Key points

  • Recognises the issues of occupational stress in general dental practice.

  • Investigates the use of mentorship routinely in general dental practice.

  • Highlights the barriers that are perceived to exist in the profession towards routine mentorship.

Introduction

Stress has been defined as 'the adverse reaction people have to excessive pressure or other types of demand placed on them'.1 In recent years, many studies have identified high levels of occupational stress within general dental practice.2,3,4,5 This stress can manifest itself in many ways, having a detrimental effect both on the individual and their ability to perform their professional duties.5 Occupational stress among general dental practitioners (GDPs) has been linked to a multitude of issues including, but not limited to, low self-esteem, depression and anxiety.6 In a study by Russell and Leggate (2002),7 36% of GDPs identified stress as the reason for choosing to retire early. Brown et al.8 subsequently identified mental and behavioural disorders, including stress, as the second most common reason for retiring early, only being eclipsed by musculoskeletal disorders.

There have been many contributing factors cited as potential causes of occupational stress in dental practice, such as the recognition that general practice is often an isolating environment in which to work.9 Additionally, there are fears of litigation and meeting patient expectations.10 Potentially normal daily occupational stressors could become overwhelming if not identified and addressed. Bayley et al.11 asserted that it is not 'stress per se' that is damaging, but rather one's inability to cope with it. Conversely, several studies, including that undertaken by Kay and Lowe9 recognised that, while dentistry can be a stressful environment in which to work, dentists were generally able to cope with stress levels in a positive way. With the personal and societal investment in training dentists, along with the professional issues of underperformance of the stressed GDP, it would be of benefit if the individual had the ability to recognise when they are in danger of failing to cope, enabling them to institute change.

For the purposes of this study, the following definition of mentoring was adopted: 'A process where a professional colleague (the mentor) guides another (the mentee) in the development and re-examination of their own insight, enabling the mentee to take control of their personal and professional development.'11

The subject is underexplored in dentistry compared to other non-healthcare12 and other healthcare13,14 settings. The literature discusses in detail the use of mentoring as a tool in professional development, rather than focusing on the technique as a preventative tool in stress management.13,15 This may well be driven by a lack of understanding of the process within the dental profession and its potential usefulness.

The use of mentoring as a tool to address occupational stress, as opposed to professional development, was investigated in a study by Keller et al.12 The study explored an example of mentoring practice within the United States Army. This model utilised a system of peer-driven mentorship and support to provide the earliest possible identification of stress within their group. In 2007, MacLeod14 additionally demonstrated that mentoring had a useful role in stress reduction and role adaptation among doctors working within the National Health Service (NHS). There is evidence to show that mentoring can have a positive role in reducing occupational stressors in large corporations and additionally be a beneficial tool in the development of professional career pathways, in both non-healthcare and healthcare settings.15,16,17

The intention of this study was to explore the perceptions of foundation dental trainers within the Health Education, Kent, Surrey and Sussex (HEKSS) postgraduate deanery regarding the usefulness of mentorship. The research question was: 'what are the perceptions of foundation dental trainers towards routine mentoring as a means of reducing the risk of occupational stress?'.

Methods

A qualitative approach was adopted with the use of semi-structured interviews. The sampling was purposive, with fixed aspects controlling the sample group.18 Target participants were experienced foundation dental trainers with three or more years' experience within the HEKSS deanery. As an experienced foundation dental trainer it would normally be expected that the individual would have undertaken some formal mentorship training. A specific inclusion criterion was that the participant had undertaken such a mentoring course.

Foundation dental trainers currently working for HEKSS were emailed by the deanery and invited to participate if they met the experience criteria. Six trainers, five males and one female, responded to the invitation. All of the respondents were UK-qualified practice owners, who had been qualified for between 21 and 39 years at the time of the study. Semi-structured interviews, using a defined topic guide, lasting approximately one hour were conducted face to face at a location chosen by the participant. The topic guide was emailed to the participant five days in advance (Appendix 1).

The recordings were transcribed by a professional transcriber. The completed transcription was emailed to the participant to review the content and rectify any errors or clarify any ambiguity in the transcript before analysis. An analytical approach using thematic coding analysis was undertaken by one author (RS), using a coding system to identify emerging themes and credibility indicators were used including inter-observer reliability.19 This was achieved by a second assessor (DPR), experienced in qualitative research, rechecking the analysis and the themes. Four themes emerged at this stage. Before analysing the significance and meanings of the themes further it was necessary to apply additional credibility indicators to the process. This was to ensure that the results were, as far as reasonably possible, void of researcher bias and had not misrepresented the interviewees' opinions. The researcher was mindful of being an 'insider' to the target group.20 For this validity, member checking was utilised.19 Each participant was forwarded a copy of their transcript and the analysis and confirmed that their contribution had not been misrepresented.

An initial request for guidance regarding NHS ethical approval was made through the Health Research Authority (HRA), who confirmed that NHS ethics was not required. Ethical approval was therefore gained from the research ethics advisory group of the University of Kent's Centre for Professional Practice (RS/16/07/16).

Results

Four themes were identified (Table 1).

Table 1 Themes
Full size table

Theme one: barriers to mentoring

The barriers to the use of routine mentoring in practice were seen as either practical or perceived factors that prevent practitioners utilising mentoring routinely within general dental practice. There were a number of barriers to the provision of mentoring, with three main barriers identified, practical barriers, training and perceived barriers.

Practical barriers

Practical issues were time, money and scheduling. These three issues can be considered as linked. Additional money would buy extra time in a schedule to allow dedicated time for mentorship. Without exception, all of the participants were practice principals who had an overarching responsibility for the clinical care of their patients and the financial success of their practice:

'You'd literally have to block out time in your day which means then you don't do the UDAs (sic units of dental activity) which means there's a financial implication as well' (P4);

'Okay, I think knowing what I know about mentoring, I think it's a good idea, it would need to be timetabled, it would need to be controlled' (P5).

The very real and practical barriers of time and money were issues that many of the participants struggled to identify realistic solutions to. Indeed, participant three insightfully noted that time management could be fuelling a stressful situation:

'So much of dentistry comes down to time management, I think one of the biggest stressors is lack of time… I would love to have, you know, put my mentor hat on and say to everybody "Right I'm around, come and talk to me between. I don't know, these hours, or whatever" yeah, but I think again it's just practice… just trying to make it happen and make it work and I'm sure… there probably is a way probably but it's difficult, it's difficult, you know, an NHS, mixed, busy, NHS practice, trying to find that time slot' (P3).

Training

A further practical barrier was a lack of training within mentors at practice level. Participants recognised mentoring to be a highly skilled role and the level of training required to be a mentor was far greater than the training they felt that they had undertaken to date. This was more evident when non-clinical aspects of mentorship were involved, such as those relating to stress management:

'I think you really do need to be trained, I think you need to know which cases you can, which individuals you can reasonably mentor and which ones, you know, you don't want to mess up your own head by going away with viewpoints' (P1);

'I think that would be very difficult actually without more training, and I speak for myself, I would be lost there, I wouldn't know how to do that and that's with my limited training' (P5).

Perceived barriers

Within this theme, there was a belief among the participants that there would be barriers to the uptake of routine mentoring in practice due to individual practitioners' perceptions of the need for the service, irrespective of any practical barriers being removed. The perception was that there would be individuals who would not be open to the idea of mentoring:

'I think some peoples' personalities may be a bit more open and may be suitable for a mentoring approach and other people may be a bit more alpha male and say "Well you know, I can't be bothered with that, you know this isn't for me" and be closed so I think the personality is something that needs to be thought about' (P6).

The potential stigma of mentoring was raised as a perceived practical barrier to the uptake of routine mentoring. The lack of mentoring in the mainstream of general dental practice did not translate into a belief that having a mentor would be seen in a negative light:

'I don't see there's any social stigma to having a mentor, or being a mentee, I think it's quite a good thing to have that from that angle, there's no social stigma' (P5).

Theme two: preventative routine mentoring is largely impractical or unnecessary

This can be defined as the apparent benefit to the participants of routine or preventative mentoring, as distinct from the use of mentoring in a problem-solving approach. This notion was termed by the participants in this study as 'a reactionary approach'. There were interesting attitudes towards whether mentoring should be preventative or reactionary. The emerging theme was that preventative routine mentoring is largely impractical or unnecessary:

'Well routinely would probably be good in an ideal world… as a reactive thing then you've already got a problem and you're already probably stressed, whereas routinely you could possibly pre-empt things before they happen' (P4).

However, others believed that while it would be ideal to act preventatively, it would be difficult to predict issues and therefore considered using mentorship as a response to identified stresses as a more practical approach:

'In an ideal world, I think mentoring would be much more useful as a preventative tool, as with other issues, it would be better to prevent issues or, before they occur, what I struggle to see is how you would do that, what I see much more easily is how I would use mentoring, or how mentoring would be used as a reactionary tool' (P5);

'I think mentoring is a sort of something, a tool to be used ad hoc, as and when needed. I think mentoring has its place but as a reactive tool rather than as a sort of preventative, daily sort of routine' (P6).

Theme three: benefit to a hybrid of mentoring and coaching

The third theme was that a mixed approach to both mentoring and coaching was a more appropriate utilisation of the process. The data identified the benefit of a hybrid of both mentoring and coaching as a tool in general dental practice. The data identified that some of the participants saw mentoring and coaching as a continuum, recognising similarities and differences, rather than discrete activities:

'I think that there is a difference… it is a part of a spectrum and I think perhaps sometimes when you're undertaking certain aspects of mentoring you stray towards the side of coaching' (P3);

'I think that as they develop there are similarities, there are similarities between the relationship, but yes, I do see them as being different entities, not completely separate, but different… I think coaching is a more rigid process with a finite end or a clear objective, whereas I see mentoring as more of a sort of expansive, growing kind of relationship' (P1).

In contrast, others recognised a clear distinction between mentoring and coaching:

'Is coaching giving them more answers and making them more a "mini" you? Where you're sort of, you know, coaching, I'm just thinking like say football coaching, it's like teaching them the skills "This is what you do" and… you impart your knowledge, whereas this isn't, is it? It's more sort of guiding them so that they come to a solution for themselves, its helping them think, work through their thought process to work out solutions' (P4);

'My understanding… generally I will listen to the issue, or identify the issue myself, process it myself and then give an answer, that I believe is coaching, mentoring is more to do with allowing the mentee to develop their own solution to the problem and it's more powerful because they have ownership of that issue, problem, whatever it may be, as opposed to me just giving an answer' (P5).

Theme four: benefit to both mentor and mentee

The fourth theme was one of mentoring being beneficial to both mentor and mentee. This is defined as both parties gaining positive outcomes from the relationship. The data identified the need for an insight into that relationship which would benefit both parties:

'I do think other dentists would have more insight into your situation than somebody who wasn't' (P4);

'You'll get a lot more out of it by working with somebody who's maybe trodden the same path or has (sic), is treading the same path with you at the same time' (P6).

Professional parity (intra-professional mentoring)

The participants considered that having a peer of professional parity was of benefit in the mentoring dynamic, suggesting that a mentor's direct experience of the situation under consideration was of benefit to a mentoring relationship:

'I think ideally it would need to be professional parity for the simple reason that I think dentists have rather unique stress predictors which is much easier for another dentist to understand' (P5);

'I think essentially what I'm saying is within that big clump of work-related stress, there are personal factors, there are professional factors. Now in order to deal with the professional factors, I think that we've got a common ground, we come from a very similar place' (P1).

Discussion

Much has been discussed in the literature about the benefits of a culture of routine mentoring and the positive impact both on personal and professional outcomes.14 The results of this study, however, identified that while the participants recognised a need for mentoring, they had certain reservations towards its routine use. This was reinforced by a belief that the approach had greater benefit when used as a reactive tool. They recognised a benefit to a hybrid of mentoring and coaching. The participants acknowledged a benefit to both the mentor and mentee from the process.

The participants discussed the theme of barriers to mentoring in detail. A potential barrier to the uptake of routine mentoring identified was one of a perceived lack of need. This is counter to Keller et al.12 who reported on the value of routine mentoring. All of the participants considered that mentoring was most usefully undertaken in response to an issue or problem rather than as a preventative approach. This is described as a reactionary approach to the provision of mentoring and in opposition to the question posed, which was: 'what are the perceptions of foundation dental trainers towards mentoring as a means of reducing the risk of occupational stress?'. Within this cohort of trainers, the perception was that there was a lack of need of routine mentoring among the profession, and/or a lack of understanding of the process of mentoring as a lifelong tool in 'life management'. Education of the profession to the benefits of routine mentoring would be necessary to change these preconceived ideas and should be initiated during undergraduate education.

Further barriers to routine mentoring consistently identified time and financial constraints. Although direct financial implications were not discussed by Yang et al.,15 they found that direct supervisors were inclined to view mentoring adversely as an unwelcome added time pressure. The participants in this study were all practice owners, responsible for both clinical service as well as ensuring the welfare of their staff, while maintaining the sustainability of their practice in a competitive business arena. As a result, the practical barrier of cost and time was a major theme in the perceived ability to provide routine mentoring.

The participants found it difficult to rationalise how the concept of mentorship would work as a preventative approach, including stress management. This theme identified a perception that there would be more use in addressing specific issues as and when they arose in a reactionary way. This would align more with a coaching approach of guiding someone through a specific issue with a predetermined end stage, rather than a long-term, preventative mentorship approach. The participants were all more comfortable with the concept of clinical mentoring which was more within their field of expertise, and therefore their relative comfort zones. This approach could be considered as coaching since clinical competence tends to be a finite learning outcome, compared to the continuum of mentoring.23 They all recognised the need for extensive training to undertake mentoring and that their current level of training was inadequate to mentor someone with overwhelming stress, especially if there were stressors alien to their own personal experiences.

Some literature recognises the continuum between coaching and mentoring,23 while others are precise in detailing where they perceive differences.24 Clutterbuck considered mentoring to have a focus on longer-term goals, giving support through aiding reflective learning, pastoral support and developing capability, compared to coaching which is primarily focused on developing specific skills.24 It was therefore not surprising that the participants identified a lack of clarity as to the precise nature of mentoring versus coaching. The participants recognised a role for both mentoring and coaching within general dental practice, particularly in the problem-solving and solution-focused arena of general dental practice.

Holt and Ladwa25 discussed the benefits both in clinical performance and in the improved morale and positive culture that mentoring could enhance. None of the participants reflected on the potential business benefits that mentoring could provide, which is surprising as that would be in their specific skill set. It could be argued that highly motivated staff would provide increased productivity which could offset the direct cost of providing routine mentoring. MacLeod14 and Thomas and Lankau. et al.17 noted increased professional productivity by those who had been mentored in the workplace. Participants in this study recognised the improved outcomes from clinical mentoring, but were generally less convinced of the benefits of routine, preventative mentoring in relation to stress management.

A limitation of the study was the relatively small numbers of participants, who were all drawn from the same group and all working for HEKSS which has a very strong ethos of mentoring. The selection process may have introduced an element of bias as the participants were self-selecting from a group with a specific interest in the topic or a desire to help a colleague with their research. The participants, although having undertaken training in mentoring, often questioned the validity of the proactive use of the tool. The sample size was small and saturation of data was not achieved. Further research is needed to investigate the perceptions of routine mentorship across a larger cross-section of the profession in order to confirm generalisable findings. This should focus on additional groups including those earlier in their careers who may have had more exposure to the concept of mentorship, practitioners who have different working profiles such as associates, those working in the corporate environment, specialist or solely private practice.

Conclusion

Within the limitations of this study four main themes were identified. These were: perceived barriers to routine mentoring; preventative or routine mentoring is largely impractical and/or unnecessary; there was a recognised benefit to a hybrid of mentoring and coaching; and finally that participants identified a benefit to both the mentor and mentee. The analysis identified that currently experienced foundation dental practitioners do not consider routine mentoring as a practical option in the prevention of occupational stress. However, with additional resources buying time, a hybrid model of mentoring and coaching has significant potential in general dental practice.