Burnout among Dental Students of Private and Public Dental Colleges in Pakistan - A Cross-Sectional Study

Burnout


Introduction
Burnout is a condition resulting from chronic workplace stress that is not adequately managed.The term burnout was introduced in the 1970s by Maslach and Leiter and was defined as a syndrome with emotional exhaustion, depersonalization, and diminished personal accomplishment that can occur among individuals working with people [2].A significant risk factor for the onset of burnout syndrome is ongoing stress at work [3].When a person cannot manage stress efficiently, they may experience burnout, which can have detrimental effects on their mind and health, leading to serious health consequences [4].
Burnout among health professionals is characterized by different levels of enthusiastic depletion, depersonalization, and a low feeling of individual achievement [5].Burnout syndrome is more common in health professionals, including doctors, dentists, nurses, pharmacists, etc., but it can be observed in any profession [6].
Burnout syndrome has been reported to be particularly common among students pursuing healthcare professions like dentistry, nursing, and medicine [7][8][9].Research has indicated that dentists are more vulnerable to burnout syndrome because of the nature of their clinical and practical work [10][11][12].Burnout syndrome in medical and dental schools has the potential to harmfully impact students' academic development and overall well-being, with burnout identified as a significant independent predictor of suicide ideation/tendencies and dropping out of medical school [13,14].
Academic performance is influenced by emotional, mental, and psychological wellness, which is a common fact.A stressful workplace impairs academic performance, increases student worry and trepidation, and ultimately leads to burnout.In addition, a change in social, environmental, cultural, and lack of familiarity also contribute to stress.Stress levels are increased by financial obligations, societal demands, expectations, and the dread of failing [15].Burnout can be seen at every stage of the profession, which has a direct impact on the personal as well as professional life.It impacts students and practitioners with decades of experience [16].It is most critical when dentists make their first step into professional life.
Over the last two decades, the number of public and private dental schools has increased in Pakistan [17].A number of studies have been done across the world tackling this issue, but very little attention has been paid to depression among dental students in Pakistan.
Therefore, there is a dire need to incorporate stress management skills/ workshops/seminars/programs in different dental institutions within Pakistan [18].Therefore, this study aimed to assess the prevalence of burnout among dental students of public and private institutions in Khyber Pakhtunkhwa and Punjab, Pakistan.

Study Design and Sampling
This cross-sectional survey study was conducted by using a validated self-administered questionnaire This adaption indicated the original design's factorial structure and good psychometric qualities.This offers support for applying the questionnaire and lists the possibility of quickly differentiating between students using clinical burnout categories.
A pre-validated BCSQ-12-SS19 was used for this study.The nineteen-item questionnaire was broadly categorized into two sections: Section I comprised of participant's background information such as age, gender, academic year, and place of residence and Section II of the questionnaire consisted of 12 significant statements about academic experiences in student life.Respondents were requested to choose among five options provided: "strongly disagree," "disagree," "undecided," "agree," or "strongly agree".
Initially, the Burnout Clinical Subtype Questionnaire [18] was pilot-tested on 30 randomly selected dental students in 1 st academic year.First academic year students were chosen as they were freshly inducted and exposed to different parts of the syndrome.Consequently, further questionnaire modifications were done before the actual survey.The questionnaire was mailed to the dental undergraduate students of the second-, third-and final academic year.

Statistical Analysis
Descriptive statistics that included (mean with standard deviation) were calculated.As the data were not normally distributed, the Mann-Whitney U test was applied to compare students from public and private institutions.SPSS software version 20.0 (IBM Corp., Armonk, NY, USA) was used for statistical analysis, with a significance level of p≤0.05.

Ethical Clearance
Ethical approval was obtained from the Research Ethics Committee of the HBS Medical and Dental College, Pakistan (approval no.IRB/22/248).

Results
A total of 274 dental undergraduate students -second (42.3%), third (35.4%), and final (22.3%) academic year participated in this study.The mean age of the respondents was 21.9, with the range of 20-26 years.Most participants were females (74.1%) compared to the males (25.9%).Table 1 shows the demographic data of respondents.Regarding the student's academic experiences, a significant difference was noted for the statements "I give up when faced with any difficulty in my tasks as a student" (p=0.013) and "When the effort invested in studying is not enough, I give up" (p=0.028).There was no difference regarding burnout syndrome among dental students from private and public institutes, as shown in Table 2. Scale: 1 = Strongly Disagree; 2 = Disagree; 3 = Undecided; 4 = Agree, and 5 = Strongly Agree; *Statistically significant.

Discussion
Emotional exhaustion was the most critical component affecting Sudanese dental students [20].
Burnout components similarly affected the students regarding gender (male and female) in 3 rd and 4 th year students.The selection of dentistry as the first career did not affect the burnout symptoms.Burnout occurs at a personal level, and its progression may take decades.It appears gradually and progresses almost unperceptively, and the affected individual is usually in denial [21].
A recent study found a statistically significant increase in stress mean scores in Karnataka Lingayat Education University dental students compared to Rajiv Gandhi University of Health Sciences [22].Applying the strict rule of burnout syndrome, there is a statistically significant rise in burnout syndrome, with an odds ratio of 3.97 times, as found in Karnataka Lingayat Education University dental students.No difference in burnout and stress between males and females and the social classes was noted.This concluded that burnout and stress were significantly more prevalent among dental students at Karnataka Lingayat Education University than at Rajiv Gandhi University of Health Sciences [22].
This study shows that 2 nd , 3 rd , and final-year dental students participated, of which females were the majority compared to males.There was no difference regarding burnout syndrome among dental students from private and public institutes.These students addressed the following statements; 'I think I'm investing more than is healthy in my commitment to my studies,' 'I would like to study something else that would be more challenging to my abilities,' 'When the result of my studies are not good at all, I stop making an effort,' 'I neglect my personal life due to pursuing great objectives in studying,' 'I feel that my current studies are hampering the development of my abilities,' 'I give up in response to an obstacle in my studies,' 'I am endangering my health in pursuing good results in my studies,' 'I would like to study something else in which I could better develop my talent,' 'I give up when faced with any difficulty in my tasks as a student,' 'I ignore my own needs to satisfy the requirements of my studies,' 'My studies do not provide me with opportunities to develop my abilities' and ' when the effort invested in studying is not enough, I give up.'There is no significant difference among public and private dental colleges.The study contradicts other studies [22,23], and the reason for this is that the students are dependent on their parents mostly during their undergraduate education and might have good financial support.The burnout syndrome is strongly linked with excessive handling of the patients, which imparts specific negative effects on their personal and professional life and well-being.Students have to do a limited number of patients during their second-, third-and final years who are not overburdened as general dentists and can easily cope with their clinical stress as senior faculty members always supervise them.Students are not held solely responsible for the patient's clinical outcomes and procedures.Few studies reported that burnout syndrome is related to a lack of family support, education, and working environment, which may be due to night shifts and long working hours, and have advised that policymakers should amend the list of occupational diseases for the work-related stress risk assessment [24,25].
There are a few limitations associated with this study.Firstly, the sample size is small.Secondly, the causes and effects of dental students cannot be assessed through this study owing to the study design.Therefore, techniques like in-depth interviews or case studies are recommended for the future.However, the findings of this study might aid policymakers and other stakeholders in counseling students to reduce anxiety and stress via mentoring and other health promotion and awareness programs.Also, there are more suitable tools than the instrument used, the MBI HSS tool (for healthcare professionals) [1].Furthermore, additional research could be carried out in other dental education phases in various dental colleges to ascertain whether these findings are generalizable.
The study's strength is that no such comparative cross-sectional study has yet been conducted among dental students in Pakistan.It might be an initial step toward further investigation.Additionally, because the study used dental student samples from two autonomous communities and four different institutions of private and public sectors, it became easier to generalize the results.
It is recommended that a similar study on a larger scale be conducted.It will be essential to examine larger populations of both public and private medical and dental institutions in Pakistan to identify the factors associated with emotional drainage and perceived tension/pressure.

Conclusion
No burnout was present in public and private dental college undergraduate dental students.
from 01 June 2022 to 31 May 2022 among the dental students of four different dental institutes of Pakistan wherein the Ayub Medical and Dental College (Abbottabad) and Khyber College of Dentistry (Peshawar) are the public institutes.In contrast, Peshawar Dental College (Peshawar) and Foundation University College of Dentistry (Islamabad) are private institutes.The participants were recruited using a purposive sampling technique, and the target population was the second-, third-, and final-semester-year dental students.

Table 2 . Responses about students' academic experiences.
QuestionnaireInstitute N Mean SD p-value 1.I think I invest more than is healthy in my commitment to my studies