It is well recognised that stress impacts on well-being. Even without the new NHS contract, dentistry has always been high on the list of most stressful jobs. There is a strong belief that dentists regard their potential for suicide to be greater than other professions, but what about the rest of the dental team? And why is stress such a big problem anyway?

Occupational stress

Occupational stress poses a risk to most businesses and compensation payments for stress related injuries are rising.

According to the Chartered Institute of Personnel and Development (CIPD) (2006) ‘stress is one of the most important reasons behind sickness from work and stress related absence is increasing’.1

The Health and Safety Executive (HSE) (2007) indicated that stress is likely to become the most dangerous risk to business in the early part of the twenty-first century. Self reported stress, depression or anxiety account for an estimated ‘10.5 million reported lost working days per year in Britain’.2 As part of their overall strategy to reduce work related ill health the HSE has developed clear guidance on stress management standards. The Management standards for work-related stress3 launched in November 2004 encourage organisations to take preventative measures through risk assessment. The risk assessment consists of organisations comparing themselves against:

  • demand – being able to cope with the demands of the job

  • control – having an adequate say over how work is done

  • support – having adequate support from colleagues and superiors

  • roles – understanding roles and responsibilities

  • relationships – not being subjected to unacceptable behaviours

  • change – being involved in any organisational changes.

These are highly relevant for ALL dental team members – our work, employers and patients may be too demanding, we may have little say over how the business is run, change is managed or how much time is allocated for tasks. There may be an inadequate number of staff, insufficiently trained staff, poor or unfair allocation of roles and responsibilities – not to mention dealing with aggressive, phobic or difficult patients.

The standards are voluntary but the HSE has indicated that they will be used as evidence against employers that continue to ignore their responsibilities in managing stress under the Health and Safety at Work Act 1974.

As well as reducing sickness absence costs to the practice, tackling stress can have a positive effect on:

  • employee commitment to work

  • staff performance and productivity

  • staff turnover or intention to leave

  • staff recruitment and retention

  • customer/patient satisfaction

  • practice image and reputation.

What is stress?

The dictionary definition of stress is: ‘a physical, chemical or emotional factor that causes bodily or mental tension and may be a factor in disease causation. Stress can be defined as a negative emotional state in response to events that are perceived as beyond the person's ability to cope’.4

Types of stress

A study by Holmes and Rahe5 attempted to measure stress in relation to 43 common life events involving change of some kind. This became known as the Social Readjustment Rating Scale (SRRS). For example, retirement scores 45 out of a possible 100. Business readjustments 39, change in financial state 38, change to different line of work 36, change in responsibilities at work 29, and trouble with the boss 23. Each event should be considered if it has taken place in the last 12 months and when totalled up indicates your susceptibility to illness and mental health problems. Scores over 200 suggest moderate to major susceptibility. The value of the list is that it acts as a warning. If you are experiencing a period of rapid change in your social and/or professional life it may be wise to slow things down, or take action to manage the process safely ensuring the seeds of future health problems do not find fertile ground.

Stress can also be categorised as:

  • acute – demands and pressures of the recent past and anticipated demands and pressures of the near future

  • episodic – enduring acute stress frequently – life feels chaotic, out of control

  • chronic – unrelenting demands and pressures for seemingly interminable periods of time.

What is the stress response?

The ‘stress response’ is historic – our ancestors needed extreme physical reactions and a burst of energy to enable them to fight a wild animal or run away.

A certain amount of stress helps us to function – the appropriate arousal of the nervous system motivates us to do things, move out of the way of an oncoming vehicle, work out at the gym, or give a presentation. However, the problem arises when we are continually preparing for emergencies that never happen.

This puts an unnecessary strain on our immune systems, ultimately ‘burning out’ our adrenal glands and spreading toxins around the body.

Stages of stress

Stage 1: Mind perceives a threat

…at stressful times it is important to eat well: drink water, a minimum of two litres (three pints) a day.

Stage 2: If pressure perceived as threatening the body prepares for action – sympathetic nervous system

Stage 3: Sympathetic nervous system activity causes physiological changes – heartbeat quickens, pupils dilate, adrenaline released into blood stream, digestion halts, blood pressure rises, and the immune system is suppressed – fight or flight response

Stage 4: Appraisal of how well one coped with the situation (Cognitive Appraisal)

Stage 5: If positively appraised the parasympathetic nervous system reduces stress. If negatively appraised, stress builds up. Stress hormones then lower the immune system.

Psychologists emphasise the importance of Cognitive Appraisal (Stage 4) – how the person thinks about the situation they find themselves in, and how much in control they feel.

Symptoms of stress

Physical – sleep disturbances, palpitations, acid stomach, constipation/diarrhoea, weight loss, hair loss, chest pain, back/neck/shoulder pain, tension or migraine headaches, sweaty palms/cold hands and feet

Emotional – nervousness/anxiety, depression/moodiness, irritability, butterflies, memory problems, lack of concentration, trouble thinking clearly, substance abuse

Relational – increased arguments, isolation from social activities, road rage, violence/conflict, lowered sex drive.

A certain amount of stress helps us to function – the appropriate arousal of the nervous system motivates us to do things…

So stress has a direct impact on our concentration, our ability to think clearly and our memory. ‘High blood pressure correlates with loss of mental ability.’6

The single biggest cause of ill-health is an inappropriate response to stress. Many studies have shown that the major threat in modern life is being killed by our own defence system being triggered too often – by our response to stress. Amazingly the nervous system cannot differentiate between a real physical threat or challenge and a mental one. ‘Whatever happens in the mind influences the body and vice versa. In fact mind and body cannot be considered independently one from the other’ (Hippocrates 460-377 BC).

‘stress can affect the immune system, impair the brain's learning centres and damage the intellect.’ 7

Special features of dentistry

According to a UK national study of general dental practitioners8 ‘the stress levels in the profession are high, likely to go higher and are already having effects both in deteriorating levels of mental well-being and in the significant numbers of GDPs with low levels of job satisfaction’. The research identified the medical emergency as the greatest source of stress for both male and female dentists. Uncooperative patients, running behind schedule, constant time pressures and dealing with very nervous patients were ranked highly by both sexes. Another interesting finding from this work was the extent to which the needs of the practice in terms of scheduling, income, staffing and quality control were prime concerns with the potential for raising stress levels. By 1998, stressors included coping with NHS system changes, higher patient expectations, and hostile and aggressive behaviour towards staff in the practice.

The nature of the work is subject to a variety of demands. Examples include being given too little time to finish a task, being faced with a situation that has been set up to fail, being unable to predict an outcome, being presented with a task beyond your skill level, or beyond your control.

Stress can also occur when there is too much change happening at once. A lack of feedback or emotional support for actions will raise and maintain stress levels.

Being forced to act in a way which is contrary to your key values is a stress-heightening factor, for example being encouraged by the practice principal to promote certain products or services such as bleaching when you do not believe they are in the patients' best interest. Going against your key values leaves you with a feeling of incongruence and ultimately stress.

The study of British dentists8 suggested several strategies for dealing with time pressure, pay, uncooperative patients, and incompetent staff. Interestingly, dentists reported that the most likely way in which they would deal with these stressors was to ‘try to control the situation’ and the least likely response reported by dentists was to seek support.

Seeking outside help was very uncommon. Negotiation, cooperation, and searching for mutually acceptable solutions were never mentioned in these open-ended surveys.

Nurturing team spirit

As a poor team can make or break your business and add to your stress levels as well as their own, it is important to foster team spirit. Make sure the equipment you expect them to work with – works, the environment is comfortable and safe, and they have sufficient materials/resources to do their job properly. Your business will only grow if your team do.

Here are some more suggestions:

  • hold regular staff meetings and team building programmes

  • hold skills-based team sessions (excellent for building team morale)

  • subscribe to educational material and industry magazines and make them available to the team

  • have induction and appraisal programmes

  • have contingency staffing plans

  • develop a system for recognition and remuneration

  • develop a system to resolve conflict

  • have a mission statement and set practice and individual team member goals in line with it

  • run time management training

  • if possible build a career structure within the practice

  • consider coaching.

Managing personal stress

Positive mental attitude

Henry Ford is accredited with the saying ‘If you think you can, or you think you can't – you're probably right’. Some people like to use affirmations. This is great if you are prone to negative ‘mind chatter’.

Diet and stress

It can be difficult to eat healthily when you lead a busy life and are pushed for time. Unfortunately the way we respond to stress has a profound effect as its onset triggers strong desires for particular types of food, such as highly flavoured, instant reward, high fat chocolate, biscuits, and full fat crisps as well as caffeine rich tea, coffee and cola. The energy we derive from these foods is high and immediate although it is depleted just as rapidly leaving us with the type of blood sugar swings that are likely to lead to overeating, weight gain and increased stress. So at stressful times it is important to eat well:

  • five portions of fruit and vegetables every day

  • complex carbohydrates including brown and wild rice, oats, wholemeal pasta, potatoes and wholemeal bread

  • protein, pulses, nuts, white meat and oily fish

  • drink water, a minimum of two litres (three pints) a day.

Exercise

We all know that moderate amounts of exercise are good for us. However, at stressful times this is more important as exercise is also good for mental well-being, influencing your ability to cope with and manage stress and anxiety. A single exercise session is reckoned to release enough of the natural morphine-like endorphins into the brain to alter mood for as long as two hours. In addition physical exertion helps to burn off the stress hormones released into the blood stream as a result of the ‘fight or flight’ response to stressful situations. Exercise helps to restore proper digestion and produces a lower resting heart rate. Walking briskly daily is aerobic and gives the mind time to think, problem solve and de-stress.

Stress management programmes

Most programmes for general stress management tend to be based on Cognitive Behavioural Therapy (CBT). This usually involves assessment of the stress symptoms and individual coping style/response to stress followed by goal setting and education. Education may involve teaching clients about the stress response, the mind-body connection, exercises in managing stress, effects of stimulants, the prevention of panic attacks and the rationale for learning relaxation and breathing techniques. Finally interventions are planned to bring about change; these are tailored to meet the needs of the individual and may involve encouraging clients to take responsibility, lifestyle changes and making the client more aware of their emotional reaction to stress in order to explore alternative strategies.

Neuro-Linguistic Programming (NLP)

This is a range of fast acting techniques developed in the 1970s by Richard Bandler and John Grinder. NLP sessions are designed to show you how you experience and understand the world, help you identify concerns or limiting beliefs, and develop techniques to bring about change. From the NLP perspective the issue is not about avoiding stressful situations, it is about how we respond to situations in order to cope effectively with stress.

NLP can be effective for:

  • team meetings

  • building rapport quickly with patients

  • developing excellent communication skills

  • dealing with aggressive patients

  • influencing and motivating patients

  • personal development

  • learning

  • dealing with dental phobia

  • motivation/goal setting (staff and patients)

  • changing unwanted behaviours or habits

  • building good quality relationships, replacing conflict with cooperation.

Relaxation, meditation and hypnosis

Certain types of stress tend to be acute but short lived. Once the event is over everything returns to normal. It is the chronic stress caused by the unrelenting demands and pressures for seemingly interminable periods of time that causes the major health problems.

Relaxation

Breathing

  • Deep breathing from the stomach, ensuring the out breaths are longer than the in breaths

  • Imagining and visualising tension leaving your body in the form of a coloured vapour. You can watch the vapour rise in and eventually disappear

  • Imagining that you are on a swing, breathing in as the swing goes up, and breathing out as the swing goes down, again allowing the tension to leave the body on the out breath; gradually the swing becomes slower and slower until it is moving in slow motion.

Progressive muscle relaxation

This can be achieved in one of two ways. By imagining each muscle group relaxing, starting at the feet and moving up the body, or by tensing each muscle group first before relaxing it.

The power nap

Relaxes and revives in about five minutes. Winston Churchill, Albert Einstein, Leonardo Da Vinci and Thomas Edison were all power nappers. Very easy to learn.

Meditation

Meditation involves sitting in a relaxed position and clearing your mind. You may focus on a sound, like ‘om’, or on your own breathing, or on nothing at all. It's necessary to have five to 20 distraction-free minutes to spend. It's helpful to have silence and privacy, but more practised meditators can do it anywhere. Many practitioners of meditation attach a spiritual component to it, but it can also be a secular exercise.

It does take some practice, however, and some people find it difficult to ‘get it’ in the beginning. It also requires patience, and may be difficult for people with little free time.

Self-hypnosis

Successful stress management ultimately creates a more successful practice.

Once learned, self-hypnosis can be a valuable life skill. It can be used for relaxation, to take ‘time out’ and maintain equilibrium, to focus attention as part of exam preparation, to maximise achievement by ‘future rehearsing’ an interview or presentation, to gain insight and problem solve, and to increase creativity. Self-hypnosis can be invaluable in dealing with stress related illness such as migraine headaches, IBS, asthma, insomnia, anxiety disorders, over eating and smoking. Ideally self-hypnosis should be taught by a qualified hypnotherapist but books are available and it can be self-taught.

Success through harmony

It is time for dental practices to wake up to the health and safety issues of organisational stress. Successful stress management complements practice management, resulting in better team working and communication skills, more positive attitudes and harmony among co-workers, less sickness, better patient management and ultimately a more successful practice.