PsychologicalReports, 1990, 66, 715-722. O Psychological Reports 1990
STRESS-RELATED SYMPTOMS AMONG DENTAL HYGIENISTS ' REBECCA JESSEN LANG
JOAN L. GILPIN
Department of Health, Physical Education G Recreation, Universiq of Northern Iowa
Department of Health Sciences, Hawkeye Institute of Technology
ANDREW R. GILPIN
University of Northern Iowa Summary.-A sample of 49 practicing dental hygienists responded to a survey which included Derogar~sand Spencer's 1982 Brief Symptom Inventory, a measure of stress-related symploms, and a list of items considered stressful based on previous research with hygienists, arranged in six content categories. As hypothesized, in comparison with national norms, hygienists displayed significantly more symptoms on the over-all inventory and also on eight of nine subscales. Also as hypothesized, on the list of stressors, items pertaining to time pressure were rated as significantly more stressful than items from other behavioral domains. However, contrary to prediction, the correlation between over-all symptom level on the inventory and self-rated stress did not reach statistical significance. A variety of implications for stress reduction in dental hygiene practice are discussed.
Research has consistently shown that health-care professionals are gener-
ally characterized by low job satisfaction and high stress (e.g., Constable
&
Russell, 1986; Motowidlo, Packard, & Manning, 1986). Although most research has focused on medical personnel, several investigators have examined job-related stress in dentists, generally supporting the conclusion that such levels are substantial (e.g., Checchini, 1985; Cooper, 1980; Tetrick & LaRocco, 1987). I t is rather puzzling that stress levels in dental hygienists have received comparatively scant attention. There are several reasons to expect that hygienists would be especially at risk for stress. To the extent that dentists are stressed by their general work environment, hygienists would also presumably experience stress since they share the same general work setting (Cooper, 1980). Because most hygienists are women, they are probably subjected to stress resulting from lack of support for work involvement often found to characterize working women, particularly in nontradtional roles (Freedman & Bisesi, 1988). Finally, the role of the dental hygienist is presently fraught with lack of consensus regarding definition of the field as a profession (presumably implying a Bachelor's degree) versus definition as a technical or paraprofessional specialty, implying two-year programs (Walsh,
'Address requests for reprints to Dr. Andrew R. Gilpin, Department of Psychology, Universiry of Northern Iowa, Cedar Falls, IA 50614.
7 16
R. J. LANG, E T A L .
Heckman, Hannebrink, Kerner, & Ishida, 1988); such role ambiguity is often quite stressful (Levi, 1981). Such research as is available has generally focused either on tangentially related phenomena such as job satisfaction or has employed ad hoc instruments with unknown validlty (Rubenstein & May, 1986). For example, McAdams (1976) surveyed a sample of California hygienists, identifying aspects of the job which they particularly liked or disliked. In a survey of students and graduates of the hygienists' program at Ohio State University, Pitchford, Broslu, and Reynolds-Goorey (1980) employed a standard measure of job satisfaction, the Job Descriptive Index, and concluded that their subjects scored below the 25th percentile on national norms. In a study of hygienist alumni of the University of Missouri, Deckard and Rountree (1984) found that hygienists had lower scores than many other health-care professionals on the Maslach Burnout Inventory (i.e., were less predisposed to burnout), but the scores were still unacceptably high by absolute standards. Several other investigators have also reported empirical data indicating substantial job dissatisfaction among hygienists (e.g., Heine, Johnson, & Emily, 1983; Lawson & Martinoff, 1980; Odrich & Wayman, 1987). Several behavioral domains seem particularly problematic in terms of hygienists7satisfaction. Those most relevant to the present study include the following: (a) pressures associated with scheddng and time management (Farrugia, 1984; Lawson & Martinoff, 1980; McAdams, 1976; Reiter, 1983, (b) relationships with colleagues (Deckard & Rountree, 1984; Heine, Johnson, & Emily, 1983; Logan, 1980), (c) patients' resistance (Cecchini, 1985; Cooper, 1980; McAdams, 1976), (d) concerns with equipment and safety of self and patient (Farrugia, 1984; Levi, Frankenhaeuser, & Gardell, 1986; McAdams, 1976), (e) the need for continued professional challenge (Farrugia, 1984; Heine, Johnson, & Emily, 1983; Lawson & Martinoff, 1980), and (f) conditions of employment, e.g., job security, salary, or fringe benefits (Farrugia, 1984; Heine, Johnson, & Emily, 1983; Lawson & Martinoff, 1980; McAdams, 1976). The factors just enumerated represent consistent categories of job satisfaction among hygienists, but in a theoretical review, Rubenstein and May (1986) have suggested that most of the same categories constitute critical sources of stress. Of the factors noted, the most important may well be time pressure. As Rubenstein and May noted, hygienists often face tight schedules with little flexibility. Many things which can disrupt the schedule are outside their control, for example, delays caused by patients arriving late or a dentist's inability to perform an examination at a particular time. Time pressure has been a primary source of stress for other health-care professions as well (Bugen, 1979; Holt, 1982; Levi, 1981; Seamonds, 1986). The present study surveyed a sample of practicing dental hygienists.
STRESS IN DENTAL HYGIENISTS
717
The respondents were asked to rate a variety of sources from the categories described above, with respect to how stressful they were. Respondents also completed a standard instrument assessing psychiatric distress, Derogatis and Spencer's (1982) Brief Symptom Inventory. This measure is a short version of a longer scale, the SCL-90-R, which has been widely validated in research with numerous populations as assessing psychiatric symptoms associated with psychological stress (Derogatis, 1982). The following hypotheses were tested. First, it was hypothesized that hygienists would have significantly higher distress than the national norm on the Brief Symptom Inventory. Second, it was hypothesized that hygienists would report that time-related factors were significantly more stressful than factors involving colleagues' support, patients' resistance, personal safety, professional development, or employment. Thud, it was hypothesized that there would be a positive correlation between symptoms reported and selfrated stress associated with all factors combined.
Subjects
The population surveyed included all practicing clinical dental hygienists in the Waterloo, Iowa district of the Iowa Dental Hygienists' Association. A total of 69 surveys were mailed out, representing the entire membership.
Questionnaire A covering letter provided for informed consent and requested that the subject complete the questionnaire and return it in a stamped envelope provided. I n the questionnaire were three sections. The first section assessed a number of demographic variables (age, marital status, type of degree, highest degree, current employment, primary practice setting, number of offices employed in, hours per week worked, and years of previous employment) which were included for exploratory purposes and are not discussed further. The second section consisted of Derogatis and Spencer's (1982) Brief Symptom Inventory, a 53-item self-report form designed to assess a variety of symptoms of psychological distress. Instructions specify the subject read each of a list of problems and complaints (e.g., "Pains in heart or chest" and "Trouble falling asleep"), and to mark a response that describes "how much discomfort that problem has caused you during the past week including today." Responses are made on a five-point scale from "not at all" (0)to "extremely"(4). Previous researchers have demonstrated the validity of the inventory (Derogatis, 1982), and norms are available for a variety of populations, the most relevant being a sample of 719 adults who were not psychiatric patients. The inventory generates three global indices (the Global Severity Index, combining information on numbers of symptoms and intensity of distress;
R. J. LANG, ETAL
the Positive Symptom Total, reflecring the number of symptoms; and the Positive Symptom Distress Index, an intensity measure adjusted for number of symptoms present). I n addition, there are scores on nine primary symptom dimensions, including somatization, obsession-compulsion, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism. The third section of the questionnaire contained a list of 31 sources of stress, culled from previous studies discussed above. Items were arranged in random order, with five items representing each of six content areas: (a) scheduling and time management (e.g., "Lack of time for patient education"; "Too little time scheduled for hygiene appointments"), (b) colleague relationships (e.g., "Relationships with coworkers are not satisfyingH; "Lack of praise from employer"), (c) patients' resistance (e.g., "Patients have not followed home care instructions"; "Patients have a high level of anxiety"), (d) equipment and safety (e.g., "Office equipment is not working"; "Safety procedures are not being used, e.g., lead shield, glasses, etc."), (e) professional challenge (e.g., "Lack of opportunities to use own judgment"; "Lack of opportunities to perform a variety of dental hygiene services"), and (f) conditions of employment (e.g., "Salary is unsatisfactory"; "Work hours are reduced due to lack of 'busyness' in dental practice"). An additional item, "Lack of quality in dentist's work," was also included but not incorporated in any of the content areas. Instructions for the third section, which was labeled "Stress Intensity Scale," were as follows: "Please indicate on a scale from O (no stress at all) to 4 (a great deal of stress) the amount of stress you experience in the following situations in your dental hygiene practice. After each item place an X in the most appropriate box." Items in the first and third sections were pilot-tested by a panel of five dental education research experts for clarity and appropriateness.
RESULTS Of the 69 surveys that were mailed, six were undeliverable. A total of 52 were returned after follow-up by telephone; of these, three were incomplete or the hygienist was not currently employed in clinical practice. Analyses reported below involved 49 respondents, representing 77 8% of the 63 surveys actually received by the individuals contacted. The mean age of the respondents was 3 2 . 1 yr. (SD= 7.8); 85.7% were married; and 71.4% had a 2-yr. Associate degree (vs a Bachelor's degree). Respondents reported working a mean of 27.9 hr. per week (SD = 8.9).
Brief Symptom Inventory Table 1 presents a comparison between the mean scores of the 49 subjects and the normative mean scores for nonpatient adult subjects on the
719
STRESS IN DENTAL HYGIENISTS
three global indices of the inventory. Independent group t tests indicated that on the Global Severity Index (t = 7.96), the Positive Symptom Total (t = 9.20), and the Positive Symptom Distress Index (t = 3.77), subjects had significantly higher ( p < .001, df = 766) scores than the normative sample. Also represented in Table 1 are the normative and sample means for the nine symptom dimensions. Independent groups' t tests indicated that on eight of the nine dimensions, subjects had significantly ( p < .05, df = 766) higher scores than the normative sample: Obsession-Compulsion (t = 7.82), Interpersonal Sensitivity (t = 10.25), Depression (t= 6.39), Anxiety (t= 4.89), Hostility (t= 6.75), Paranoid Ideation (t = 7.09), Psychoticism (t = 8.08), and Somatization (t = 2.48). The subjects did not differ significantly from the normative mean on Phobic Anxiety (t = 1.49, ns). TABLE 1
COMPARISON OF NORMSFORBRIEF SYMITOMINVENTORY AND HYGIENIST SAMPLEMEANS Index Global Severity Positive Symptom Distress Positive Symptom Total Somatization Obsessive-Compulsive Interpersonal Sensitivity Depression Anxiety Hostility Phobic Anxiety Paranoid Ideation Psychoticism
Sample (n = 49) M SD .68 1.52 22.51 .44 1.01 1.09 .74 .68 .78 .25 .82 .54
.48 .58 11.62 .54 .76
33 .79 .55 .58 .41 .57 .60
Norms (n = 719) M SD .30 1.29 11.45 .29 .43 .32 .28
.35 .35 .17 .34 .15
.31 .40 9.20 .40 .48 .48 .46 .45 .42 .36 .45 .30
Ratings of Stress Items rated for stress were arranged in six sets of five items each. For each category, ratings of the five items were summed, yielding a score ranging in theory from 0 to 20, with high scores representing high stress. The means and standard deviations for the six categories appear in Table 2 . It was hypothesized that the time category would be rated as significantly more stressful than the other categories. To test this hypothesis, an analysis of variance with repeated measures was computed on the category scores represented in Table 2. Category did in fact have a significant effect (F,,2,, = 21.33, p .05). TABLE 2 MEANSAND STANDARD DEVIATIONS FOR SELF-RATED STRESSBY CATEGORY (N = 49) Category S c h e d h g and Time Management Colleague Relationships Patient Resistance Concern with Equipment and Safety Professional Challenge Conditions of Employment
M
SD
13.10 7.69 8.71 8.63 7.02 9.69
3.32 4.80 3.56
4.92 3.66 5.31
Npha (Cronbach, 1951) was computed across the 31 items which were rated, yielding a (n = 30) = .92 (p
STRESS-RELATED SYMPTOMS AMONG DENTAL HYGIENISTS ' REBECCA JESSEN LANG
JOAN L. GILPIN
Department of Health, Physical Education G Recreation, Universiq of Northern Iowa
Department of Health Sciences, Hawkeye Institute of Technology
ANDREW R. GILPIN
University of Northern Iowa Summary.-A sample of 49 practicing dental hygienists responded to a survey which included Derogar~sand Spencer's 1982 Brief Symptom Inventory, a measure of stress-related symploms, and a list of items considered stressful based on previous research with hygienists, arranged in six content categories. As hypothesized, in comparison with national norms, hygienists displayed significantly more symptoms on the over-all inventory and also on eight of nine subscales. Also as hypothesized, on the list of stressors, items pertaining to time pressure were rated as significantly more stressful than items from other behavioral domains. However, contrary to prediction, the correlation between over-all symptom level on the inventory and self-rated stress did not reach statistical significance. A variety of implications for stress reduction in dental hygiene practice are discussed.
Research has consistently shown that health-care professionals are gener-
ally characterized by low job satisfaction and high stress (e.g., Constable
&
Russell, 1986; Motowidlo, Packard, & Manning, 1986). Although most research has focused on medical personnel, several investigators have examined job-related stress in dentists, generally supporting the conclusion that such levels are substantial (e.g., Checchini, 1985; Cooper, 1980; Tetrick & LaRocco, 1987). I t is rather puzzling that stress levels in dental hygienists have received comparatively scant attention. There are several reasons to expect that hygienists would be especially at risk for stress. To the extent that dentists are stressed by their general work environment, hygienists would also presumably experience stress since they share the same general work setting (Cooper, 1980). Because most hygienists are women, they are probably subjected to stress resulting from lack of support for work involvement often found to characterize working women, particularly in nontradtional roles (Freedman & Bisesi, 1988). Finally, the role of the dental hygienist is presently fraught with lack of consensus regarding definition of the field as a profession (presumably implying a Bachelor's degree) versus definition as a technical or paraprofessional specialty, implying two-year programs (Walsh,
'Address requests for reprints to Dr. Andrew R. Gilpin, Department of Psychology, Universiry of Northern Iowa, Cedar Falls, IA 50614.
7 16
R. J. LANG, E T A L .
Heckman, Hannebrink, Kerner, & Ishida, 1988); such role ambiguity is often quite stressful (Levi, 1981). Such research as is available has generally focused either on tangentially related phenomena such as job satisfaction or has employed ad hoc instruments with unknown validlty (Rubenstein & May, 1986). For example, McAdams (1976) surveyed a sample of California hygienists, identifying aspects of the job which they particularly liked or disliked. In a survey of students and graduates of the hygienists' program at Ohio State University, Pitchford, Broslu, and Reynolds-Goorey (1980) employed a standard measure of job satisfaction, the Job Descriptive Index, and concluded that their subjects scored below the 25th percentile on national norms. In a study of hygienist alumni of the University of Missouri, Deckard and Rountree (1984) found that hygienists had lower scores than many other health-care professionals on the Maslach Burnout Inventory (i.e., were less predisposed to burnout), but the scores were still unacceptably high by absolute standards. Several other investigators have also reported empirical data indicating substantial job dissatisfaction among hygienists (e.g., Heine, Johnson, & Emily, 1983; Lawson & Martinoff, 1980; Odrich & Wayman, 1987). Several behavioral domains seem particularly problematic in terms of hygienists7satisfaction. Those most relevant to the present study include the following: (a) pressures associated with scheddng and time management (Farrugia, 1984; Lawson & Martinoff, 1980; McAdams, 1976; Reiter, 1983, (b) relationships with colleagues (Deckard & Rountree, 1984; Heine, Johnson, & Emily, 1983; Logan, 1980), (c) patients' resistance (Cecchini, 1985; Cooper, 1980; McAdams, 1976), (d) concerns with equipment and safety of self and patient (Farrugia, 1984; Levi, Frankenhaeuser, & Gardell, 1986; McAdams, 1976), (e) the need for continued professional challenge (Farrugia, 1984; Heine, Johnson, & Emily, 1983; Lawson & Martinoff, 1980), and (f) conditions of employment, e.g., job security, salary, or fringe benefits (Farrugia, 1984; Heine, Johnson, & Emily, 1983; Lawson & Martinoff, 1980; McAdams, 1976). The factors just enumerated represent consistent categories of job satisfaction among hygienists, but in a theoretical review, Rubenstein and May (1986) have suggested that most of the same categories constitute critical sources of stress. Of the factors noted, the most important may well be time pressure. As Rubenstein and May noted, hygienists often face tight schedules with little flexibility. Many things which can disrupt the schedule are outside their control, for example, delays caused by patients arriving late or a dentist's inability to perform an examination at a particular time. Time pressure has been a primary source of stress for other health-care professions as well (Bugen, 1979; Holt, 1982; Levi, 1981; Seamonds, 1986). The present study surveyed a sample of practicing dental hygienists.
STRESS IN DENTAL HYGIENISTS
717
The respondents were asked to rate a variety of sources from the categories described above, with respect to how stressful they were. Respondents also completed a standard instrument assessing psychiatric distress, Derogatis and Spencer's (1982) Brief Symptom Inventory. This measure is a short version of a longer scale, the SCL-90-R, which has been widely validated in research with numerous populations as assessing psychiatric symptoms associated with psychological stress (Derogatis, 1982). The following hypotheses were tested. First, it was hypothesized that hygienists would have significantly higher distress than the national norm on the Brief Symptom Inventory. Second, it was hypothesized that hygienists would report that time-related factors were significantly more stressful than factors involving colleagues' support, patients' resistance, personal safety, professional development, or employment. Thud, it was hypothesized that there would be a positive correlation between symptoms reported and selfrated stress associated with all factors combined.
Subjects
The population surveyed included all practicing clinical dental hygienists in the Waterloo, Iowa district of the Iowa Dental Hygienists' Association. A total of 69 surveys were mailed out, representing the entire membership.
Questionnaire A covering letter provided for informed consent and requested that the subject complete the questionnaire and return it in a stamped envelope provided. I n the questionnaire were three sections. The first section assessed a number of demographic variables (age, marital status, type of degree, highest degree, current employment, primary practice setting, number of offices employed in, hours per week worked, and years of previous employment) which were included for exploratory purposes and are not discussed further. The second section consisted of Derogatis and Spencer's (1982) Brief Symptom Inventory, a 53-item self-report form designed to assess a variety of symptoms of psychological distress. Instructions specify the subject read each of a list of problems and complaints (e.g., "Pains in heart or chest" and "Trouble falling asleep"), and to mark a response that describes "how much discomfort that problem has caused you during the past week including today." Responses are made on a five-point scale from "not at all" (0)to "extremely"(4). Previous researchers have demonstrated the validity of the inventory (Derogatis, 1982), and norms are available for a variety of populations, the most relevant being a sample of 719 adults who were not psychiatric patients. The inventory generates three global indices (the Global Severity Index, combining information on numbers of symptoms and intensity of distress;
R. J. LANG, ETAL
the Positive Symptom Total, reflecring the number of symptoms; and the Positive Symptom Distress Index, an intensity measure adjusted for number of symptoms present). I n addition, there are scores on nine primary symptom dimensions, including somatization, obsession-compulsion, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism. The third section of the questionnaire contained a list of 31 sources of stress, culled from previous studies discussed above. Items were arranged in random order, with five items representing each of six content areas: (a) scheduling and time management (e.g., "Lack of time for patient education"; "Too little time scheduled for hygiene appointments"), (b) colleague relationships (e.g., "Relationships with coworkers are not satisfyingH; "Lack of praise from employer"), (c) patients' resistance (e.g., "Patients have not followed home care instructions"; "Patients have a high level of anxiety"), (d) equipment and safety (e.g., "Office equipment is not working"; "Safety procedures are not being used, e.g., lead shield, glasses, etc."), (e) professional challenge (e.g., "Lack of opportunities to use own judgment"; "Lack of opportunities to perform a variety of dental hygiene services"), and (f) conditions of employment (e.g., "Salary is unsatisfactory"; "Work hours are reduced due to lack of 'busyness' in dental practice"). An additional item, "Lack of quality in dentist's work," was also included but not incorporated in any of the content areas. Instructions for the third section, which was labeled "Stress Intensity Scale," were as follows: "Please indicate on a scale from O (no stress at all) to 4 (a great deal of stress) the amount of stress you experience in the following situations in your dental hygiene practice. After each item place an X in the most appropriate box." Items in the first and third sections were pilot-tested by a panel of five dental education research experts for clarity and appropriateness.
RESULTS Of the 69 surveys that were mailed, six were undeliverable. A total of 52 were returned after follow-up by telephone; of these, three were incomplete or the hygienist was not currently employed in clinical practice. Analyses reported below involved 49 respondents, representing 77 8% of the 63 surveys actually received by the individuals contacted. The mean age of the respondents was 3 2 . 1 yr. (SD= 7.8); 85.7% were married; and 71.4% had a 2-yr. Associate degree (vs a Bachelor's degree). Respondents reported working a mean of 27.9 hr. per week (SD = 8.9).
Brief Symptom Inventory Table 1 presents a comparison between the mean scores of the 49 subjects and the normative mean scores for nonpatient adult subjects on the
719
STRESS IN DENTAL HYGIENISTS
three global indices of the inventory. Independent group t tests indicated that on the Global Severity Index (t = 7.96), the Positive Symptom Total (t = 9.20), and the Positive Symptom Distress Index (t = 3.77), subjects had significantly higher ( p < .001, df = 766) scores than the normative sample. Also represented in Table 1 are the normative and sample means for the nine symptom dimensions. Independent groups' t tests indicated that on eight of the nine dimensions, subjects had significantly ( p < .05, df = 766) higher scores than the normative sample: Obsession-Compulsion (t = 7.82), Interpersonal Sensitivity (t = 10.25), Depression (t= 6.39), Anxiety (t= 4.89), Hostility (t= 6.75), Paranoid Ideation (t = 7.09), Psychoticism (t = 8.08), and Somatization (t = 2.48). The subjects did not differ significantly from the normative mean on Phobic Anxiety (t = 1.49, ns). TABLE 1
COMPARISON OF NORMSFORBRIEF SYMITOMINVENTORY AND HYGIENIST SAMPLEMEANS Index Global Severity Positive Symptom Distress Positive Symptom Total Somatization Obsessive-Compulsive Interpersonal Sensitivity Depression Anxiety Hostility Phobic Anxiety Paranoid Ideation Psychoticism
Sample (n = 49) M SD .68 1.52 22.51 .44 1.01 1.09 .74 .68 .78 .25 .82 .54
.48 .58 11.62 .54 .76
33 .79 .55 .58 .41 .57 .60
Norms (n = 719) M SD .30 1.29 11.45 .29 .43 .32 .28
.35 .35 .17 .34 .15
.31 .40 9.20 .40 .48 .48 .46 .45 .42 .36 .45 .30
Ratings of Stress Items rated for stress were arranged in six sets of five items each. For each category, ratings of the five items were summed, yielding a score ranging in theory from 0 to 20, with high scores representing high stress. The means and standard deviations for the six categories appear in Table 2 . It was hypothesized that the time category would be rated as significantly more stressful than the other categories. To test this hypothesis, an analysis of variance with repeated measures was computed on the category scores represented in Table 2. Category did in fact have a significant effect (F,,2,, = 21.33, p .05). TABLE 2 MEANSAND STANDARD DEVIATIONS FOR SELF-RATED STRESSBY CATEGORY (N = 49) Category S c h e d h g and Time Management Colleague Relationships Patient Resistance Concern with Equipment and Safety Professional Challenge Conditions of Employment
M
SD
13.10 7.69 8.71 8.63 7.02 9.69
3.32 4.80 3.56
4.92 3.66 5.31
Npha (Cronbach, 1951) was computed across the 31 items which were rated, yielding a (n = 30) = .92 (p
