational stress and emotional distress among practicing dentists. Although the sample studied here is

Dentists’ stress and mental health 159 not necessarily representative of US dentists, is predominantly male, and represents only about 20 per cent of the initial random survey sample of California dentists, such limita- tions may not be highly problematic. The findings are consistent with those of more recent multivariate predictive models and at the very least, some tentative conclusions can be drawn from the present research and future research questions can be posed.

The levels of stress and mental health of dentists in the present research were found to be very similar to those of other health professionals and samples of individuals of similar age and income status. This finding supports some recent data suggesting that dentists are generally quite healthy and may not be highly susceptible to stress-related disorders (Bureau of Economic Research and Statistics, 1977; Rankin & Harris, 1990).

What determines the occupational stress that dentists do feel? The literature on the professional job stresses and dissatisfactions of dentists has tended to focus on the more tangible elements of practice such as income, business concerns and coping with difficult patients (Brand & Chalmers, 1987). The present research lends support to additional findings that less tangible factors, such as dentists’ attitudes and beliefs, particularly about their profession, may be as important or more important than income, office man- agement and dealing with patients in determining well-being (Katz, 1987), Although the present research included measures of both objective and subjective income and time spent working, as well as subjective measures of managementhff problems and patient relationships, dentists’ emotional well-being (mental health and lack of stress) was best predicted by their feelings of being respected and having prestige. Stress was also pre- dicted by having few opportunities to develop clinical skills and to interact with other health professionals. Mental health was positively related to having enough time available for leisure activities and personal life.

This research supports findings (cf. Cooper et al., 1988) that dentists’ dissatisfaction with their work is correlated with their belief that dentists are perceived negatively by patients and the general population (a belief that is not accurate) (ADA News, 1987; Miller & Truhe, 1991). The present research confirms the importance to dentists’ mental health and low occupational and life stress of their perceptions that they are working in a respected and prestigious profession. The findings of this research are in concert with results of studies of other health professionals that demonstrate the central importance to job satisfaction of receiving respect from patients and the public (Linn, Yager, Cope & Leake, 1985; McCranie, Hornsby & Calvert, 1982).

The opportunity for dentists to interact with other professionals and to maintain and improve their dental skills and current knowledge appears, in this research, to be critical to preventing high levels of stress. Katz (1987) similarly found that dentists who were satisfied with their work took off more time for continuing dental education courses than those who were less satisfied with their work. Perhaps the opportunity for increased skill development augments coping resources and therefore mitigates stress. In contrast with the relationship between lower work stress and the availability of professional time, the availability ofpersonal time (for leisure, family, etc.) predicted better mental health (lower levels of depression and anxiety, and higher levels of positive well-being) in this sample. Perhaps the opportunity to enjoy personal time improved dentists’ chances to recover from daily work pressures and so improved their mental health.

Despite some evidence from previous research linking external locus of control to job dissatisfaction and emotional exhaustion (Frost & Wilson, 1983; St-Yves et dl., 1989), the

160 M . R. DiMatteo, D. A. Shugars and R. D. Hays present study did not find a unique effect of locus of control on dentists’ levels of stress or poorer mental health. The reliability of the locus of control scale in this sample was rather low ( . 5 5 ) and may have accounted for this lack of association. On the other hand, the inclusion of measures which dealt directly with perceptions of dental practice may have dwarfed the role of general locus of control in predicting the emotional state of dentists. (The zero-order correlations of locus of control with general life stress and poorer mental health were positive and statistically significant.) Likewise, although the Affective Communication Test (ACT) had a significant zero-order correlation (r = .34, p < . O l ) with dentists’ satisfaction with their relations with patients (this finding is consistent with a positive correlation between the number of patients that physicians saw per clinic day and their ACT scores in the DiMatteo et al., 1986, study), it did not, however, have a unique direct effect on mental health or on the stress of the dentists in the multiple regression equations in the present study.

These findings have important implications for training and professional life in den- tistry. There is some evidence that staff relations in dental offices (Bader & Sams, 1992), the care delivered by dentists (Shugars, Johnson, DiMatteo, Hays & Cretin, 1990), and even the interest of potential applicants to the profession (Reese & Harmon, 1987) might be adversely affected by highly-stressed or impaired dentists. That both occupational stress and general life stress were predicted in this study by perceived lack of respect and lack of professional time suggests opportunities for directing programmatic initiatives by organized dentistry and dental educators. For example, dental educators could explore with students and those in the profession their basic notions and expectations of respect and ways of enhancing professional self-concept. Dental school programmes could encourage professional and personal time management strategies, and the effects of these interventions on dentists’ stress and mental health could be evaluated. A critical future step in this research is to map out the effects of dentists’ occupational and life stress and mental health on their patients. Recent research indicates that health care providers’ job dissatisfaction predicts their patients’ dissatisfaction with care (McGlynn, 1988) and their patients’ non-compliance with medical treatment (DiMatteo et a[., 1993; Hays & White, 1987; Weisman & Nathanson, 1985). Are the patients of more relaxed, emotionally healthier dentists more likely to return for their scheduled appointments, more satisfied with their dental care and more adherent to preventive measures? Further research on occupational stress and mental health in dentists is needed to answer these important out- come questions.

Acknowledgements This research was supported by Intramural and Intercampus Research Grants from the University of California, Riverside; the Robert Wood Johnson Foundation; the University of North Carolina; the University of California, Los Angela, School of Dentistry; the Research Network on Health and Behavior of the John D. & Catherine T. MacArthur Foundation; and the American Dental Association. The authors are grateful to Carl Sneed for his contributions to the data analysis.

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Received 27 April 1992; revised version received I 6 October I992