key: cord-0692874-rwwht1g1
authors: Khoo, Edmund; Saeed, Sophia G.; Chiu, Hong-Yan; Quach, Vicky; Janal, Malvin; Stewart, Kelton
title: Stress and Anxiety in Orthodontic Residents during the COVID-19 Pandemic
date: 2022-05-02
journal: Am J Orthod Dentofacial Orthop
DOI: 10.1016/j.ajodo.2022.04.011
sha: 35cb68ed4ca862d51a46a4032a11e0fa60b2c11f
doc_id: 692874
cord_uid: rwwht1g1

INTRODUCTION The coronavirus disease 2019 pandemic has had far-reaching effects on health care providers and health professional students; however, little is known about the factors related to stress and anxiety levels, specifically among orthodontic residents during this time. METHODS A 2-part questionnaire, which included modified stress and anxiety inventories, was disseminated electronically to U.S. orthodontic residents between June and July 2020. Descriptive and comparative statistics were used to analyze the data. RESULTS Overall, 261 participants responded (56% female), representing a response rate of 26.8%. Significant gender differences were found in 18 stress items, with female respondents expressing more stress than their male counterparts. Only 1 stress item (ie, fear of being unable to catch up if behind) varied as a function of the difference on the basis of respondents' stage in the program. First-year residents reported more stress in relation to this than more senior residents. Responses to all anxiety items but 1 item varied by gender, with females reporting higher scores. Residents in the middle stages of their program responded with higher anxiety scores with significant differences on 3 anxiety items. CONCLUSIONS Although financial responsibilities and travel plans were the most stressful and anxiety-inducing items for orthodontic residents during the early aspect of the coronavirus disease 2019 pandemic, multiple items contributed to their stress and anxiety. In addition, both gender and stage of progress in a residency program impacted the level of stress and anxiety reported by respondents.

There has been a growing interest in burnout among healthcare providers and health professional students in the US and across the world. [1] [2] [3] [4] [5] [6] [7] [8] [9] [10] [11] Burnout is associated with stress, inefficient work processes, and barriers to achieving meaning in one's work. [1] [2] [3] [4] 13 Concerns and studies related to healthcare worker burnout originated from the medical profession. While the rate of physician burnout varies by specialty, the average rate of physician burnout has been shown to be higher than the general population, with an increasing trend over time. 14, 15 Other health professions soon followed suit in studying how stress and burnout present among their cohorts, including students and residents. [10] [11] [12] Stress levels among dental students are higher than medical students, 16 however, it is challenging to compare dental residents to medical residents, primarily because of the scarcity of data relative to dental residents. Depending on their stage in the curriculum, stress among dental students has been shown to be associated with academic factors, clinical factors, inconsistent faculty feedback, assigned workload, performance pressure and self-efficacy beliefs. [17] [18] Levels of anxiety among dental students have also been found to be high. [19] [20] Within the field of orthodontics, specifically, factors impacting stress and anxiety of residents have not been well-studied.

In the early months of 2020, the COVID-19 pandemic created a significant global impact. In the US, most people experienced mandated lockdowns, rendering them unable to interact with anyone other than those with whom they lived. This isolation worked to increased stress among the general public. 21 Primary and secondary education quickly transferred to online J o u r n a l P r e -p r o o f modalities, and those who had young children had to adapt. As more became known about the emerging SARS-CoV-2 virus, some essential segments of society reopened, including healthcare.

Personal protective equipment was in short supply, and during the first six months of the pandemic, dental professionals were thought to be at very high risk of occupational exposure 22 because of the aerosols generated during treatment. Residents and students were unsure if they would be able to attain the clinical experiences needed to complete their training on-time, or with confidence. Influenced by university, dental board, and governmental recommendations, the guidance to the profession continued to shift, as did the availability of PPE and willingness of patients to present for treatment. This required constant adaptation and flexibility. This multitude of pandemic associated factors appeared to magnify the amount of stress and anxiety experienced by dental students and residents, including orthodontic residents. Stress, anxiety, and burnout among healthcare providers are associated with decreased productivity, increased errors, and poorer quality of care for patients. However, there are currently no studies that have sought to elucidate the impact of the COVID-19 pandemic on the levels of stress and anxiety experienced by orthodontic residents in the United States.

Therefore, the aim of this study was to gauge the factors that impacted the stress and anxiety of North American orthodontic residents during the early months of the COVID-19 pandemic.

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Residents enrolled in North American postgraduate orthodontic programs in June 2020 were invited to participate in this study. An online questionnaire was constructed using Qualtrics software (Qualtrics Provo, UT); Institutional Review Board approval (IRB-FY2020-4497) was obtained from New York University. The questionnaire was distributed through the American Association of Orthodontics (AAO) Partners in Research Program, via email to North American orthodontic residents. The questionnaire was also posted to the AAO Residents Champion Facebook page. The questionnaire was administered from June 2020 to July 2020 with two reminders sent at 4 and 6 weeks. Informed consent was obtained from the respondents; participation was voluntary and anonymous. Since there was no data on orthodontic residents using a similar survey instrument prior to the COVID-19 pandemic at the time of the study, the questionnaire specifically stated that participants were asked to "Participate in a survey to assess your feelings about the impact of the novel coronavirus that causes COVID-19." In addition, survey questions were prefaced with the following statement, "In response to the COVID-19 pandemic, please indicate the degree to which you experience stress from each of the items listed below as part of your orthodontic education experience."The questionnaire included demographic data pertaining to gender and stage in the program. Due to the variability in duration of orthodontic programs, the stages in the program were classified as "first year", "midway" and "final year." Two sets of measures were used to assess stress and anxiety.

The Dental Environmental Stress Questionnaire (DESQ), a validated 38-item instrument 23 , was modified to be more orthodontic-specific. Survey modifications included the removal of some J o u r n a l P r e -p r o o f items and the addition of two new items to assess the impact of perceived discrimination on stress. The final modified DESQ used for this study contained 37 items, which were broken down into ten categories: "Self-efficacy beliefs", "Faculty and administration", "Workload", "Patient treatment", "Clinical training", "Performance pressure", "Personal relationships", "Personal life", "Professional life" and "Discrimination". Residents were asked to assess each item as "not stressful", "slightly stressful", "moderately stressful" or "very stressful."

Respondents rated each of the 37 items on a 4-point Likert scale with 1= not stressful, 2= slightly stressful, 3= moderately stressful, and 4= very stressful. An additional option of 0= not pertinent was given, for items that did not apply to the respondent. The scale was modified from the original DESQ, which scored the items 0-3 and did not include a "not pertinent" response option (Table I) .

Anxiety was assessed using a 10-item instrument that was adapted from a published questionnaire 24 used to measure self-reported anxiety during the 2009-2010 H1N1 swine flu pandemic. The words "swine flu" were changed to "COVID-19." Respondents rated each item on a 4-point Likert scale with 1= very little, 2= somewhat, 3= a lot, and 4= very much. The questions were sequenced randomly to minimize response bias (Table II) .

In order to compose a summary measure for the stress items (Total stress score), we determined the internal consistency for the 26 stress items, which had at least 200 responses not including "non-pertinent". Cronbach's alpha was 0.93, which is excellent. The summary measure for the anxiety scale (Total anxiety score) included all items. Cronbach's alpha was 0.84, which is good. 25 J o u r n a l P r e -p r o o f

The data were analyzed using descriptive statistics. Gender differences were evaluated with the Mann Whitey U test and program stage differences with the Kruskall-Wallis test. Total stress and anxiety score differences were evaluated using one-way ANOVA All analyses were completed using IBM SPSS version 28 (IBM Corp., Armonk, NY). Statistical significance was set P<0.05.

A total of 261 responses were received. Based on an estimated yearly enrollment of 975 orthodontic residents, the response rate was 26.8%. Most respondents were female (55.9%) and there were a similar number of respondents in each stage of the program. Summary demographics of the sample population, based on gender and stage of progress, is presented in Table III .

"Financial responsibilities" was rated the most stressful of all factors assessed, with 63.9% (n=219) respondents rating it as "moderately stressful" or "very stressful." "Lack of input into the decision-making process of the program" caused stress in 60.6% of the respondents.

Several other items were ranked as "moderately stressful" or "very stressful" by the majority of respondents and included "responsibilities of comprehensive care" (58.3%), "insecurity regarding professional future" (57.5%), and "difficulty learning clinical procedures" (57.5%).

There were seven items that few respondents considered to be "moderately stressful" or "very stressful." These include, in ascending order, "amount of cheating in program" (3.0%), "relationships with members of the opposite gender" (3.5%), "conflict with partner over career J o u r n a l P r e -p r o o f decision" (6.8%), "attitude of school toward women dental students" (9.1%), "forced postponement of marriage or engagement" (9.2%), and "competition for grades" (9.2%). (Table IV) .

A total of 18 items (48.6%) showed statistically significant differences between genders (Table   IV ). In all cases, female respondents reported more stress than their male counterparts.

Only one item, "fear of being unable to catch up if behind", varied as a function of the respondents' stage in the program. First year residents reported more stress in relation to this item than "more senior residents (p<0.0001)..

Respondents reported three items that caused "a lot" or "very much" anxiety: "To what extent has the threat of COVID-19 influenced your travel plans?" (84.5%), "How much exposure have you had to information about COVID-19?" (81.6%), and "To what extent has the threat of COVID-19 influenced your use of safety behaviors (e.g. hand sanitizer)?" (80.6%). The three lowest ranked items were "If you did become infected with the novel coronavirus that causes COVID-19, to what extent are you concerned that you will become seriously ill?" (20.0%), "How likely is it that you could become infected with the novel coronavirus that causes COVID-19?" (Table V) .

Reponses to all items but one varied by gender, with females reporting higher scores (Table V   and Table VI) .

There was significant differences on three items, with residents in the middle stages of their program responding with higher anxiety scores (Table V) .

Total stress scores were higher in female than male respondents but did not differ as a function of stage in program. Total anxiety scores were also higher in females than male respondents and higher in those at the beginning or end of the program than those in the middle (Table VI) .

Even before the COVID-19 pandemic, stress and burnout among healthcare providers was of significant concern, as it relates to retention in the workforce, medical errors, and patient outcomes. The specific factors impacting stress among orthodontic residents in North America, however, have not previously been described. With the onset of the pandemic, stress and burnout among healthcare providers, as well as anxiety, has increased. 26 This study demonstrated that the primary sources of stress, at the time the survey was administered, were related to the categories "Clinical training", "Patient treatment", "Faculty and Administration", and "Personal life". This is comparable to existing evidence on the stress levels in dental students and graduate students. 17 

For individual stress-provoking items, the highest ranked was "Financial responsibilities". In addition to the well-documented increasing cost of dental education, the high rate of unemployment, parallel spike in US inflation rates, and the need to switch to online remote learning for school-aged kids may have compounded financial strains that orthodontic residents already experienced at baseline. For financial reasons as well, many senior practicing clinicians decided to continue to practice rather than retire. Moreover, others were not in a financial position to hire new associates. These elements likely heightened orthodontic residents' stress associated with finances.

The second highest ranked stress item was "Lack of input into the decision-making process of the program". This is reflective of a "top-down" management approach in which department chairs, program directors, and administrative leadership make decisions without input or involvement from their constituents. Style of leadership and management are critical to setting the tone for an organization and the top-down approach is now considered by many to be outdated. Today's students, residents, and workers expect to be viewed more as partners who have a say in decision-making. The top-down approach of many dental institutions, including orthodontic programs, may be a generational mismatch between outdated management philosophies, and those that are viewed as more contemporary.

The remaining highest-ranking stress-provoking items were "Responsibilities of comprehensive patient care", "Insecurity concerning professional future" and "Difficulty in learning clinical procedures". It is not surprising that in a program that has a heavy clinical emphasis, residents would feel stressed about learning clinical procedures while clinics were closed, at limited capacity, or otherwise complicated by an amount of PPE that was not usual or comfortable to J o u r n a l P r e -p r o o f wear. Additionally, in a job market with the uncertainty described earlier, it is understandable that respondents would feel stressed about job security and their professional futures.

Residents were least stressed about the "Amount of cheating in the program." Cheating has been a concern in dental schools 27, 28 as students try to distinguish themselves as top performers, especially since the national boards transitioned from numerical scores to a pass/fail system. Once in an orthodontic residency, however, it is likely that cheating and competition are less pronounced than in dental school, as residency certificates are viewed as "terminal degrees."

The remaining bottom-ranked stress-provoking factors were primarily related to the category "Personal relationships." Respondents did not seem significantly stressed about "Relationships with members of the opposite gender", "Conflict with partner over career decision", "Attitude of school toward women dental students" and "Forced postponement of marriage or engagement." This is consistent with previous studies of dental students and residents, which indicate that personal factors are not highly stress-inducing. 17 It is important to note that in the majority of the five bottom-ranked items, residents responded "Not pertinent," which would also in part explain why these items were lowly ranked.

When comparing respondents by their stage of progress in the program, "Fear of being unable to catch up if behind" in the "Workload" category was found to be significantly more stressinducing for first-year residents as compared to those further along in the program. This survey was disseminated between June and July, when many residents both initiate and conclude their formal orthodontic training. Regardless of their stage in the program, all respondents, at the time of survey administration, had experience with the pandemic impacting their formal training. This included respondents who were fourth-year dental students in March 2020 and first-year orthodontic residents in July 2020. Those who were first-year residents in June 2020 may have fallen short of program expectations regarding the volume of patients seen. If program expectations were not adjusted because of the pandemic, it is logical that respondents were concerned about being able to catch up. However, when the total scores were analyzed for all stress items between stage in program, no significant difference (p<0.05) was identified.

Perhaps most striking findings of the study are the differences between male and female respondents. The total stress scores when comparing genders were highly significant (p<0.005). Across many fields, women have been shown to lack confidence when compared to their male counterparts who are equally or less qualified. 29, 30 This gender difference seems to be rooted in deep societal gender norms 30 and likely pre-existed among orthodontic residents before the COVID-19 pandemic. Paired with an academic and learning environment that female residents find to be more stressful than male residents, our observation that female respondents felt more stressed about learning clinical procedures and precision skills is understandable. Academic environments have been shown to have a profound impact on learner performance, 31 and learning environments within dental schools have been shown to be rampant with misogyny and sexism. [32] [33] [34] [35] [36] [37] [38] Notably, female residents also relayed a greater amount of stress associated with necessary delaying of engagement, marriage, or having children.

Finally, the stress associated with discrimination was significantly higher among female respondents as compared to males. Because of the language associated with this item, it is J o u r n a l P r e -p r o o f unclear if this is because of gender, or some other aspect of the respondents' identity, such as race, ethnicity, sexual orientation, religion, ability, or other minority status. While there are more female orthodontic residents in the US as compared to males, the preponderance of faculty in dental schools are white males. 39 With regard to the factors that were found to be associated with the greatest amount of anxiety, this study was conducted during the third and fourth months of the COVID-19 pandemic, at which time the prevailing belief about the SARS-CoV-2 virus was that it spread by respiratory droplets and it infected and caused serious illness or death primarily in adults older than 65 or those with certain medical conditions, including obesity. While medical conditions are unknown, it is safe to assume that most, if not all, orthodontic residents in North America were under the age of 65. Therefore, it is logical that respondents were not highly anxious about contracting or becoming seriously ill from the virus. However, obtaining basic items for disinfection during this period, such as hand sanitizer and PPE, were challenging due to interrupted supply chains. Thus it is interesting that respondents noted this as a source of anxiety, even though they were less concerned with contracting the virus. The differences between genders and stage in program are reflected in the total anxiety scores, which showed that females and respondents in the middle stages of their program had significant higher levels on anxiety.

Despite the survey clearly stating that the questions should be answered in respect to the COVID-19 pandemic, the authors acknowledge that this study is a snapshot in time and may not be an absolute comparison to orthodontic residents' stress and anxiety pre-pandemic.

Additionally, at the time of submission, the pandemic has been occurring for well over eighteen individuals. If this study was repeated in the current environment, it is possible that the factors that evoke the highest amount of stress and anxiety would likely evolve. That said, the stark differences observed in our study between male and female respondents suggest that orthodontic residency programs must evaluate and reflect on the academic environments they create for female residents. They must then work with female residents to make interventions that will allow them to feel more welcome and less marginalized. Along with establishing a more inclusive environment, such actions will inevitably lead to improved performance.

Concurrently, program directors and professional societies are encouraged to reflect on the need for workshops, storytelling, and other ways for faculty to better understand the experiences of female residents. With millennials now accounting for the majority of orthodontic residents and the majority of faculty being from a different generational period, the expectations that female residents have of their working and learning environment have J o u r n a l P r e -p r o o f evolved and it is critical for programs to assure that they foster a more contemporary learning environment.

As the pandemic continues, and with the hope that some semblance of normalcy will return within the next year, the authors believe it would be valuable to repeat this study. As more research is conducted on factors that specifically impact orthodontic residents' stress and anxiety, and as residents become increasingly diverse across gender, race, ethnicity, religion, and other parameters, studying stress and anxiety will become increasingly important. Chronic stress from the workplace leads to burnout and that impacts performance, medical errors, and productivity. Orthodontic programs should strive to create safe, welcoming, and non-toxic environments for their residents. By studying and understanding the factors that impact stress and anxiety among their residents, programs will be better positioned to provide a high-quality educational experience that effectively produces technically and emotionally competent practitioners for our communities today and tomorrow.

This survey-based study found that whilst financial responsibilities and travel plans were the most stress and anxiety inducing items respectively for orthodontic residents during the early aspect of the COVID-19 pandemic there were multiple items that contributed to their stress and anxiety. Additionally, both gender and stage of progress in a residency program impacted the level of stress and anxiety reported by respondents. J o u r n a l P r e -p r o o f J o u r n a l P r e -p r o o f 

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Table II: COVID-19 Anxiety Items

How likely is it that someone you know could become infected with the novel coronavirus that causes COVID-19?

How much exposure have you had to information about COVID-19?

To what extent has the threat of COVID-19 influenced your decisions to be around people?

To what extent has the threat of COVID-19 influenced your travel plans?

Psychological Predictors of Anxiety in Response to the H1N1 (Swine Flu) Pandemic

The authors would like to express their sincere thanks to the AAO Partners in Research program for their assistance in this study.

This research did not receive any specific grants from funding agencies in the public, commercial, or notfor-profit sectors.J o u r n a l P r e -p r o o f