Exploring stressors in paediatric dentistry clinical training among Polish and international dental students at the Medical University of Lodz

Abstract

Providing dental treatment to children during clinical training appears challenging for undergraduate students. Various factors, including overall perceived stress (PS) and studying abroad, may affect the way students interpret stressful situations. To gain deeper insights into these issues, an anonymous online questionnaire, consisting of a 5-point scale of stress level related to paediatric dentistry training, questions regarding its sources, and the Perceived Stress Scale (PSS-14), was sent via e-mail to 4th- and 5th-year students. A total of 115 students (40 out of 50 enrolled in the English-taught dentistry program and 75 out of 248 Polish students) completed the survey. Polish students showed a statistically higher mean PSS-14 score compared to their foreign counterparts (34.11 vs. 27.58, p < 0.001). The mean rating of stress linked to clinical training did not differ significantly between international and Polish students, and for both groups, it correlated with the PS level. Endodontic treatment and local anaesthesia were identified as the most stress-inducing procedures. From a given list of potential stressors, Polish students ranked the child’s attitude as the top stressor, followed by the supervisor’s attitude, whereas international students ranked them inversely. Only 30% of international and 22.6% of Polish students expressed interest in choosing paediatric dentistry as their speciality after graduation. Supervisors should be aware of stressors inherent to clinical training and differences in stress perception between international and native students in order to mitigate the effects of stress and enhance students’ motivation for future practice of paediatric dentistry.

Introduction

As per Lazarus and Folkman’s perspective, stress can be defined as a specific interaction between an individual and their surroundings, wherein the person perceives it as placing demands or challenges that exceed their capacity to deal with it and pose a threat to their overall well-being. Psychologists also suggested that the way we would interpret an event and emotions that arise from it may have a greater impact on our stress levels than the event itself^1,2. Stress is a pervasive factor among students in all academic fields, particularly manifesting among medical and dental students who contend daily with demanding tasks, vast amounts of study materials, and profound sense of the responsibility associated with patient care³. Remarkably, stress levels among dental students have been observed to surpass those among medical students^4–6. This discrepancy may be attributed to factors such as stringent time constraints, relentless pursuit of aesthetic treatment precision, exacting treatment standards, and intense competitiveness within the field of dentistry. Unfortunately, stress does not go unnoticed; it can persist even after the stressor is removed, affecting students’ mental health, eroding their confidence, and significantly influencing their educational performance^7,8. High levels of stress and persistent stress exposure may culminate in burnout syndrome, characterized by the experience of long-term work-related exhaustion and diminished interest in personal accomplishment^9,10. Although burnout refers to a long-term process, it is apparent amongst students too, especially those in their later years of study^10–13. Chronic stress may also encompass a spectrum of health impacts, including physical ailments, such as digestive problems, skin and cardiovascular diseases and psychological manifestations, including hostility and cynicism^11,12. Furthermore, the dental profession is considered to be one of the most stressful health professions, mainly due to intense interaction between dentist and patient^7,9,13.

Stress in students may have many sources such as student-related, academic (amount and difficulty of classwork, exams and grades) or faculty-related factors, but senior students additionally face challenges of clinical training^7,10,12,14. It is also worth noting additional stressors e.g. the aspects of providing oral care to children or differences in residency status that could impact a particular demographic such as students studying overseas. Effective communication is crucial when interacting with patients, as it not only enables the collection of vital information about their health but also helps put them at ease. Interacting with native patients can present a challenge for international students who do not fluently speak the language of the country in which they reside. Moreover, the so-called paediatric dentistry treatment triangle, which includes the development of the doctor-patient and doctor-patient’s parent/caregiver relationships, instead of offering a sense of comfort, could potentially add stress for the student providing treatment to children¹⁵. In a demanding role of an undergraduate dentist, where one must diagnose and treat patients flawlessly while simultaneously preparing for exams, these interactions could potentially emerge as a notable stress-inducing factor, amplifying the overall stress experienced. Though numerous studies have explored the stress experienced by dental students^{4–10,12–14,16–21}, there has been very limited research focused on stressors related to paediatric dentistry training^22–24. Additionally, due to our best knowledge, no study has compared stress while performing paediatric dental treatments between international and native students in Poland.

The Medical University of Lodz offers a 5-year Dentistry program in the Polish language, as well as English-taught dentistry program, that has been available for over 20 years. The program of Polish and English divisions of Dentistry at the Faculty of Medicine culminates in the degree of Doctor of Dental Medicine (DMD). Currently, the English division of Dentistry has an international community with students from all over the world. Curriculums of Paediatric Dentistry courses for both Polish and international students are identical, except for the language in which they are taught. There is a growing trend in numbers of international students enrolling in dental studies in Poland. Thus, it is crucial to compare stress levels and sources related to paediatric dentistry clinical training in national and international students in order to understand and mitigate specific challenges faced by these groups of students. This, in turn, could allow for targeted support from the faculty.

The objective of our study was therefore to investigate the level of experienced stress and possible stress-provoking factors related to clinical paediatric dentistry training in undergraduate 4th- and 5th-year dental students, and to examine the obtained data in terms of differences between senior students of the English and Polish divisions of Dentistry. Furthermore, the study aimed to assess if overall perceived stress load has an impact on experienced stress when providing dental treatment in children, as well as to investigate the desire to choose paediatric dentistry specialty as a future career.

Materials and methods

Study design

In this cross-sectional study an anonymous questionnaire was sent via e-mail to 4th and 5th -year students of English an Polish divisions of Dentistry during the summer semester of the academic year 2022–2023.

The study protocol was approved by the Medical University of Lodz Bioethics Committee, Resolution Number RNN 32/23/KE. The survey was conducted in compliance with the principles of the revised 2013 Helsinki Declaration. The research was carried out in accordance with relevant guidelines and regulations.

Data collection

The questionnaire was prepared using the Microsoft Forms program and the link was sent to student’s official email accounts in March 2023, allowing for the completion within one semester. E-mails with invitation to participate in the survey were sent to all international and Polish senior dental students with a cover letter containing an explanation of the study purpose, the voluntary, anonymous nature of the study participation, and the link to the questionnaire in English and Polish languages, respectively. Upon clicking the provided link, students were directed to the questionnaire. Although, the survey was anonymous, students were asked at the beginning of the questionnaire to confirm their agreement to anonymous participation. Informed consent was obtained from all participants. Respondents were not required to provide any personal information, such as their names or surnames, during the questionnaire completion to guarantee the anonymity and confidentiality of the participants. Furthermore, we aimed to prevent students from providing biased responses due to concerns about their answers being accessible to their teachers. The questionnaire was structured into three segments. The initial segment comprised questions aimed at gathering demographic data: study year, age, and gender, if desired. The core segment contained bespoke questions regarding clinical factors. Students were asked to determine the following using a 5-point Likert - type scale (ranging from 1 to 5):

• the level of self-reported stress when performing dental treatments on paediatric patients in general and when performing particular (12 selected) procedures; For analysis, the scores were interpreted: 1- no stress, 2- mild stress, 3- moderate stress, 4-much stress, 5-extreme stress;

• the influence of the presence of the child’s parent during treatment on the level of experienced stress;

• how the knowledge of the Polish language allows them to communicate effectively with patients, how it affects the treatment time and if it has an impact on achieving success in children’s dental treatment of children;

• the impact of preclinical training as well as the number of times they performed the given clinical procedure on their level of confidence in performing paediatric dentistry procedures;

• the level of agreement (from strongly disagree-1 to strongly agree − 5) to selected statements about the influence of stress on their clinical work quality, and the children’s age as factors exacerbating their stress during practical paediatric dental training.

Furthermore, students were asked to:

• rank additional potential stressors during dental treatment in children: the supervisor’s attitude, patient’s attitude, time pressure, language barrier, practical skills requirements, theoretical knowledge requirements and strive for perfection in order from the most to the least onerous.

• answer questions: “Do you think paediatric dentistry is an easy specialty? Would you consider working in the field of paediatric dentistry after graduating?”

To evaluate the level of overall perceived stress (PS) in students the concluding segment of the survey included the Perceived Stress Scale (PSS-14), the internationally recognized self-report psychological assessment tool comprising of seven negative (representing perceived helplessness) and seven positive items (representing self-efficacy) summarized in 14 questions. Respondents were asked how often during the last month they felt or thought a certain way when faced with different situations in their life, and each of the questions required the student to provide a rating on a five-point Likert scale of 0 to 4, with options: “never”, “almost never”, “sometimes”, “fairly often”, and “very often,” as appropriate. PSS-14 scores were obtained by reversing the scores on the seven positive items; therefore, they were recoded (0 = 4, 1 = 3, 2 = 2, 3 = 1, 4 = 0), then summed across all with total scores ranging from 0 to 56 and then categorized as Low Stress (scores 0–18), Moderate Stress (scores 19–37), and High Stress (scores 38–56), as coded earlier by Higgins²⁵. The PSS-14 is a tool commonly utilized for gauging the extent to which individuals perceive life situations as laden with stress. The scale originally developed by Cohen et al. (1983), was translated into more than 20 languages²⁶. PSS was used for stress perception assessment in research worldwide^27–29, including those on dental students^12,14,15. Its psychometric properties in assessing perceived psychological stress have been satisfactorily verified^26–29, and also the Polish version, used in a study of 591 university students, showed good internal consistency and reliability³⁰.

Statistical analysis

Statistical analysis was performed using Statistica for Windows software (version 13.3). The normality of distribution was checked by the Shapiro-Wilk test. The results were expressed as mean ± standard deviation. Comparisons between the study subgroups were performed using the t- test. Correlations were assessed by correlation test (r). Differences were considered significant if p was less than 0.05. Additionally, descriptive analysis for categorical variables was performed (frequency, percentage were calculated). A Chi-squared test was used to analyse the differences in categories of perceived stress between the groups. Multivariate regression analysis was performed to assess potential confounders of stress.

Results

The overall response rate was 38.59% (115 of 298 potential participants). A higher response rate was among international students than Polish ones (40 of 50 students − 80% versus 75 of 248–30.24%). The mean age of the respondents was 24 years (ranging from 22 to 30 years) and was 24.146 ± 1.61 vs. 23.66 ± 1.83 for native and international students, respectively. Among the participants, 70.43% (n = 81) were female, 27.83% (n = 32) were male, and 2 students (1.74%) preferred not to say their gender. Table 1 illustrates the distribution of respondents by academic year level and gender.

Table 1.

The characteristic of the study group.

Division of Dentistry	Academic year level	Male n	Female n	Prefer not to say n	Sum n	Overall n (%)
Polish division	4th year	5	21	–	26	75 (65.22%)
	5th year	7	42	–	49
English division	4th year	10	11	1	22	40 (34.78%)
	5th year	10	7	1	18
OVERALL n (%)		32 (27.83%)	81 (70.43%)	2 (1.74%)	115 (100%)	115 (100%)

Evaluation of student responses (given using a 5-point scale) regarding stress experienced when performing procedures on paediatric patients showed that the mean rating of stress was 3.23 ± 0.97 vs. 2.95 ± 0.96 for the Polish- and English-division students. The stress provoked by providing dental treatment to children did not differ significantly between both groups (p = 0.145). Neither were found any differences between male and female students ( p = 0.461 and p = 0.685 for Polish and international groups, respectively), and when comparing the study years (p = 0.083 and p = 0.974 for native and international students, respectively).

98.2% of Polish and 90% of international students reported experiencing stress when performing dental procedures on children. Stress level was most often scored 3- moderate stress by international students (40%) and 4 -much stress by Polish students (34.66%). None of the responders studying at the English division rated stress as extreme, while score 5 was given by six Polish students (8%). Figure 1 presents the distributions of particular answers (interpreted as: 1- no stress, 2- mild stress, 3- moderate stress, 4-much stress, 5-extreme stress).

Fig. 1.

Distribution of stress levels when performing dental treatment on children among students of the English and Polish divisions.

Table 2 presents mean stress scores for particular dental procedures assessed using a 5-point scale, surveyed according to the study groups. Both Polish students and those studying in English rated stress as being the highest while performing endodontic procedures. However, self-reported mean stress score was significantly higher among Polish students. For both groups of students, the second most stressful procedure was administering local anaesthesia to children. Additionally, Polish students perceived significantly higher stress during caries cavity preparation in mandibular teeth and when restoring the cavity with composite resin. In contrast, procedures such as topical fluoride application or silver nitrate treatment of early childhood caries and distinguishing between milk and permanent teeth while carrying out dental examination in children with mixed dentition were considered more stressful by students studying in English. No statistically significant differences were observed between international and Polish students for other procedures mentioned in Table 2 such as local anaesthesia injection, taking dental impression or simple extraction of milk teeth. Caries removal in mandibular teeth was scored by both groups of students as significantly more stressful than cavity preparation in maxillary teeth (Table 2).

Table 2.

Mean stress scores for particular dental procedures assessed using 5-point scale, surveyed according to the study groups.

Procedure	Polish division n = 75	English division n = 40,	Significance (p)
	Mean value ± SD [95% CI]	Mean value ± SD [95% CI]
Distinguishing between permanent and deciduous teeth while caring out dental examination	2.11 ± 1.26 [1.82, 2.39]	2.70 ± 1.02 [2.31, 3.09]	0.015
Administration of local anaesthesia	3.60 ± 1.13 [3,34, 3.86]	3.15 ± 1.27 [2.74, 3.56]	0.055
Caries removal in maxilla	3.23 ± 1.072* [2.98, 3.47]	2.83 ± 1.21** [2.43, 3.21]	0.071
Caries removal in mandible	2.56 ± 0.99* [2.33, 2.79]	1.85 ± 1.10** [1.50, 2.20]	< 0.001
Glass ionomer placement	2.03 ± 1.04 [1.79, 2.27]	2.05 ± 1.22 [1.66, 2.44]	0.914
Composite placement	2.51 ± 0.99 [2.28, 12.73]	2.03 ± 1.16 [1.65, 2.39]	0.021
Fluoride application	1.13 ± 0.41 [01.04, 1.23]	1.48 ± 0.98 [1.16, 1.79]	0.010
Silver nitrate impregnation	1.75 ± 1.0 [1.52, 1.98]	2.33 ± 1.42 [1.87, 2.78]	0.012
Indirect pulp capping	3.35 ± 1.12 [3.09, 3.60]	3.20 ± 1.34 [2.77, 3.63]	0.535
Endodontic treatment	4.36 ± 0.91 [4.15, 4.57]	3.68 ± 1.94 [3.27, 4.08]	0.001
Simple deciduous tooth extraction	2.76 ± 1.13 [2.45, 3.07]	2.45 ± 1.14 [2.01, 2.89]	0.247
Taking impressions with alginate	2.71 ± 1.12 [2.42, 2.99]	2.48 ± 1.13 [2.11, 2.84]	0.330

Statistically significant differences within study groups: Polish group: *p < 0.001 ; English group: **p < 0.001.

While looking at additional factors exacerbating stress, students’ responses to the question “How much does the presence of a child’s parent during treatment affect the level of stress you feel?” were analysed. Answers were given using a Likert scale which provided a range of response options from 1 to 5. No statistically significant differences were found between mean scores of Polish students and those studying in English (3.02 ± 1.22 vs. 2.95 ± 1.25, p = 0.752).

Both groups of students agreed with the statement that knowledge of the language the patient communicates in has a significant impact on reducing the length of the visit (mean level of agreement in 5-Likert’s scale was 4.43 ± 0.79 for Polish residents and 4.08 ± 1.1 for international students, respectively). Similarly, students agreed that the ability to communicate in the patient’s language contributes to success of dental treatment in children (mean level of agreement in 5-Likert’s scale was 4.41 ± 0.71 for Polish residents and 4.13 ± 1.13 for international students, respectively). No statistically significant differences were found for the above comparisons (p = 0.064 and p = 0.085).

Preclinical training seems to have stronger influence on international students’ confidence in performing clinical procedures (mean 3.55 ± 1.33 vs. 4.28 ± 0.96 for Polish and English division students, respectively, for p = 0.0029). While for Polish students the number of times they performed the given clinical procedure seems to affect their confidence level more (mean 4.73 ± 0.70 vs. 4.30 ± 1.06 for Polish and international students, p = 0.01).

Analysing students’ agreement levels with the statement about the influence of a child’s age as a factor exacerbating stress during practical training showed that the level of experienced stress depends on patient’s age − 42.5% of students enrolled in the English-taught dentistry program and 60% Polish students agreed or strongly agreed that the younger the patient was, the more stressed they felt. A higher percentage of Polish than international students agreed or strongly agreed that the level of stress they experience depends on the age of the patient (57.33% vs. 32.5%). In addition, 60% of native and 52.5% of international responders shared the opinion that stress affects the quality of their work. Figure 2 shows students’ agreement assessed with 5- point Likert type scale to mentioned statements.

Fig. 2.

Students agreement (rated with 5-point Likert scale) to particular statements, surveyed according to the study groups.

Potential stressors ranked by respondents in the online survey, in order from the top to the bottom stressor are illustrated in Fig. 3. Patient’s attitude was placed at the top of the stressors hierarchy by Polish students, followed by supervisor’s attitude, whereas in international students the order of those two stressors was reversed. However, time pressure was mentioned in third place in both groups of students. Differently from Polish students, international students ranked the language barrier higher than theoretical knowledge and practical skills.

Fig. 3.

Ranking of stress-inducing factors by divisions of Dentistry-English and Polish.

Most students do not assess paediatric dentistry as an easy speciality (Fig. 4) and only 12 of 40 (30%) international students and 17 of 75 (22.6%) Polish students showed interest in working in the field of paediatric dentistry after graduation (Fig. 5). Additionally, students who prefer not to choose paediatric dentistry as a future career reported higher level of self-reported stress linked to performing dental treatments on children (r = 0.265 p = 0.004). Whereas, there was no correlation with higher PSS level and lack of willingness to work in the field of paediatric dentistry after graduation.

Fig. 4.

Students answers to the question “Do you think paediatric dentistry is an easy specialty?

Fig. 5.

Students interest in working in the field of paediatric dentistry after graduating.

The mean of the PSS-14 scores was 34.11 ± 7.87 (minimum 19, maximum 46) and 27.58 ± 6.24 (minimum 11 maximum 42) for Polish students and those studying in English, respectively. In both groups the mean score responded to moderate stress level. Figure 6 shows distribution of stress categories (low, moderate and high stress) among the study groups.

Fig. 6.

Distribution of perceived stress levels in subgroups of students undertaking education at English and Polish Divisions. PSS-14 scores categories as Low Stress (scores 0–18), Moderate Stress (scores 19–37), High Stress (scores 38–56). *Chi-square (χ2) = 20.1, df = 2, p = 0.0004

Table 3 shows the means of the PSS-14 scores in the study groups. There were statistically significant differences in perceived stress (PS) between Polish and international students, also when analysing the score according to genders.

Table 3.

PSS scores according to the study group, gender and the year of the study.

	Polish division Mean value ± SD [95% CI]	English division Mean value ± SD [95% CI]	Significance Polish vs. English div.
Pooled	34.11 ± 7.87 [32.37, 35.84]	27.58 ± 6.24 [25.57, 29.57]	p < 0.001
Men	33.83 ± 6.99 [29.39, 38.27]	26.8 ± 7.63 [23.22, 30.37]	p = 0.014
Women	34.16 ± 7.71 [32.22, 36.10]	28.16 ± 4.27 [26.04, 30.29]	p = 0.002
Significance men vs. women	p = 0.892	p = 0.506
4th year	34.54 ± 7.21 [31.01, 35.91]	25.59 ± 5.76 [23.03, 28.14]	p < 0.001
5th year	33.88 ± 7.79 [31.00, 36.40]	30.0 ± 6.08 [26.97, 33.03]	p = 0.267
Significance 4th vs. 5th year	p = 0.720	p = 0.024

When comparing the mean score for PSS between female and male students within the groups, there were no statistically significant differences for both Polish and international students. When examining of the PSS according to the year of the study we found higher stress in 4th -year Polish students comparing to students enrolled in the English division. Among international students lower stress was observed in 4th -year compared to those of 5th year (Table 3).

The analysis of potential confounders might have impact on PSS is showed in Table 4. The year of the study and the division of the study ( English / Polish ) turned out to relevant in this regard.

Table 4.

Results of the multiple linear regression analysis - potential confounders independently associated with PPS (pooled study groups).

Explanatory variables	Unstandardised coefficient		Standardised coefficient	t	p
	b	Std. error	Beta
Age	− 0.07	0.08	0.39	− 0.785	0.434
Gender	− 0.06	0.08	1.42	− 0.658	0.511
Study year	0.253	0.09	1.38	2.866	0.005
Study Division	0.346	0.09	1.46	3.852	0.0002

A positive correlation was found between PPS-14 score and level of stress for carrying out dental treatment in children for both Polish and international students (r = 0.3 for p = 0.009 and r = 0.32 for p = 0.043, respectively).

Discussion

It has been reported previously that dental education is known to be highly demanding and induces considerable stress on students^10,16–18. Clinical training seems to be the most critical phase of dental education as students are expected to acquire a wide range of knowledge and skills that should help them succeed in their studies and in providing dental treatment to their patients²⁰. Moreover, the clinical years has been shown to be more stressful than the pre-clinical years^7,19. Data from the literature suggest that understanding of how students experience and perceive their studies might be helpful for creating a positive academic environment²⁰.

In this study, the PSS-14 was employed to measure the general stress load in 4th and 5th -year students and Likert-like scale to pinpoint the specific paediatric dental procedures that exert the most significant stress on students, as that information may be of value not only from psychological point of view, but also might be relevant to faculty teachers to guide them how to support students during clinical courses. In present study, the mean score of overall stress reported by both Polish and international students was within the range of moderate stress level. It is in accordance with results of surveys on dental students in the UK, North-West Russia and China, in which the shortened version of the PSS with 10 items was used^6,10,14. However, we observed higher percentage of both native and international students with high level of stress (22.5% and 37%, respectively), than it was reported for Russian students (4.9%), but lower comparing to UK dental students (56%)^6,10. What’s more Juszka et al., who also used the PSS scale, reported a moderate level of perceived stress among 4th - and 5th -year students. Similarly to our survey, the authors found significantly higher stress levels in Polish students than in international students enrolled in the English division of Dentistry, but only when analysing all students together and specifically 4th-year students. In contrast to our study, the level of stress among 5th-year students was higher in international than Polish students¹⁸.

Sanders et al. noted peaking of the stress at 4th -year of study in the group of Australian dental students.⁸ Furthermore, in the survey conducted by Gorter et al. 5th-year students showed relatively high mean MBI (The Maslach Burnout Inventory) scores, and negative development from year one to year five in relation to emotional exhaustion and psychological distress was observed¹³. According to Sanders et al. for senior students, the accumulative effect of stress is also confounded by the increased technical difficulty in performing clinical tasks⁸. This seems to be in line with our observations, as we found a positive correlation between the PPS score and level of stress experienced when providing dental treatment to children for both native and international students. The increase in perceived daily stress level can be also explained by findings of other authors that final year students showed greater anxiety about the future¹⁷.

Similarly to the study of Cohen we found no significant difference in PSS scores between male and female students in any of the survey group²⁶. Also, other studies conducted in several European dental schools, as well as in China and Mexico did not find gender differences in perceived stress assessed using PSS or the Dental Environment Stress (DES) scales^{11,13,14,18,21}. In addition, Wilson et al. assessed stress among recently graduated dentists and the ones in practice for a longer time and described gender differences only to be significant amongst the latter group³¹. However, data on disparity in perceived stress between genders are not unanimous. Some previous studies that enrolled students of all years noted greater perceived stress scores in female dental students^{4,6,10,16,18,19}. In contrast, research conducted in India showed that male dental students exhibited higher levels of stress than women did which might be associated with sociocultural influences^17,32. However, it has been stated that gender differences in the dental profession would diminish as more females would take on an assertive role in society¹³.

The mean PSS-14 score in the sample of senior students enrolled in the English division (25.59) in our study was comparable to the score reported by Singh et al. for last year’s dental students in India (26.86), and slightly higher than that reported by Cohen for the sample of College students in the USA (23.67)^16,26. However, Polish students reported much higher stress level (34.54). The STADA Health Report 2022 online survey of almost 30,000 respondents in 15 European countries showed that Polish adults are most susceptible to feel burnout compared to the rest of Europe. In Poland, 70% of responders reported they have experienced feelings of burnout at least once in their lifetime. The youngest age group surveyed (18-24-year-olds) was shown to be especially susceptible to it³³. Similar PSS scores to our survey were reported only for senior undergraduate dental students in Saudi Arabia during COVID-19 pandemic (31.33, 33.04 and 34.41 for 4th -, 5th - and 6th - academic year students, respectively)¹⁹. It cannot be excluded that the pandemic made students more stressed. Sanders et al. who examined stress level in dental students using DES scale found in category of clinical training no statistical differences in stress score between Australian and international students, however difficulty in learning clinical procedures was ranked higher in stressors’ hierarchy by national than international students. The authors showed higher mean score for international students in comparison to Australian students, when sources of stress such as self-efficacy beliefs, faculty and administration; and peer pressure were analysed. According to the authors this finding may be due to cultural determinants (the fact that international students derived mainly from Asian countries) language difficulties and acculturative adjustment⁸.

Even in our study, we not only focused on the particular dental procedures performed during clinical training as a source of stress, but also we tried to determine also the influence of the lingual barrier in communication with child patients and impact of the supervisors’ attitude. One of the main factors contributing to overall disappointment and inability to achieve treatment goals with young patients could stem from poor communication, which in case of international students often results from a language barrier between the undergraduate student and the patient. In such scenarios, soothing the child and attaining the desired outcomes can prove to be challenging. Both Polish and international students responded that knowledge of the language that patients speak highly affects the treatment success, and additionally, international students ranked the language barrier higher in stressors’ hierarchy than theoretical knowledge and practical skills requirements. The issue of language barrier previously primarily affected international students at our university, given that Polish is considered one of the most challenging languages to acquire. A study conducted in Finland found that the language barrier posed significant difficulties to the international nursing students and resulted in negative experience of being an outsider, decreased self-esteem, sense of giving up and anticipation of difficulties³⁴. Non-native medical students in Saudi Arabia reported a lack of empathy and trust between them and the patients due to an absence of effective communication. As a result of this limitation in active interaction with patients during history taking and physical examination, as well as the need to rely on their peers and supervisors to understand patients’ complaints, they sometimes felt lacking in attaining required clinical skills³⁵.

Due to evolving political dynamics and recent events, language barrier has now become a concern for native students as well. Since the beginning of Russian military aggression against Ukraine with the outbreak of a full-scale war and the subsequent massive influx of refugees from Ukraine to Poland, has changed the situation in medical services. The Ukrainian citizens who arrived in Poland on or after February 24, 2022, received full access to national medical care and have been treated the same as insured Polish citizens by the National Health Fund. These patients and their caregivers may not have the proficiency to communicate effectively in Polish, therefore native dental students have to overcome the problems with the language barrier when providing dental treatment to children as a part of clinical training at medical universities.

A systematic review of stress among dental students showed that of the clinical factors, the major stressor was fear of failure to complete clinical requirements. But, among other factors criticism by supervisors, the atmosphere created by clinical faculty, as well as contact with patients and bearing the responsibility for comprehensive patient care played also important role^7,8. Also, our study confirms those observations as the supervisor’s attitude and patient’s attitude were placed at the top of the stressors hierarchy in both survey groups. Nevertheless, international students ranked higher on the supervisor attitude. It seems to be in line with the results of the above-mentioned study of Sanders et al. that items connected with faculty are stronger stressors for international students, despite the fact that the group evaluated by those authors was made up exclusively of students of Asian origin, and in our study, it was more multicultural⁸. Also, Kaipa et al. showed that 4th -year students in South India perceived the atmosphere created by clinical supervisors (particularly receiving criticism from supervisors) as the highest stress inducing factor, while in studies conducted by Kumar et al. on Indian students and Morse et al. on Fijian students, this factor was ranked third^36–38. This underlines how important role plays academic teacher in creating atmosphere during clinical period of dental education. It should be also noticed that the confidence of new graduates to treat paediatric patients will be influenced by their clinical undergraduate experience³⁹. However, there are some factors inherent to international students and the placement environment that made facilitating their learning complex. It was shown that the students themselves have identified that their different cultural backgrounds create challenges for learning and may influence supervisors’ perception of them.⁴⁰ Another aspect of learning that can pose a challenge to international students is the hidden curriculum. It can be described as the set of influences that function at the level of organisational structure and culture including, for example, implicit rules to survive the institution such as customs, rituals, and taken for granted aspects. As well as damaging learning through negative role modelling and student mistreatment, the hidden curriculum of clinical experiences can also negatively impact a student’s future speciality choice⁴¹. International students who were brought up in a culture vastly different from that of the country they are studying in may experience difficulties in grasping the unspoken expectation of how they are supposed to act. Successful supervisory behaviours for culturally diverse students should include being positively responsive to cultural issues, identifying cultural features of communication and creating a safe environment for discussion about them. Those strategies facilitate non-native students’ adjustment for the placement leading to a trusting supervisory relationships.⁴².

Treating children was reported as the primary reason for the UK community dental service being so stressful⁴³. Also, Ayers et al. showed that providing dental treatment to difficult children was the most frequently mentioned stress factor by New Zealand dentists (52%), followed by time pressure mentioned by 48% of responders⁴⁴. This stays in agreement with the results of present study since time pressure was ranked third most stress-inducing factor by both, Polish and international students. Working under time constraints, which is a common occurrence in dentistry, becomes even more pronounced when dealing with children. It is crucial to avoid prolonging treatment sessions as children have limited attention spans and can only remain focused and cooperative for a limited duration, even when dental assistants and practitioners make efforts to engage and entertain them.

The level of stress experienced by dental students during their paediatric dentistry training seems to depend also on the type of procedures they have to carry out. Our study confirmed that administering local anaesthesia to children induces elevated levels of stress in dental students. It can be explained by the fact that children often exhibit anxiety, making it challenging for students to administer the anaesthetic precisely. Also, Alazmah at al. reported that dental students were quite stressed when performing this procedure in children. Additionally, the distribution of the respondents’ answers according to the most stressful procedures, was analysed giving local anaesthesia was listed in second place, and it was preceded only by managing the child’s behaviour²².

Similarly, previous studies evaluated that the procedure of administering local anaesthesia has been a strong stressor for dentists, since 18.8% of 711 dentists participating in the study of Simon et al. reported that constant stress felt during the administration of injections causes them to reconsider dentistry as a career, whereas only 2% had no negative reaction to this aspect of dental practice⁴⁵. Surprisingly the study of Davidovich et al. showed that compared to general practitioners and specialists, dental students reported a low level of stress during the injection of anaesthesia. According to these authors it might have been due to the fact that students participating in the study treat only cooperative children and they had no experience in treating anxious children. Additionally, working under supervision of a senior dentist who can help and finish the procedure in case of failure, might have given students a sense of confidence²³.

In our study, analysis of ratings of stress level using 5-point Likert type-scale showed that endodontic treatment was the most stress provoking paediatric procedure. Moreover, the self-reported stress score was significantly higher among Polish than international students. Alazmah et al. used a 3-point scale for rating stress level and observed that 51.1% of students found performing pulp therapy in children to be quite stressful²². The discrepancy in stress levels during endodontic procedures between Polish and English division’s students may be partially explained by the lower overall stress levels of foreign students or may be related to the fact that, due to the language barrier, these students receive more support from supervisors and assistance in managing children’s behaviour during difficult endodontic procedures. This hypothesis may be supported by the observation that international students experience more stress than Polish students during simple procedures such as impregnation or fluoride application, when much less assistance is provided by the senior dentist. Caries removal in the mandible seems to be less stressful for both Polish and international responders of the present survey. Also, Farokh-Gisour and Hatamvand who examined dental stress level during performing paediatric procedures by dental students and dentists in Iran observed that preparation of the cavity for mandibular teeth is less stressful, and it was suggested to be due to the direct vision and easy access²⁴.

Paediatric dentistry is a demanding specialty that presents numerous stressors which encompass procedural complexity, differences between treatment methods in adolescent patients and in adults, behavioural management of anxious children, as well as other factors like parental expectations and the pursuit of excellence in treatment. Due to these challenges, students infrequently opt for specialization in this area of dentistry⁴⁶. Our study confirmed that paediatric dentistry is assessed as a difficult specialty by the majority of both national and international students. Unfortunately only, 30% of international and 22.66% of Polish students consider working in the field of paediatric dentistry after graduating. Also, the study of Alazmah et al. showed that only a third of 5th-year Indian students want to pursue paediatric dentistry as a specialty²². Data from surveys among the US senior students showed even lower interest in this specialty. 6.1% of female students and 1.5% of male students had post graduate plans to choose paediatric dentistry as specialty. Regarding personal quality of life, only 5% of respondents believed that paediatric dentistry offers the best future. Additionally, just 3% thought this specialty provides the best salary prospects⁴⁶.

Conclusion

The majority of Polish students and those studying dentistry in English experienced moderate to high stress during clinical practice in paediatric dentistry, which, in their opinion, hurt the quality of their clinical performance. Students with higher PS levels felt more stress when performing dental procedures on children. Understanding the nature of stress related to the clinical training among dental students, particularly those facing language-related challenges, is crucial for developing support systems that can help mitigate detrimental effects of stress on their well-being and increase students’ motivation in pursuing future practice in paediatric dentistry.

Study limitation

The result was obtained from a single-center study, so the findings might not necessarily be representative of the entire senior undergraduate dental student population in Poland. The other concern was the small number of participants mainly due to the low response rate of Polish division students. We are also unable to infer whether students with higher stress might have been more motivated to participate in the survey. Even though the response rate was much higher among international students, there were only 50 students (25 from 4th and 5th year) in the academic year 2022/2023. Beside non-response bias, potential limitations were sample imbalance and not applying triangulation in the methodology. Furthermore, the use of a bespoke paediatric dentistry stress questionnaire can be bias inherent, but there are no established psychological questionnaires to assess stressors related to paediatric dentistry training. Nevertheless the results of this survey are in line with other research on stress perceived among undergraduate students when performing paediatric dental procedures. This study does not provide data on changes in stress levels over time, and does not assess causality of stress. Although the achieved power for a medium effect size (Cohen’s d = 0.5) was 0.72, which is below the conventional 0.80 threshold, the observed effect size in our data (d = 0.56) corresponds to power of 0.80 achieved in a post hoc analysis.

However, the implication derived from the present study may be important for the university faculty, as they might use the results to improve study conditions and lessen students’ stress related to clinical practice. In addition, this study compared overall perceived and clinical-related stress within the same cohort of dental students, which is rare in the literature.

Author contributions

AB-Z and JD designed the study, collected and analyzed the data, did the literature search, and wrote the draft of the paper. Both authors reviewed the manuscript.equal co-first authorship.

Funding

This work was funded by the Medical University of Lodz, Poland.

Data availability

Detailed survey data are available from the corresponding author upon request.

Declarations

Competing interests

The authors declare no competing interests.