Stress: TABOO. A 'practice that is prohibited or restricted by social or religious custom'.

There are many of these in today's society, and many of them have no place. Talking about – and more importantly identifying – stress is another.

After a study by the British Dental Association (BDA) discovered four in ten community dentists are stressed at work – similar to levels of stress reported in the corresponding survey last year – it is clear many dental professionals are under stress.

This throws up a number of questions, and in part one of a three part series, Tim Newton and Brid Hendron tackle some of those.

Tim Newton is Professor of Psychology as Applied to Dentistry and Honorary Consultant Health Psychologist at King’s College London Dental Institute. Tim has worked in the behavioural sciences in relation to dentistry for over 20 years, and his particular interests include the management of dental anxiety, interventions to enhance oral health related behaviour and the working life of the dental team. In particular he has published on the sources of stress and burnout amongst dental practitioners as well as designing interventions to alleviate stress.

Stress is complex and difficult to define as it both ambiguous and context dependent. It is experienced by our profession as a whole, service providers both secondary and primary care (independent or corporate) and internally at the level of the individual professional. Individuals often choose their own words to describe stress such as anxiety, pressure or unhappiness but there is a general consensus that stress is something most of us would prefer to be without.

It is not uncommon to hear from professionals who wish to make changes and reduce the stress experienced in their professional life. Dental professionals are practical individuals and consequently are quick to implement change; however, they are also diagnosticians and invariably need to understand the reasons why they feel stressed. Therefore, it is helpful to have a framework for exploring stress. Dr Alex Concorde, creator of New Individual-Paradigm Psychology, once described stress as 'negative pressure arising when demands and resources are out of sync' and the negative pressure created can be compounded by a third variable, namely time. Applying this in our work context creates a diagnostic framework. Stress arises when we have:

• Demands which are unreasonable in nature or too numerous for current resource

• Reasonable demands which prove challenging as we lack one or more resource (eg capability, skills, equipment, staff, energy, money)

• Demands which are reasonable and sufficiently well-resourced but the allocated time determines that the proposition is challenging

• Time and resources are available but we have too few or insufficiently taxing demands.

The challenge in our professional lives is to balance demands and resources while keeping an eye on the time. This sounds incredibly obvious and simple yet in the context of health care with infinite variables and externally dictated ever-changing demands this is extraordinarily challenging. Balancing all three – demands, resource and time – requires skill and adaptability. It is accepted in all contexts of healthcare delivery that periods of imbalance will arise creating acute stress such as staff absence, equipment failure, cash flow problems, too many patients, too few patients. Ordinarily these can be accommodated as they are transient with a clear end in sight. It is persistent stress which seems to destroy careers and cause unhappiness and anxiety.

Persistent stress over a protracted period at some juncture no longer registers as an exception and becomes viewed as somewhat 'normal'. This explains why we often claim we were unaware we were stressed and declare we thought this was normal. This has also occurred on the level of the profession as a whole so this backdrop has evolved with stress exposure becoming an accolade of membership? Would you like to see a stressed doctor?

Stress has long been highlighted as endemic among dental practitioners, yet it seems that recent changes in the funding and practice of dentistry are likely only to exacerbate this issue. The system of payment and government changes in the funding system were identified as one of the top stressors for dentists as long ago as 1996, yet the changes continue. Furthermore, the profession is now facing ever increasing levels of governance, which whilst laudable in their goals of protecting the public, seek to impress upon members of the profession the perception that their masters simply do not trust them.

Surveys conducted within the last ten years measuring burnout levels in the profession suggest that between 8% and 16% are facing levels of stress which are potentially harmful to their health, and a further 18% have signs that suggest the onset of burnout.^1,2 Burnout is a particular form of stress found among the healthcare professions. It has three characteristics:

• Emotional exhaustion – the feeling that the person can no longer find it within themselves to do the emotional work of caring for their patients

• High levels of depersonalisation – the practitioner feels psychologically 'removed' from their job, often feeling as if they are going 'through the motions'

• Low sense of personal achievement – the individual affected feels that they derive no sense of achievement or satisfaction from their work.

Burnout has consequences both for the individual and the profession. At the individual level burnout carries with it a great risk to mental health, as it is associated with depression and increased risk of suicide. At the very least a highly stressed dentist will lose their enjoyment of work, perhaps leading to greater absenteeism and strained working relationships. Early retirement may seem like a solution for those faced with high levels of stress, but this is a concern for a profession which risks losing highly trained and experienced individuals from the workforce. There is a moral imperative to address these high levels of stress both for the care of individuals who deliver invaluable healthcare services, as well as for the patients they serve that benefit from the expertise of the dental profession.

There is good evidence that the stress faced by dentists begins early with levels of stress and psychological distress being high amongst dental students.³ Recent research concluded that the evidence is incontrovertible – dental students face high degrees of stress and this has an adverse long term effect on their health and well being.

So what causes it? There can be little doubt that dentistry has many characteristics that make it prone to high levels of stress. A system of payment that relates directly to workload parallels the traditional 'piecework' payments of production lines which were always associated with high levels of stress. In addition, dental treatment requires high levels of concentration and physical demands that place a stress on the individual. Finally, general dentistry may not in itself provide sufficient intellectual challenge for those engaged in it.

Previous research has highlighted differences that exist between dentistry and other human service professions, which may predispose to burnout.⁴ A dentist usually works in isolated working conditions and is usually the head of staff, instead of working within institutional settings with colleagues and superiors. Gerry Humphris⁵ also offers a few suggestions as to why many dentists are prone to burnout. He singles out time pressures (thorough choice, expectation from senior staff or from system led parameters), lack of appreciation from patients, the large number of patients seen, the parallel strain of maintaining quality, and the physical proximity between clinician and patient. Adelson⁶ makes an excellent point when he speaks of 'the commitment to an ideal, a standard of perfection, an often unachievable standard encouraged in the training of the dentist', and the frustration at seeing these standards becoming devalued or more impossible to meet, generating the feelings of burnout.

To try and tackle the issue, a three pronged attack on the problem should be adopted:

Prevention

First we should address the primary prevention of stress related illness by providing dental students and practitioners with coping skills and training in stress management. However, there is surprisingly little evidence of such approaches in the dental literature.

Personal support

In contrast to the lack of evidence for prevention, there have been numerous attempts to provide dental practitioners who are already experiencing the harmful effects of stress and burnout with interventions to ameliorate such distress. Two small scale studies^7,8 found a positive impact of psychological counselling and support for dentists experiencing high levels of stress. The nature of the intervention in both instances was individually tailored to the dental practitioners. In Holland there has been extensive work undertaken to help dentists facing high levels of occupational stress and burnout.^9,10These studies commenced by identifying groups of dental practitioners with high burnout risk, who were then given feedback on their scores and invited to participate in an intervention programme. The intervention comprised individual and group meetings the first of which focused on (re)-discovering personal talents and motivation, moving towards a new perspective, and incorporating this perspective into the dentists' personal and professional life. The second phase of the intervention included dealing with dilemmas, making choices, setting priorities, and acting effectively. Communication and action was the central theme of the final phase. Each participant of the programme received a personal plan of action, which they prepared with the help of counsellors. The intervention showed great promise in the first month following the intervention, but within a year all benefits had faded away. It may be that the gains made were lost when the dental practitioners returned to the stressful work environment.

Revolution – or at least some change

As a dentist you can address your stress simply by some analysis and application. This analysis to determine the root cause of your immediate stress is just as important as the correct diagnosis in clinical dentistry and will dictate the necessary steps to remediate the situation. This may sound like a patronising over simplification; however, professionals often misdiagnose the cause. It is essential we approach persistent stress unemotionally and are quite surgical in our dissection.

Tim Newton is Professor of Psychology as Applied to Dentistry and Honorary Consultant Health Psychologist at King's College London Dental Institute. Tim has worked in the behavioural sciences in relation to dentistry for over 20 years, and his particular interests include the management of dental anxiety, interventions to enhance oral health related behaviour and the working life of the dental team. In particular he has published on the sources of stress and burnout amongst dental practitioners as well as designing interventions to alleviate stress.

Brid Hendron is a qualified dentist and communication coach. Brid provides customised training for healthcare professionals and their teams to optimise performance and eliminate stress in person and by webinar. She is a qualified NLP trainer and provides one-on-one life and business coaching for all dental professionals.

In the next issue Tim and Brid look at why we might feel stressed and we hear from someone who can testify how bad things can get.