Career expectations and influences among dental students in Malaysia

Abstract

Introduction: It is important to understand career expectations of emerging dental graduates if human resources are to be harnessed in support of oral health. The aims of this study were to explore students’ career expectations and their perceived influences, and to examine variation according to student and school characteristics. Methods: All final-year students registered for 2013/2014 across 11 dental schools in Malaysia were invited to participate in a self-administered questionnaire (n = 530). The instrument explored short- and long-term career expectations, influences and students’ background using a mix of open- and closed-ended questions. The chi-square test was used for comparison according to student and school characteristics. Results: Three-hundred and fifty-six (83%) students, across eight schools, completed the questionnaire. In the short term, undertaking specialist training (46%) was the most commonly cited career goal, and achieving financial stability (79%) was the greatest influence. In the long term, 59% planned to specialise (with a significant difference found according to ethnic group), and 67% considered working full-time, with men significantly more likely to do so than women (P = 0.036). More Malay students (90%) ranked childcare commitments as an important influence on the number of sessions they planned to work per week compared with Chinese students (75%) and Others (74%; P = 0.001). Work–life balance (95%) and high income/financial security (95%) were the main influences on respondents’ long-term goals. Conclusion: There was a high level of interest in specialisation and a desire to achieve financial stability and work–life balance in the group of dental students who responded to the survey. Long-term career expectations varied according to student but not according to school characteristics.

INTRODUCTION

The health workforce is an essential aspect of the delivery of health care¹ and dentistry is no exception. Dental graduates are entering a profession in which the pace of change and impact of globalisation are significant². It is therefore vital to identify the career expectations of expensively trained graduating students in order to understand their post-qualification plans and their proposed contribution to the dental workforce3., 4., 5., with a view to retaining a motivated and highly skilled dental workforce for the benefit of the population they serve.

In dentistry, studies exploring career expectations among the emerging workforce3., 4., 6., 7., 8., 9., are predominantly from high-income countries3., 5., 6., 7., 10.. They report specific dimensions of career expectations, including: future roles as a generalist or a specialist7., 11.; the specialist area of interest3., 4., 6., 8., 9.; work setting3., 4., 6.; and working pattern3., 4., 6., 9., in both the short-term⁶ and the long term³, together with a wide range of influences3., 4., 5., 6.. Research on short-term career expectations reveals a wide range of goals – professional, personal and financial3., 4., 6. – whereas long-term career expectations include an anticipation of professional development3., 4., work–life balance3., 4. and financial stability3., 4., with variations according to sex³ and ethnicity⁴. Reported career plans and their influences have also been shown to differ according to age¹², sex³ and ethnicity⁴. The majority of these studies are based on a single school3., 4., 6., 13. and do not necessarily represent dental students at country level. Internationally, comparative research suggests that there may be differences between schools, and perhaps countries, with Japanese and Canadian students more likely than Thai students to report planning to work as a general practitioner than to train as a specialist⁷. However, there is little such research from middle- and low-income countries.

There is no research on career expectations to date in Malaysia, a middle-income country that is currently facing rapid workforce growth based on the output of dental schools, both established and new¹⁴, together with increasing numbers of international graduates¹⁵. Malaysia has recently experienced a significant expansion of dental education, with 12 new dental schools opened in the past decade. An average of 700 students graduate annually, with that number expected to increase over time, and there is great concern about the readiness of clinical facilities15., 16.. Moreover, there was also a low percentage of specialists in the country in 2012 (7% of total practitioners), given the need and demand for complex and specialist care in this growing cosmopolitan community¹⁷. The dental workforce in Malaysia comprises dentists (65%) and dental therapists (35%) as operating clinicians¹⁸, with the majority of dentists working full time in the public sector (64%)¹⁹. Although working in the private sector offers dentists greater financial rewards, most prefer to work in the public sector where they could access other benefits, such as scholarships for postgraduate training¹⁷. It is therefore timely to examine the career expectations of a prospective dental workforce in Malaysia to inform decision making in relation to human resources. This study explored final-year students’ short- and long-term career expectations and their influences, as well as whether these varied according to students’ and school characteristics.

METHODS

Study population

There were 15 dental schools operating in Malaysia in 2013, and a cross-sectional survey was carried out among the 11 dental schools (six public and five private) with final-year students at the end of 2013. The study protocol was approved by KCL Biomedical Sciences, Dentistry, Medicine and Natural & Mathematical Sciences Research Ethics Subcommittee (Reference BDM/12/13-129), and the research was conducted in full accordance with the World Medical Association Declaration of Helsinki. Completion and return of the questionnaire (either in part or completely) was taken as consent to participate, as outlined in the information sheet provided to students.

Data collection

Data were collected using a self-administered questionnaire. Introductory letters were sent to all dental school deans requesting permission to conduct the survey. In the participating schools, students were provided with information in advance and received a verbal explanation from the primary researcher during a scheduled meeting. The questionnaire, which took up to 30 minutes to complete, was administered within a classroom setting. The survey was conducted in English, the medium used for teaching in all Malaysian dental schools.

The original questionnaire, which includes the Gallagher Motivation Instrument (GMI)²⁰, was informed by qualitative research among final-year dental students in London and vocational dental practitioners (new graduates) within the UK21., 22.. It has subsequently been used with final-year dental students in London20., 23. and elsewhere²⁴. The questionnaire has six sections and 31 questions. It explores student’s vision of dentistry as a professional career (three questions), short-term career aspirations (five questions), long-term career aspirations (six questions), influences on their career choices (five questions), views on state health care (three questions) and their demography (sex, age, ethnicity, family income and social background; eight questions). This paper focuses on students’ career aspirations and their influences, the findings on motivation having already been reported²⁵. The section on short-term career expectations referred to the 5 years immediately after graduation and included multi-choice questions on preparation of undergraduates for entry into the workplace and when and where to start practice. Student perceptions on nine factors that influenced the location of practice were collected using 5-point ordinal scales from ‘1’ (very important) to ‘5’ (not important). Two open questions were asked of students about their short-term goals and views on compulsory service. The section on long-term career expectations referred to 10 years or more after graduation and included multi-choice questions on future role, area of interest, type of setting and working pattern. Students’ perceptions on factors influencing working pattern (seven items), overall career decisions (12 items) and working for the Ministry of Health (MOH; 15 items) were collected using a 5-point ordinal scale with a score of 1 (very important/or strongly agree) to a score of 5 (not important/or strongly disagree). One open question asked about the anticipated level of work in the private sector and the reasons for the response given.

Students also provided sociodemographic information. Ethnicity in this instrument was self-assigned as Malay, Chinese, Indian, Kadazan, Dayak, Sikh or Others, and responses were regrouped as Malay, Chinese and Others for analysis. Total household income per month was collected based on a question from the national Household Income Survey and was categorised as low [below Malaysian Ringgit (MYR)2,000], middle (MYR2,001–MYR5,000) or high (MYR5,001 and above)²⁶. Two indicators were used to characterise dental schools: the first was school sector, classified as public or private; and the second was school type, classified as established (10 years and more of operation) or new (less than 10 years of operation).

The questionnaire was revised to improve its cross-cultural validity for Malaysia. First of all, questions on sociodemographic characteristics and health services were amended to make them suitable to the Malaysian context27., 28.. A pilot study was conducted with 20 final-year dental students at two universities. These schools represented the full range of ethnic groups and student backgrounds. The questionnaire was revised in line with students’ recommendations for improvement, using ‘Others’ as an option in every section to allow alternatives to emerge.

Statistical analysis

Data were entered into a computer and analysed using spss 20.0 for Windows (IBM Corporation, Armonk, NY, USA)²⁹. Descriptive analysis was carried out to summarise the respondents’ demographic (sex, age, ethnicity and family income) and school [school sector (public/private) and school type (new/established)] characteristics. For factors influencing short- and long-term career expectations (i.e. items measured using a 5-point Likert scale), we collapsed response options for strongly agree and agree on one end of the scale and disagree and strongly disagree on the other.

The distribution of responses according to students’ and schools’ characteristics was examined by the chi-square test using Bonferroni correction to adjust the significance level for multiple comparisons³⁰. The new significance level was set at 0.01 after dividing the standard significance level by the number of comparisons made for that item (P = 0.05/6 = 0.01). We only reported comparisons where significant differences were found. Otherwise it can be assumed that there were no differences according to respondents’ demographic or school characteristics.

RESULTS

Eight of the 11 dental schools in Malaysia with final-year dental students agreed to participate (i.e. all six public and two private). Of the 431 final-year students in the eight schools, 356 (83%) respondents were included in this analysis. Most respondents were from public/state schools (77%), were women (71%) and Malay (55%); the modal age was 24 years (48%) and the largest group was from middle-income families (38%). The average age of respondents was 24 years (standard deviation = 0.9; range: 22–28 years).

Short-term career expectations and influences

Most respondents (87%) reported that they would start their compulsory dental service the year after graduation. Kuala Lumpur (14%), Selangor (13%) and Pulau Pinang (10%), were the states most preferred by students for their compulsory service. Proximity to family (89%) and career opportunities (86%) were cited as the most important influences on their choice.

Undertaking specialist training (46%) was the most commonly cited short-term goal in response to an open-ended question (Table 1), followed by improving skills or being competent (20%) and gaining knowledge and experience (15%). These short-term goals were influenced by achieving financial stability (79%), having a balance between work and other aspects of life (73%) and gaining professional experience (68%) (Table 2).

Table 1.

Short-term career expectations of Malaysian final-year dental students 2013/2014 (n = 305)

Career goals	Percentage
Undertaking specialist training	46.2
Improving skill/being competent	20.3
Gaining experience/knowledge	15.1
Set up own dental clinic	10.2
Achieving financial stability	3.0
Mission/volunteer for community services	2.0

Table 2.

Influences on short-term career expectations amongst Malaysian final-year dental students 2013/2014 (n = 305)

Influences	Percentage of total students
Financial stability	79
Balance of work and other aspects of life	72
Gaining professional experience	68
Good lifestyle	62
Work towards achieving career goals	46
Family commitments	44

Note: multiple responses are possible.

Long-term career expectations and influences

Fifty-nine per cent of respondents reported that they intend to specialise in the long term, with only 18% aspiring to work as a general dental practitioner. A significantly lower proportion of Chinese students (44%) reported a desire to specialise compared with Malay students (68%) and those of other ethnicities (69%). Oral and maxillofacial surgery (21%), restorative dentistry (15%), prosthodontics (13%) and orthodontics (12%) were the most commonly cited dental specialities among those who expressed a desire to become specialists (n = 210). They (prospective specialists) also stated a preference to work in the MOH hospitals (26%) and private clinics (23%). Amongst those who wished to become a general dental practitioner, 35% wanted to be employed as a practitioner at the MOH, 21% as a practice owner (joint), 19% as associated (group practice) and 17% as a practice owner (sole).

Sixty-seven per cent of respondents considered working full time in the long term, with significantly more men than women (78% cf. 63%; P = 0.036) anticipating doing so, whilst 20% considered working part time and a minority did not know or respond (12.8%). Amongst respondents who anticipated working either full time or part time (n = 308), 48% expected to work 10 sessions per week. Important influences were: work–life balance (97%), family commitments (91%), financial stability (87%) and childcare commitments (83%). Significantly more Malay students (90%) ranked childcare commitments as an important influence compared with Chinese (75%) and other ethnicities (74%; P = 0.001).

The majority (64%) of respondents stated a ‘wish’ to work in the private sector; with 40% of these students considering undertaking at least half of their work in the private sector. Influences on respondents’ long-term goals were mainly work–life balance (95%), high income/financial security (95%), standard of living (92%) and family commitments (89 (Table 3). Significantly more women than men strongly agreed that family commitments were an overall influence (51% cf. 39%; P = 0.004).

Table 3.

Influences on long-term career expectations of Malaysian final-year dental students in 2013/2014 (n = 356)

Influences	Percentage of total students
Work–life balance	95
High income/financial security	95
Standard of living	92
Family commitments	89
Occupational flexibility	89
Career progression	86
Team work with professionals	86
Professional fulfilment	85
Working terms and conditions	83
Working facilities	82
Opportunities to pursue other interests	71
Dental policy	70

Multiple responses are possible (strongly agree/agree).

When questioned about factors that might influence working for the MOH, respondents ranked support for professional development (83%), teamwork with professionals (82%) and occupational flexibility (77%) as the most influential factors (Figure 1).

Figure 1.

Factors that would attract Malaysian final-year dental students from 2013/2014, to work with the Ministry of Health Malaysia (n = 356). Note: multiple responses are possible.

DISCUSSION

Our findings suggest that the career expectations of the emerging dental workforce in Malaysia revolve around achieving professional and personal goals, with a desire to achieve financial stability and work–life balance. A high level of interest in specialisation was reported, particularly in relation to their long-term career expectations, together with enhancing skills and experience in their early years of working. We found significant differences in relation to future roles and influencing factors on the number of working sessions according to ethnicity, and for working pattern and overall influences on their long-term career expectations according to sex.

Some limitations of this study need to be borne in mind when interpreting the present results. First, this was a cross-sectional study³¹, in which some schools and students did not participate; hence, the findings may not be generalisable to the whole student population or to future cohorts of graduates. Second, researching dental students who are about to join the dental profession, instead of new graduates, may be considered as a constraint; however, there is evidence that the views of new graduates²² and final-year students are similar¹⁰. Third, although the choice of instrument could be considered a limitation in that it does not specifically use a career and professional advancement theory or assessment tool, it is important to state that there is not one obvious theory-based tool relevant to an Asian and dental context. We therefore used a dental-specific tool, derived from inductive research, which has been successfully used in several studies to examine career expectations4., 5., 6., 10. thus enabling useful comparisons. Furthermore, combining a theoretical tool with a dental tool could have been of further benefit, but would have led to a longer questionnaire with implications for the response rate.

Short-term career expectations

The short-term career expectations of these students focused on improving skills/being competent and gaining knowledge/experience, all of which may be considered as realistic for new graduates, together with undertaking specialist training. Undertaking specialist training was notably prominent, and past research suggests that it has always been perceived in both the low- and middle-income countries as an endeavour to enhance dentists’ quality of life and social status7., 8.. The high interest in specialisation correlates with the motivation of these Malaysian students to study dentistry as a professional career, in which academic factors were dominant²⁵, suggesting that there might be a demand for continuous learning among these students.

Short-term career expectations were mainly influenced by seeking financial stability. By undertaking specialist training, emerging graduates could have assumed that they will gain a better and more attractive salary in the longer term. Given that the majority of students were from public schools and scholarship funded, this may not be necessary to address debts; however, given the current economic situation within the country³², future financial commitments and their desire for a better work–life balance, the findings lend support to the social cognitive theory which suggests that individuals tend to exercise actions in adapting certain behaviours to achieve and maintain their correspondence with the work environment and its influences³³; similar findings have been reported by students in the UK5., 6. and the United Arab Emirates (UAE)⁴.

In terms of location, the majority of respondents anticipated starting work immediately in the densely populated states of the Peninsular Malaysia, with being ‘close to family’ reported as the greatest influence on their location of practice, suggesting a strong family bond, which is a typical characteristic for Asian culture³⁴. However, it could be argued that in their next few years of working, they will become economically independent and can harness the benefit of technology, such as the Internet and mobile devices, to sustain valuable family relationships. There was also a high anticipation of working in the public sector; however, there is evidence that graduates who initially choose to work in the public sector migrate to the private sector after gaining clinical experience12., 35., influenced by limited career options and pressure on dental facilities13., 17.. It is therefore important to anticipate the needs of the future workforce in order to fulfil the psychological contract with them³⁶, thus facilitating retention in the public sector¹³. In an economically challenged climate, however, it may be necessary for new graduates to take opportunities where they exist.

Long-term career expectations

In the long term, about two-thirds of respondents anticipated specialising in dentistry, suggesting that there is a need to consider both the population need for specialist/complex care and the current demand for, and supply of, specialists, together with the rights of new graduates. Looking at the big picture, 11% of the total registered dental practitioners at the MOH Malaysia are currently specialists¹⁷, albeit that registration of specialist status is not yet compulsory³⁷; this compares favourably with 10% in the UK (2013)³⁸, but less so with the USA for which the corresponding value is 21% (2008)³⁹. However, neither comes close to the level of interest amongst these students. Given the above issues and the fact that there were nearly 28% unoccupied specialist posts in the ministry in 2012¹⁷, it seems that the country may arguably need more specialists to strengthen their tertiary care and services in the short term. It could also be argued that there is a growing need for more complex care in the country with high levels of need40., 41., and increasing patient demand for services, as demonstrated by attendance at specialist clinics¹⁷; however, much of this requires a public health approach to reduce the future burden of oral disease, rather than merely a treatment-based approach. Interestingly, there was less reported interest in Dental Public Health as a specialty amongst the students. This is of concern given the oral health needs of the population40., 41., 42., 43.; however, at the time of this survey, Dental Public Health had not been completely given the benefit status of a specialty by the MOH. This change may attract a higher number of graduates to the specialty in the future.

Chinese students had slightly lower interest than Malay and Indian/other students in specialising. This could be explained by the majority of Chinese students coming from private schools, being self-funded or having used private loans to support their education; this was in contrast to Malay students who, in the main, studied in public schools (≥90%) and were publically funded. In contrast to studies within the UK³ but similarly to findings from the UAE⁴, there was no difference according to sex.

This interest in specialisation potentially puts health providers and educators under pressure. First, this level of specialisation may not be required. Second, specialist training is expensive, and if it is to be provided it should meet quality standards. At the moment only a few public institutions in the country offer postgraduate training for dentists in all Malaysian public sectors¹⁴. With such restrictions in funding, and places normally being offered only to those with work experience of 3 years and longer at the MOH⁴⁴, dentists might choose to pursue study abroad using private or self-funding, which might later burden them with an educational debt. Moreover, the government might also have some resource limitations on taking them all into public service; these trends eventually influencing them to settle abroad or join the private sector. Overall, many of the respondents anticipated working in the private sector in the long term (dentists, 67% vs. specialists, 65%). Some might also argue that there may be a trend of uncontrolled numbers of specialists in the future, influenced by globalisation and neo-liberalisation², which leads to policies on freedom of movement by the workforce between countries. Should dentists move more towards specialisation, other team members will be required to provide routine and preventive care, an approach which is emerging in other countries⁴⁵.

Work–life balance and personal and financial factors were reported as the most important influences on long-term career expectations, in line with their main short-term influences. Women were significantly more likely to report family commitments as the main overall influence compared with men, which is similar to one UK study⁴⁶. Women’s traditional role in the home setting is emphasised by Malay³⁴ and Islamic culture in particular⁴⁷, with the requirement to be a great teacher and parent for their children. Women from these cultures face the challenge of balancing work and family obligations, and this has been reflected in their commitment-proposed working patterns; women were significantly more likely than men to anticipate working part time (78% cf. 63%; P = 0.036). As women constitute the majority of students in this cohort, it is essential to understand their overall contribution towards the profession. Nonetheless, it is important to note that their long-term career expectations demonstrated a strong interest in specialisation, which was not significantly lower than that of men (57% cf. 65%).

In considering student commitments to work in the public sector with the MOH, the majority would be influenced if the government were to provide support for their professional development and postgraduate studies⁴⁴, which is in line with Dawis and Lofquist’s framework on work adjustment theory, in which adjustments will be made to achieve better correspondence between the person and their environment ³⁶. Amongst students who anticipated becoming general dental practitioners, 60% reported an interest in working in a team setting and small practice, whereas those planning to become a specialist were willing to work in a wide range of different settings, rather than just work on their own. These anticipated work settings might support a team-working approach, which has been recognised globally as being in the best interest of patients48., 49.. The present study provides important baseline data for Malaysia as well as academic literature from an East Asian country on career expectations of newly graduated dentists. By understanding career expectations, health authorities are provided with insight and are enabled to reflect on recruitment and retention strategies in order to retain a motivated and skilful workforce, for the benefit of the patients and the public.

CONCLUSION

In the group of emerging dental students who responded to the questionnaire, there was a high level of interest in specialisation, with a desire to achieve financial stability and work–life balance. Long-term career expectations varied according to student characteristics but not to school characteristics. The short-term career expectations of final-year students in Malaysia focused on undertaking specialist training, improving skills/being competent and gaining knowledge/experience; and varied according to student characteristics (sex and ethnicity). Students have high expectations of specialising and working in the private sector in the long term, which revolve around achieving professional and personal goals, wanting to accomplish financial stability and work–life balance. The findings suggest that although women have similar professional career expectations to men, they anticipate a reduced contribution to the workforce long term, influenced by family commitments.

Acknowledgements

The authors acknowledge the contribution of all dental students who participated in the study and academic staff at the dental schools who facilitated the process of collecting data. This study has been supported by Malaysian Government and International Islamic University Malaysia (IIUM) funding.

Conflicts of interest

Two of the authors (JEG and EB) are academic staff at King’s College Dental Institute. MFCM is postgraduate research student at King’s College Dental Institute and a member of staff at the Department of Dental Public Health, Kulliyyah of Dentistry, International Islamic University Malaysia, Pahang, Malaysia.

Authors’ contributions

All authors conceived and designed the overall research programme. JEG developed the original questionnaire instrument and directed the revisions to the questionnaire. MFCM conducted the fieldwork, entered the data into SPSS, analysed the data and drafted the first version of the manuscript as part of his PhD programme. EB advised on and supervised data analysis. All authors contributed to and approved the final manuscript.