A survey of stress, burnout and well-being in UK dentists

Br Dent J 2019; 226: 40–49; http://dx.doi.org/10.1038/sj.bdj.2019.6

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We live in a world where stress is almost unavoidable. However, too much stress can negatively impact individual well-being, leading to burnout and psychological distress. The dental profession is already subject to higher levels of occupational stress than the general population. With introduction of the 2006 NHS general dental practice contract and various regulatory changes, the landscape of the profession has transformed dramatically in recent years. This research aimed to provide a current account of well-being in UK dentists working in all fields of dentistry, as well as identify the key stressors.

Out of 2053 survey responses, 55% reported high job stress, with 44% deeming that this exceeded their ability to cope. Given the detrimental consequences of stress and burnout on mental health, it is not surprising that 68% showed levels of psychological distress. Those who were experiencing burnout fared worse on all well-being measures of life satisfaction, life worthwhileness and happiness. Of particular concern is the high prevalence of suicidal thoughts; nearly 10% of respondents had thought about committing suicide in the last 12 months, a sombre statistic much higher than the general population (5.4%) and the global picture (9.2%).

Consideration of different fields of dentistry found that general dental practitioners, especially those with a high NHS commitment, experienced the highest self-reported stress, burnout and psychological distress. For all fields of dentistry, these levels are markedly elevated compared to previous studies. Primary concerns cited by dentists have changed to stressors of litigation fears, dissatisfied patients and regulatory issues. Although change is inevitable, the authors highlight the chronic problem of increased regulation and rising negligence claims, calling for an improvement of working conditions to reduce stress among dentists.

A completely stress-free profession is neither achievable nor desirable. However, if a feeling of persecution continues to be at large, dentists will be hard-pressed to deliver patient care to safe, professional standards. These survey results add to the research revealing that overall stress and burnout associated with poorer health are alarmingly high in all dental fields. Individual interventions are inadequate for effective, long-lasting results. Systematic problems in the wider working environment need to be addressed for the sake of both clinicians and patients alike. Indeed, the heart of patient care is centred on improving well-being – perhaps we should extend the same approach to those working in the profession.

Ji-Yun Stephanie Yeung, Barts and The London

Author Q&A with Vicki Collin, Research Analyst BDA

What made you choose to research stress among dentists?

This was part of a wider project examining well-being and stress in dentists, which is a key strategic aim for the BDA. Previous research had highlighted high levels of occupational stress in the profession, and our recent qualitative work highlighted that stress was perceived as a key contributor to experiencing burnout and mental ill health. This research aimed to build on this and examine the extent of the problem, identify different sources of stress and determine how this may relate to burnout and mental well-being. By understanding the key stressors dentists face we can use this to inform the process of making positive changes to dentists' working environments, and promote greater well-being in dentists.

Did the results surprise you?

Although the levels found were high and exceeded previous research, it wasn't too surprising as we know that dentistry can be a very stressful profession especially with how the landscape of dentistry has changed in recent years.

What do you think the next steps should be considering your findings?

The alarmingly high levels of stress and burnout identified in the research should not be ignored. The BDA will be using these results to inform our policy and campaign work to help improve the working lives of dentists. It is apparent that increases in regulation have permeated all aspects of dentistry and fears about litigation were deemed a key concern by dentists. With this in mind, reducing the level of regulatory burden dentists face could lead to reductions in stress. For GDPs working in England and Wales changes to the NHS contract, with a reduced emphasis on UDA targets would also be a positive step forward in alleviating stress. Increasing the support available to dentists who are experiencing high levels of stress or mental ill health is also essential.

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I do not think I have ever been asked to provide a commentary on a more important piece of work than this. It provides a stark picture of a profession facing a crisis. Within the cohort surveyed here there is a sizeable group of healthcare professionals who are experiencing significant distress. By my calculations some 1740 of those surveyed exceeded the standardised cut-off for burn-out; the majority of general dental practitioners report high levels of stress; significantly the sources of stress have changed emphasis from previous research to a perception of increases in regulation, governance and litigation. I believe the root cause lies in the conflict between professional autonomy and external regulation.

Larson1,2 has described the characteristics of professions within modern societies as having the following, '(a) professional association, cognitive base, institutionalised training, licensing, work autonomy, colleague control and a code of ethics.' Put simply a professional has undertaken a course of intellectual learning and training which brings them to a standard which allows them to join an association with a strong ethical code which it enforces through critical self and peer evaluation. The notion that professions are self-governing has been suggested to infer a potential power base which the profession may use to protect itself, as well as to proscribe the practice of the profession to those with the knowledge (cognitive base), training and code of ethics which they share.3 Concerns by those outside the profession about self-regulation and the power that implies lead to increases in regulation, the threat of litigation and governance requirements which serve to undermine the belief in self-regulation and replace the individual's adherence to their personal and professional code of ethics with a requirement to comply with a set of regulations. Is it therefore surprising that this might lead to a sense of exhaustion and lack of personal engagement with the process? Might it be that the practitioner has a sense of learned helplessness, that what happens to them is unrelated to their own behaviour?

Solutions are complex and multifaceted. We need to strike a balance between autonomy and regulation, but the foundation for any solution lies fundamentally in a trust in and respect for the profession of dentistry, as well as trust in and respect for those who seek to govern.

J. T. Newton, Professor of Psychology as Applied to Dentistry King's College London