Students: Fatma Ahmad & Naela Al- Bloushi

Supervisor: Dr. Qasem Al-Omari, Dr. Muawia Qudeimat

Stress Level and Contributing Factors among Dental and Medical

Students: A Comparison between Old and New Curriculum

Prepared by: Fatma Ahmad

Naela Al- Bloushi

Supervisors: Dr. Qasem Al-Omari

Dr. Muawia Qudeimat

Elective study course No. 703

Students: Fatma Ahmad & Naela Al- Bloushi

Supervisor: Dr. Qasem Al-Omari, Dr. Muawia Qudeimat

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Content Page number

Abstract 3-4

Introduction 4-6

Materials and methods 6-7

Results 7- 10

Discussion 10-15

Conclusions 15

Limitations 16

Appendix 1 17-25

Appendix 2 26-30

Appendix 3 31-32

References 33-35

Students: Fatma Ahmad & Naela Al- Bloushi

Supervisor: Dr. Qasem Al-Omari, Dr. Muawia Qudeimat

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Abstract:

Objective: The aim of this study was to identify different resources of stress among

dental and medical students and to compare the effect of changing the curriculum on the stress

level in dental and medical students at Kuwait University.

Methods: This is a case control study conducted on undergraduate dental and medical

students (5th and 6th

year) in Kuwait university dental and medical school. A fifty- item self-

reported modified version of Dental Environment stress (DES) questionnaire was distributed

during academic spring semester 2013.Total sample size was 364, of which 187 respondents

were taken form pervious similar study measured stress level among dental and medical students

in the old curriculum. Out of the new 186 questionnaires, 159 received giving a response rate of

85.4%. A modified version of the self-administered Dental Environmental Stress (DES)

questionnaire was used. Stressors were classified into five major domains: Personal Factors,

Living Accommodations, Marital Status, Training Factors, and Academic Environment Factors.

The t-test was used in the compression of different sources of stress by gender, field of study,

level of study, GPA, marital status, and curriculum.

Results: females scored statistically significant higher values in all stressor domains. In

addition, the “dental environment” seems to be more stressful than “medical environment”.

Moreover, whether in dental or medical school, fifth year students appeared to be more stressed

than sixth year students. Undergraduate students with higher GPA were more stressed.

Additionally, students involved in old curriculum showed less stress compared to student

studying in the new curriculum.

Students: Fatma Ahmad & Naela Al- Bloushi

Supervisor: Dr. Qasem Al-Omari, Dr. Muawia Qudeimat

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Conclusions: studying the primary sources for stress among dental and medical students

emphasized the effect of gender, field of study, level of study, GPA, and marital status. In

addition, changing the curriculum from lecture oriented to a system based case-triggered

integrated system increased the stress level among undergraduate students.

Introduction:

Stress is defined as the body’s reaction to a change that requires a physical, mental, or

emotional adjustment or response. It is a prevalent and costly problem in today’s workplace.

Significant number of employee views their jobs as the number one stressor in their lives.

The profession of medicine and dentistry are considered to be extremely stressful. This is

true for all stages of dental career. Physicians suffer from especially high degrees of stress even

when compared with other health professions. Either diverse and extreme demands or lack of

resources which exceed the person’s coping capacities can be viewed as sources of occupational

stress1.

Stress has been described as two-edged sword that can either stimulate and motivate the

student to peak performance or reduce the students to ineffectiveness. Stress in dental and

medical students may be multifactorial arising from the academic environment and personal

factors2, 3

.

In a study done by Divaris and et al, post graduate dental students perceived the specialty

of prosthodontics as the highest demanding specialty. On the other hand, orthodontics was

considered as lowest demanding specialty. Regarding non clinical specialties, dental materials

considered as most stressful specialty whereas those in oral biology perceived the least stress4.

Students: Fatma Ahmad & Naela Al- Bloushi

Supervisor: Dr. Qasem Al-Omari, Dr. Muawia Qudeimat

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According to Amin and et al, the perceived stress among dental students attributed to

factors such as fear of failure, the load of academic and clinical work, unavailability of materials

for study and clinical training, performance pressure, and self-efficacy beliefs. It has been

reported that students who demonstrated high levels of stress tended to show lower grades for

clinical competency and contextual understanding. It was found that female students experienced

higher degree in emotional exhaustion than their male counterparts. The cause of high emotional

exhaustion probably related to pressures of study, examinations, competition and fulfillment of

minimum clinical requirements5.

A study done in Germany found that the factors affecting stress among undergraduate

dental students were divided into different aspects. Occupational factors include daily interaction

with patients, colleagues, and staff, time pressure, paper work, defective equipment or problems

in the treatment of patient, and possible conflicts, especially with clinical supervisors. With

regard to personal factors, examination phobia, lack of self-confidence, and difference between

reality and students' expectation proved to be considerable stressor1.

At Kuwait University, before the year 2008, the curriculum for medical and dental

students was lecture oriented. However, the education system was changed from lecture oriented

to a system based case-triggered integrated system 7 years ago. In the year 2010, two dental

students did an elective study on stress among fifth and sixth dental and medical students who

were following the old system was carried out. They found that females scored statistically

significant higher values in all of the stressors domains. Dental students in general reported

higher stress scores in almost all domains. Moreover, undergraduate students with higher GPA

Students: Fatma Ahmad & Naela Al- Bloushi

Supervisor: Dr. Qasem Al-Omari, Dr. Muawia Qudeimat

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experienced more stress than those with lower GPA. After the change in the curriculum, the aims

of this study were to:

1. Compare stress level in old system (lectures' oriented) to new system (system based case-

triggered integrated system) of education by comparing our results with previously conducted

study.

2. Identify the stress factors among undergraduate clinical years of dental and medical

students

3. To investigate whether specific stressors were related to gender, field of study, level of

study, GPA and material status

4. Compare stress level between dental students and medical students at Kuwait University.

Materials and Methods:

This study was carried out in the Faculty of Dentistry, Kuwait University (KU), which is public

university in Kuwait. Approval was obtained from health science centers’ ethical committee for

students study project and the dean of faculty prior to initiating the study.

Currently, the dental program of the faculty of dentistry in Kuwait University consists of

six and a half years. These years are divided into 4 pre-clinical years of basic sciences and 2 and

a half clinical years. On the other hand medical program consists of 7 years, which are divided

into 4 pre-clinical years of basic sciences and 3 clinical years. This case control questionnaire

study included 5th

& 6th

year dental and medical students only. The data were collected through

self-administered questionnaire (appendix 2) given to students after lectures and seminars. The

data were collected in a week that was free of any examination in order to eliminate stress due to

examinations. The results of the questionnaire were used to measure the stress level among the

Students: Fatma Ahmad & Naela Al- Bloushi

Supervisor: Dr. Qasem Al-Omari, Dr. Muawia Qudeimat

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medical and dental students and compare the results with previously conducted study. The

purpose of this survey explained to the students and confidentiality assured. Participation was

voluntary and verbal and written informed consent obtained from all participants.

Survey instrument: In order to investigate different sources of stress, a modified version

of the self-administered Dental Environment Stress (DES) questionnaire was used, which also

was used in the previous study, where it was further adjusted to be applicable for Kuwait

university students. The questionnaire sections included: demographic data (age, gender,

nationality, year of study, and marital status), level of study, field of study, and first choice of

study followed by 50 items related to possible sources of stress. These items were divided into

five major domains: 1 Personal factors (10 items), 2 Living accommodations (3 items), 3 marital

status (4 items), 4 training factors (17 items), and 5. Academic environment factors (16 items).

The students were asked to answer the questions in scale of 1-5 scores; 1(not stressful), 2(slightly

stressful), 3(fairly stressful), 4(highly stressful), 5(not applicable). The data was analyzed using

SPSS program version 20.0. Mean values, standard deviations, standard errors, and confidence

interval were calculated. Independent sample t-test was used to compare sources of stress by

gender, field of study, level of study, GPA, marital status, and curriculum.

Results:

A total of 364 questionnaires were collected, of which 159 was conducted this year and

187 taken from previous study. This year, a total of 159 students responded out of 186 Students

(overall response rate 85.4%). Of these 159 respondents, 75% were females and 25% were

males. The medical students were 114 students (72%) and dental students were 45 students

(28%). Of the dental students, 93% were females and 7% were males. In comparison, 67.5% of

Students: Fatma Ahmad & Naela Al- Bloushi

Supervisor: Dr. Qasem Al-Omari, Dr. Muawia Qudeimat

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medical students were females and32.5% were males. The percentage of non-single students was

19.5% (N=31) while the percentage of single students was80.5% (N=128). Most of the students

were Kuwaiti (91%) compared to non-Kuwaiti (9%). Fifty one percent of the students were in

the fifth year while forty nine percent were in sixth year. Majority of students had GPA 3 or less

(82.9%) while only 17.1% had GPA higher than 3. Table (1)

The means for each factor in the five main domains calculated. In the personal factors

domain, the mean value ranged from 0.77 to 2.09. Difficulty in making friends was the less

stressful factor (mean= 0.77) in this domain while the most stressful factor was reduced sleeping

time (mean= 2.09). In regards to living accommodation, having children at home causes high

stress level among the participants (mean= 1.71). Additionally, the most stressful domain was

marital status domain comparing to the rest main domains. In this domain, the mean scores range

from 3.01 to 3.17. Moreover, transition from pre-clinical to clinical years scores least mean value

(mean= 1.51). On the other hand, completing graduation requirements raise the stress level

among the students (mean=2.02). Finally, examination and grades causes the highest stress level

in academic environment domain (mean=2.26). However, expectation of dental / medical school

and what in reality it is like causes slight stress among the students (mean=1.49).

Table 2, shows the effect of gender on the mean scores of stressor domains. Females

experienced more stress than males in all stressor domains. In personal factors domains, females

had more difficulty in making friends. In addition, Participation in family activities was more

stressful to females. Among training factors, females had higher stress scores in the following

factors: transition from pre-clinical to clinical years, responsibilities for comprehensive patient

care, patients being late or not showing for their appointment, confidence in own clinical

Students: Fatma Ahmad & Naela Al- Bloushi

Supervisor: Dr. Qasem Al-Omari, Dr. Muawia Qudeimat

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decision, difficulty in learning clinical decision, difficulty in learning manual skills, and shortage

of allocated clinical time. Moreover, lack of confidence to be a successful student, lack of

confidence in self to be a successful dentist/ doctor, competition for grades, fear of failing a year,

amount of cheating in school, and fear of being unable to catch up if behind were significantly

higher in females. Males were not more than females stressed in any of the factors.

Table 3, indicates comparison between medical and dental students. Higher level of stress

among dental students was found in personal factors, living accommodation and academic

environment domains. However, medical students were more stressed in conflict with partner

over career decision (marital status domain). The training factors responsible for elevation of

stress level in dental students were transition from pre-clinical to clinical years, responsibilities

for comprehensive patient care, patients being late or not showing for their appointment,

completing graduation requirements, shortage of allocated clinical time, and difficulties in

communicating with staff. On the other hand, medical students were more concerned about

grades.

Table 4, shows the difference in the mean scores of stress between 5th

and 6th

year

students. Fifth year students showed more stress in conflict with parents over career decision,

atmosphere created by staff, concern about treatment grades, lack of confidence to be a

successful student, and competition for grades.

As shown in table 5, students with GPA more than 3 experienced more stress compared

to students with GPA less than 3 in 3 domains including personal factors, training factors, and

academic environment. Each domain contained several factors such as difficulty in making

Students: Fatma Ahmad & Naela Al- Bloushi

Supervisor: Dr. Qasem Al-Omari, Dr. Muawia Qudeimat

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friends, transition from pre-clinical to clinical years, fear of failing a year, and considering

entering some other field of work.

Table 6, shows the difference in the level of stress between single and non single

students. In regards to marital status, non single students were slightly more stressed due to

marital adjustment problems (mean 1.32), postpone having children (mean 1.61), having a dual

role as a spouse and a student ( mean 1.68), and conflict with partner over career decision (mean

1.03). However, single students were more stressed regarding grades competition.

The comparison between old and new curriculum is shown in table 7. New curriculum

students showed higher stress level in personal factors and academic environment domains. In

regards to marital status domain, marital adjustment problems, postponing having children, and

conflict with partner over career decision elevated the stress level among the new curriculum

students. In comparison, having a dual role as a spouse and a student caused higher stress level

among old curriculum students. Finally, when comparing different training factors,

responsibilities for comprehensive patient care and confidence in own clinical decision making

caused higher stress level in new curriculum students. On the other hand, difficulties in

communicating with staff, and conflict with supervisor over personal matters raised the stress

level among old curriculum students.

Discussion:

The aim of the study was to identify the perceived sources of stress among 5th

and 6th

undergraduate dental students at University of Kuwait, and compare it with their peers in

medicine. Also it aimed at comparing the stress level between the old system students to the new

one. At the time of the study, the studying program was a 6.5 years program consisting of 2 years

Students: Fatma Ahmad & Naela Al- Bloushi

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premedical, 2 years preclinical, and finally 2.5 years of clinical dental program. Through the first

four years of the program dental students study basic medical sciences and spend most of their

course with their medical peers. Having only one dental and one medical school in Kuwait

creates more pressure and stress on the students from the time of application. Moreover, the

number of seats provided for the undergraduate dental program is 1\3 of those seats available for

the medical undergraduate program. Also, seats in medical school are pre-distributed based on

the gender of the applicants, where 50% of the seats are allocated for females and 50% for males.

On the contrary, the seats in dentistry are given solely according to students’ GPA. It worth

mentioning that in order to get administered to the dental program, one must have attained a

higher GPA than those accepted at the medical program. Knowing all of that, one can only

imagine the amount of pressure in order to get administered to the dental school. That, combined

with challenges students face throughout the years of the program will create an accumulative

pressure, to even higher levels of stress. This study was conducted in order to assess whether

specific stressor domains were affected by gender, field of study (medicine-dentistry), level of

study (5th year- 6th year), GPA, marital status, and system (old vs. new). Identification of

potential stressors will enable creating more comfortable and less stressful environment which is

believed to enhance the academic performance of the students hence the final educational and

training outcomes. While the results of this study indicates that many findings are consistent with

international literatures, some findings may further enhance our understanding of dental student

stress

Students: Fatma Ahmad & Naela Al- Bloushi

Supervisor: Dr. Qasem Al-Omari, Dr. Muawia Qudeimat

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Gender:

Regarding the effect of gender in the present study, significant differences in stress scores

were found between males and females. This was in agreement with a study on Turkish6 and

Egyptian7 undergraduate dental students were females reported higher stress level. In the current

work, females were found to be more stressed about making friends. It has been suggested that

female students receive less peer support than male students8

and they also feel more pressure to

succeed in a male-dominated profession. In addition, female students were stressed in regards to

participation in family activities. This could be related to the cultural tradition in the Kuwaiti

society since females are expected to have a larger role in family activities. In terms of training

factors, females were more stressed regarding the responsibilities of the comprehensive patient

care, patients being late or not showing to their appointments, and the shortage of the allocated

clinical time. The fact that female students reported significantly higher stress was attributed in

the literature to their different patterns of response to stressful events. Sanders and Lushington

(1999), however, suggested that gender differences could be explained by the different patterns

of psychological morbidity between both genders and because males are less expressive of their

concerns and feelings9.

Field of study:

Dental schools are known to be highly demanding and stressful learning environment7.

This is reflected in the high scores given for "lack of time for relaxation", "deterioration of the

personal physical health, and "difficulty in participation in family activities". This might be due

to the fact that dental curriculum have higher number of studying subjects per year compared to

the medical curiculum, thus dental students are exposed to more exams more frequently. The

Students: Fatma Ahmad & Naela Al- Bloushi

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other factors that dental students were significantly more stressed about were related mainly to

clinical factors domain. Those factors included "transition from preclinical to clinical years",

"responsibilities of the comprehensive patient care", and "completing graduation requirements".

This could be explained logically by the differences between the dental and medical educational

programs, where each dental student is responsible for a certain number of patients with

comprehensive care and treatment planning. In comparison, the medical students are responsible

for daily rounds and group discussion of patient cases with no direct involvement in treatment

provision. In addition, completing graduation requirements and shortage of allocated clinical

time were stressful factors for dental students. This seemed to be related to the fact that clinical

training and evaluation system in dental program is based on unit requirements. Thus, successful

completion of those requirements is obviously a significant source of stress for dental students in

terms of patient compliance and cooperation which students have no control over. According to

Dodge et al (1993), students reported lower stress levels when clinical training and evaluation

were not based on unit requirements10

. This current study pointed that dental students are more

stressed when it comes to participation in family activities. This could be explained by the

extended working periods when compared to medical students. On average, dental program

official working hours exceeds medical program by five hours weekly. Not to mention that

dental students exposed to more exams compared to medical students. In addition, dental

curriculum requires more technical skills. However, medical students showed a higher stress

level when it comes to conflict with partner over career decision. A possible explanation to that

might be the fact that medical students serve at night shifts which is not preferable by most

Kuwaiti partners.

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Level of study:

Regarding the relationship of the level of the study and perceived sources of stress, fifth

year students reported higher stress levels than the sixth year students. Similar concerns were

reported in previous studies carried out in Egypt7, India

11, and Turkey

6. This might be attributed

to the fact that they are relatively new to the clinical year's program. Their knowledge and

confidence are still developing. They may be overloaded by the high academic demands of their

year of study and the absence of clinical experience7. Interestingly, these findings were not

reported in the United States12

. Not to mention the new rules and regulations they have to

accustom with. Sedky (2012) reported that the transition into the clinical setting may be difficult

for many students7.

GPA:

In attempt of demonstrating the effect of the GPA on levels of stress, students with GPA

more than 3 scored higher levels in the personal domain factors, such as "difficulty in making

friends". The results can be explained by the fact that since these students are hard working they

don't have as much free time for their personal life responsibilities. However, when it comes to

the academic environment factors opposite patterns are observed. And students with lower GPA

scored higher levels of stress in these factors which were "fear of failing a year" and "considering

entering some other field of study". The reason behind that could be because this group of

students feels less competent than their fellow colleagues.

Marital status:

Students: Fatma Ahmad & Naela Al- Bloushi

Supervisor: Dr. Qasem Al-Omari, Dr. Muawia Qudeimat

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The results of the effect of the marital status are only to be expected. The group of non-

single students was more stressed about "marital adjustment issues", "postponing having

children", "having a dual role as a spouse and a student" and "conflict with partner over career

decision". This is coincident with results of the study conducted by Uraz (2013) that also

reported married students to be more stressed possibly due to the extra duties and obligations

they have towards their spouses and maybe children6. The current results may support previous

findings that the most highly stressed students had difficulty with domestic arrangements13

.

Curriculum:

The faculty has adopted a case triggered integrated curriculum for student intake of 2005

onwards. The new system is planned on a student centered principle, emphasizing the need for

self-learning and student motivation. Evidence based dentistry, small group learning, PBL

sessions, clinical skills lab, and early clinical exposure are salient features of this new

curriculum. This could explain why the students of the new curriculum are experiencing more

stress compared to their colleagues of the older system. The personal factors and the marital

status domain are properly justified due to lack of personal time, being in a self-study system.

However the training factors and the academic environment domain are probably due to the

variation of the knowledge and skills obtained individually.

Conclusions:

In conclusion, studying sources of stress among the dental students emphasized the effect

of gender, level of study, GPA, marital status, and the teaching system. The results of the

comparison of stress levels between dental and medical students confirmed the fact that dental

students are more stressed compared to their peers in medical field. Since stress could have

Students: Fatma Ahmad & Naela Al- Bloushi

Supervisor: Dr. Qasem Al-Omari, Dr. Muawia Qudeimat

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dramatic effect on efficiency of work, quality of life and student's psychological wellbeing,

efforts should be done to reduce it and improve the student’s health

Limitations of the study:

1. The overall number of dental students was smaller than medical students. A larger sample

of dental students would be more favorable in studying the perceived sources of stress

among students providing a more powerful analysis and stronger association.

2. Majority of students in dental school were females which might have influenced the final

results of the study.

3. The cross sectional study design didn’t allow us to establish causal relationships among

the variables.

Recommendations:

Some stress is inherent in studying dentistry. Nevertheless stress prevention and

interventional measures can reduce or eliminate many sources of stress.

1. The student centered learning environment should be polished to enhance the

collaborative and interpersonal support among students.

2. The clinical training and evaluation should not be based on unit requirements which were

potent stressor for the students.

3. Stress reduction protocol should be implemented including specific courses, faculty

incorporated advising system, and student counseling.

Students: Fatma Ahmad & Naela Al- Bloushi

Supervisor: Dr. Qasem Al-Omari, Dr. Muawia Qudeimat

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Appendix 1: Figures and Tables

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Figure 1. shows the distribution of demographic variables of the study sample

0

20

40

60

80

100

120

140

160

180

200

pe

rce

nta

ge %

Demographic Data

Gender

Nationality

Marital status

Field of study

Level of study

GPA

System

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Table1. Distribution of demographic variables of the study sample

Demographic Variables N % Total

Gender Males 40 25.2 159

Females 119 74.8

Nationality Kuwaiti 145 91.2 159

Non- Kuwaiti 14 8.8

Marital status Single 128 80.5 159

Non-single 31 19.5

Field of study Medicine 114 71.7 159

Dentistry 45 28.3

Level of

study

Fifth year 81 50.9 159

Sixth year 78 49.1

GPA Below 3 119 82.9 145

Above 3 26 17.1

Group Old 187 54 346

New 159 46

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Table2. Statistically significant sources of stress according to gender of the participants

Domains

Statistically significant factors

Gender N Mean p Mean difference

Std. Error Difference

95% confidence interval

lower Upper

Personal factors Difficulty in making friends

Males 40 0.40 0.041

0.422 0.204 0.018 0.826 Females 118 0.82

Living 8accommodation

Participation in family activities

Males 40 0.93 0.018 0.478 0.200 0.084 0.873

Females 119 1.40

Training factors Transition from pre-clinical to clinical years

Males 40 1.27 0.005 0.540 0.188 0.169 0.911

Females 119 1.82

Responsibilities for comprehensive patient care

Males 40 1.55 0.002 0.535 0.169 0.201 0.869

Females 118 2.08

Patients being late or not showing for their appointment

Males 40 1.65 0.030 0.543 0.247 0.055 1.032

Females 119 2.19

Confidence in own clinical decision

Males 40 1.80 0.035 0.395 0.186 0.028 0.762

Females 118 2.19

Difficulty in learning clinical decision

Males 39 1.44 0.015 0.455 0.184 0.091 0.818

Females 119 1.89

Shortage of allocated clinical time

Males 40 1.48 0.000 0.728 0.187 0.359 1.098

Females 118 2.20

Academic environment

Lack of confidence to be a successful student

Males 40 1.33 0.016 0.522 0.215 0.097 0.948

Females 118 1.85

Lack of confidence in self to be a successful dentist/ doctor

Males 40 1.25 0.033 0.464 0.216 0.037 0.891

Females 119 1.71

Competition for grades Males 40 1.35 0.017 0.531 0.220 0.097 0.966

Females 118 1.88

Fear of failing a year Males 40 1.75 0.048 0.405 0.203 0.004 0.806

Females 116 2.16

Fear of being unable to catch up if behind

Males 40 1.85 0.009 0.464 0.176 0.116 0.811

Females 118 2.31

* Statistics based on the new study only

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Table 3. Statistically significant sources of stress according to field of study of the participants

* Statistics based on the new study only

Domains Statistically significant factors

Field of study

N Mean p Mean

Difference

Std. Error

Difference

95% confidence interval

lower upper

Personal factors Difficulty in making friends

Dentistry 45 1.02 0.031 0.429 0.197 0.041 0.818

Medicine 113 0.59

Lack of time for relaxation

Dentistry 45 2.42 0.015 0.413 0.168 0.082 0.745

Medicine 112 2.01

Personal physical health

Dentistry 45 2.00 0.031 0.387 0.178 0.036 0.739

Medicine 111 1.61

Living accommodation

Participating in family activities

Dentistry 45 1.67 0.006 0.535 0.191 0.158 0.913

Medicine 114 1.13

Marital status Conflict with partner over career decision

Dentistry 45 3.09 0.042 -0.474 0.231 -0.930 -0.018

Medicine 112 3.56

Training factors Transition from pre-clinical to clinical years

Dentistry 45 2.07 0.003 0.540 0.181 0.184 0.897

Medicine 114 1.53

Responsibilities for comprehensive patient care

Dentistry 45 2.38 0.000 0.599 0.161 0.281 0.917

Medicine 113 1.78

Patients being late or not showing for their appointment

Dentistry 45 2.44 0.024 0.541 0.238 0.071 1.011

Medicine 114 1.90

Concern about treatment grades

Dentistry 45 1.76 0.006 -0.516 0.186 -0.883 -0.149

Medicine 114 2.27

Completing graduation requirements

Dentistry 45 2.76 0.000 0.966 0.204 0.563 1.369

Medicine 114 1.79

Shortage of allocated clinical time

Dentistry 44 2.64 0.000 0.856 0.177 0.505 1.206

Medicine 114 1.78

Difficulties in communicating with staff

Dentistry 45 1.73 0.000 0.856 0.177 0.505 1.206

Medicine 114 1.33

Academic environment

Discrimination due to ethnic groups

Dentistry 45 2.29 0.044 0.578 0.285 0.015 1.142

Medicine 114 1.71

Amount of cheating in school

Dentistry 45 2.53 0.005 0.446 0.155 0.139 0.753

Medicine 114 2.09

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Table 4. Statistically significant sources of stress according to level of study of the

participants

Domains

Statistically significant factors

Level of study

N Mean p Mean

Difference

Std. Error

Difference

95% confidence interval

lower upper

Personal factors

Conflict with parents over career decision

Fifth year 81 1.33

0.035 0.513 0.241 0.036 0.989

Sixth year 78 0.82

Training factors

Atmosphere created by staff

Fifth year 80 1.90 0.002 0.477 0.151 0.179 0.775

Sixth year 78 1.42

Concern about treatment grades

Fifth year 81 2.32 0.019 0.398 0.169 0.065 0.731

Sixth year 78 1.92

Academic environment

Lack of confidence to be a successful student

Fifth year 80 1.91 0.035 0.400 0.188 0.028 0.771

Sixth year 78 1.51

Competition for grades

Fifth year 80 1.98 0.017 0.462 0.191 0.084 0.840

Sixth year 78 1.51

* Statistics based on the new study only

Students: Fatma Ahmad & Naela Al- Bloushi

Supervisor: Dr. Qasem Al-Omari, Dr. Muawia Qudeimat

23 | P a g e

Table 5. Statistically significant sources of stress according to GPA of the participants

Domains

Statistically significant factors

GPA N Mean p Mean

Difference

Std. Error

Difference

95% confidence interval

lower upper

Personal factors

Difficulty in making friends

3 119 0.60 0.041 -0.555 0.221 -0.991 -0.119

≥3 33 1.15

Training factors Transition from pre-clinical to clinical years

3 119 1.57 0.023 -0.429 0.204 -0.831 -0.026

≥3 33 2.00

Academic environment

Fear of failing a year

3 118 2.18 0.011 0.584 0.218 0.154 1.015

≥3 32 1.59

Considering entering some other field of work

3 118 2.21 0.029 0.121 0.195 -0.265 0.507

≥3 33 2.09

* Statistics based on the new study only

Students: Fatma Ahmad & Naela Al- Bloushi

Supervisor: Dr. Qasem Al-Omari, Dr. Muawia Qudeimat

24 | P a g e

Table 6. Statistically significant sources of stress according to marital status of the

participants

* Statistics based on the new study only

Domains Statistically significant factors

Marital status

N Mean p

Mean

Difference

Std. Error

Difference

95% confidence interval

lower upper

Non single

29 1.03

Academic environment

Competition for grades

Single 127 1.65 0.022 -0.475 0.242 -0.954 0.003

Non single

31 2.13

Students: Fatma Ahmad & Naela Al- Bloushi

Supervisor: Dr. Qasem Al-Omari, Dr. Muawia Qudeimat

25 | P a g e

Table 7. Statistically significant sources of stress according to Curriculum

* Statistics based on the new study only

Domains Statistically significant factors

Group N Mean p Mean

Difference

Std. Error

Difference

95% confidence interval

lower upper

Personal factors Reduced holidays compared to other students

Old 187 1.93 0.005 -0.295 0.112 -0.480 -0.039

New 158 2.19

Personal physical health

Old 187 1.67 0.010 -0.056 0.120 -0.291 0.179

New 156 1.72

Marital status Marital adjustment problems

Old 187 2.64 0.000 -0.838 0.157 -1.146 -0.530

New 156 3.47

postpone having children

Old 187 2.82 0.000 -0.727 0.145 -1.012 -0.441

New 156 3.54

Having a dual role as a spouse and a student

Old 187 2.84 0.000 0.731 0.140 -1.007 -0.455

New 156 3.57

Conflict with partner over career decision

Old 187 2.66 0.000 -0.769 0.162 -1.088 -0.450

New 157 3.43

Training factors Responsibilities for comprehensive patient care

Old 187 1.72 0.021 -0.233 0.109 -0.447 -0.019

New 158 1.95

Confidence in own clinical decision making

Old 187 1.71 0.025 -0.389 0.116 -0.618 -0.160

New 158 2.09

Difficulties in communicating with staff

Old 187 1.88 0.031 0.436 0.122 0.195 0.677

New 159 1.45

Conflict with supervisor over personal matters

Old 186 1.82 0.044 0.082 0.135 -0.183 0.347

New 158 1.74

Academic environment

Amount of assigned class work

Old 187 1.45 0.007 -0.475 0.122 -0.716 -0.235

New 159 1.92

Examination and grades

Old 187 2.11 0.021 -0.342 0.101 -0.541 -0.144

New 158 2.45

Discrimination due to ethnic groups

Old 187 1.71 0.001 -0.163 0.163 -0.484 0.158

New 159 1.87

Amount of cheating in school

Old 187 1.81 0.009 -0.406 0.108 -0.620 -0.193

New 159 2.21

Students: Fatma Ahmad & Naela Al- Bloushi

Supervisor: Dr. Qasem Al-Omari, Dr. Muawia Qudeimat

26 | P a g e

Appendix 2: the questionnaire

Students: Fatma Ahmad & Naela Al- Bloushi

Supervisor: Dr. Qasem Al-Omari, Dr. Muawia Qudeimat

27 | P a g e

Stress level and contributing factors among dental and medical students: A

comparison between old and new curriculum

Gender: female male

Year of birth: 19__ __

Nationality: Kuwaiti Non-Kuwaiti

Marital status: single engaged married (no children) married (children)

divorced widowed

Field of study: dentistry medicine

Study level: third year forth year fifth year sixth year

First choice of study: medicine dentistry pharmacy

others ( _______ )

Last GPA score: <2 2-2.5 2.5-3 3-3.5 3.5-4

I. Personal factors:

SN Not

stressful

Slightly

stressful

Fairly

stressful

Highly

stressful

Not applicable

1. Difficulty in making friends

2. Relationship with members of the

opposite sex

3. Lack of time for relaxation

4. Reduced holidays compared with

other students in the university

5. Financial responsibilities

6. Forced postponement of marriage

or engagement

7. Inadequate time for exercise

8. Reduced sleeping time

9. Personal physical health

10. Conflict with parents over career

decision

Students: Fatma Ahmad & Naela Al- Bloushi

Supervisor: Dr. Qasem Al-Omari, Dr. Muawia Qudeimat

28 | P a g e

II. living accommodation:

Not

stressful

Slightly

stressful

Fairly

stressful

Highly

stressful

Not applicable

11. Participating in home/

family activities

12. Having children at home

13. Family restrictions on

studying outside home

after school hours

III. Marital status:

Not

stressful

Slightly

stressful

Fairly

stressful

Highly

stressful

Not applicable

14. Marital adjustment

problems

15. Necessity to postpone

having children

16. Having a dual (double)

role as a wife or husband

and a dental or medical

student

17. Conflict with partner over

career decision

Students: Fatma Ahmad & Naela Al- Bloushi

Supervisor: Dr. Qasem Al-Omari, Dr. Muawia Qudeimat

29 | P a g e

IV. Training factors (clinical or laboratory):

Not

stressful

Slightly

stressful

Fairly

stressful

Highly

stressful

Not applicable

18. Transition from pre-

clinical to clinical years

19. Responsibilities for

comprehensive patient

care

20. Patients being late or not

showing for their

appointment

21. Confidence in own

clinical decision making

22. Difficulty in learning

clinical decision

23. Difficulty in learning

precision manual skills

required in pre-clinical

and laboratory work

24. Atmosphere created by

teaching/ clinical staff

25. Receiving criticism about

work

26. Concern about treatment

grades awarded

27. Inconsistency of feedback

on your work between

different instructors

28. Completing graduation

requirements

29. Shortage of allocated

clinical time

30. Difficulties in

communicating with

teaching/ supervising staff

31. Conflict with teacher/

supervisor over personal

matters

32. Unfairness in teacher/

staff distribution in some

classes/ clinics

Students: Fatma Ahmad & Naela Al- Bloushi

Supervisor: Dr. Qasem Al-Omari, Dr. Muawia Qudeimat

30 | P a g e

V. Academic environment:

Not

stressful

Slightly

stressful

Fairly

stressful

Highly

stressful

Not applicable

33. Amount of assigned class

work

34. Difficulty of assigned

class work

35. Rules and regulations of

the school

36. Lack of input into

decision making process

of school

37. Lack of confidence to be

a successful dental,

medical student

38. Lack of confidence in self

to be a successful dentist/

doctor

39. Examination and grades

40. Competition for grades

41. Fear of failing a year

42. Expectation of dental

/medical school and what

reality it is like

43. Discrimination between

students due to gender

44. Discrimination between

students due to class

status

45. Discrimination between

students due to race and

ethnic groups

46. Amount of cheating in

dental/medical school

47. Lack of time to do

assigned school work

48. Considering entering

some other field of work

49. Fear of being unable to

catch up if behind

Students: Fatma Ahmad & Naela Al- Bloushi

Supervisor: Dr. Qasem Al-Omari, Dr. Muawia Qudeimat

31 | P a g e

Ethical consideration:

Use of human subjects:

The use of human subjects in this study will be in accordance with internationally

accepted guidelines for the ethical treatment of human subjects participating in clinical studies.

The study protocol will be submitted to the appropriate ethical committee for approval. Informed

consent will be obtained from all participating subjects.

Study population:

The study subjects will be dental and medical students from Kuwait University. All

subjects qualifying for the study will be recruited without regard to color, race, or ethnic

background. There are no exclusion criteria based on color, race, or ethnic background of the

subjects

Informed consent:

All patients considered to participate in the study will be informed about the nature of the

study and all their questions answered. Only subjects consenting to participate will be included

in the study.

Patient safety:

No potential risks to the subjects are anticipated due to this study. No physical injuries or

side effects are expected since this will be survey-based study. Still, all measures will be taken to

assure patient safety during the conduct of this study.

Patient confidentiality:

Patient confidentiality will be protected throughout this study. No personal information

will be used except for the purposes of statistical analysis of the data and without reference to

individual subjects. No identification of study subjects will be made in any publication resulting

from this study.

Students: Fatma Ahmad & Naela Al- Bloushi

Supervisor: Dr. Qasem Al-Omari, Dr. Muawia Qudeimat

32 | P a g e

Students: Fatma Ahmad & Naela Al- Bloushi

Supervisor: Dr. Qasem Al-Omari, Dr. Muawia Qudeimat

33 | P a g e

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Students: Fatma Ahmad & Naela Al- Bloushi

Supervisor: Dr. Qasem Al-Omari, Dr. Muawia Qudeimat

34 | P a g e

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8

Students: Fatma Ahmad & Naela Al- Bloushi

Supervisor: Dr. Qasem Al-Omari, Dr. Muawia Qudeimat

35 | P a g e

20. Pöhlmann K, Jonas I, Ruf S, Harzer W. Stress, burnout and health in the clinical period

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J. 2013 Aug;13(3):429-36. Epub 2013 Jun 25