Academic stress may lead to reduced or compromised

Stress and Academic Performance in Dental Students: The Role of Coping Strategies and Examination-Related Self-Efficacy Antonio Crego, PhD; María Carrillo-Diaz, PhD; Jason M. Armfield, PhD; Martín Romero, PhD Abstract: Academic stress negatively affects students performance. However, little is known of the processes that may be involved in this association. This study aimed to analyze how other variables such as coping strategies and exam-related self-efficacy could be related to academic stress and performance for dental students. An online survey, including measures of coping strategies, perceived stress, exam-related self-efficacy, and academic performance, was completed by undergraduate dental students in Madrid, Spain. Of the 275 students invited to take the survey, 201 participated (response rate 73.6%). Rational coping strategies (problem-solving, positive reappraisal, seeking social support) were negatively associated with perceived stress (β=-0.25, p<0.01), whereas emotional coping strategies (venting negative emotions, negative auto-focus) were linked to increased academic stress (β=0.34, p<0.01). Moreover, rational and emotional coping strategies were, respectively, positively (β=0.16, p<0.05) and negatively (β=-0.22, p<0.01) associated with students exam-related self-efficacy, and this relation was found to be partially mediated by the students perceived stress (β=-0.30, p<0.01). Experiencing higher levels of stress during the examination period was found to be associated with poorer average grades (β=-0.21, p<0.01), but students exam-related self-efficacy partially mediated this relation (β=0.23, p<0.01). Those students who perceived themselves as more efficient in completing examinations reported better grades. Using adequate coping strategies (i.e., rational coping) may help to reduce stress for dental students and, through their effect on exam-related self-efficacy appraisals, contribute to improved academic performance. Dr. Crego is Associate Professor, Department of Psychology and Health, Faculty of Health and Education Sciences, Madrid Open University, Collado-Villalba, Spain; Dr. Carrillo-Diaz is Assistant Professor, Department of Pediatric Dentistry, Faculty of Health Sciences, Rey Juan Carlos University, Madrid, Spain; Dr. Armfield is Associate Professor, Australian Research Centre for Population Oral Health, School of Dentistry, University of Adelaide, Adelaide, Australia; and Dr. Romero is Associate Professor, Department of Pediatric Dentistry, Faculty of Health Sciences, Rey Juan Carlos University, Madrid, Spain. Direct correspondence to Dr. Antonio Crego, Department of Psychology and Health, Faculty of Health and Education Sciences, Madrid Open University (UDIMA), Camino de la Fonda, 20, E28400 Collado-Villalba, Spain; +34 902020003; antonio.crego@udima.es. Keywords: dental education, dental students, stress, coping strategies, self-efficacy, examinations, academic performance Submitted for publication 12/8/14; accepted 7/28/15 Academic stress may lead to reduced or compromised performance for students. Previous research has found that greater academic stress is associated with lower grades 1 and student burnout and is negatively associated with academic achievement. 2 A longitudinal study of medical students concluded that reported levels of stress were negatively related to their academic performance before and during medical school. 3 Research with dental students has yielded comparable findings. Silverstein and Kritz-Silverstein, for example, found that stress increased over time for first-year dental students, with negative effects on academic performance and health. 4 While stress-provoking events are common throughout dental education, examinations are often perceived by students as particularly stressful. 5,6 Having some degree of test anxiety appears as a widespread emotion among university students as well. 7 The way students cope with academic-related stress and their examination-related self-efficacy may affect the association between stress experienced during the exam period and academic achievement. The strategies individuals select to cope with problematic events affect levels of perceived stress, with stress persisting if the way of coping is ineffective. 8,9 Self-efficacy, which is one s perception of his or her capacity to successfully carry out a course of action that leads to a desired outcome, 10-12 may also affect achievement in educational contexts. Students reporting higher exam-related self-efficacy have been found to attain better academic achievement. 13-20 Interestingly, self-efficacy expectations appear connected with both coping strategies and stress perceptions. For instance, previous research has found that active-coping efforts are linked to higher self-efficacy scores and good dissertation grades. 21 February 2016 Journal of Dental Education 165

Coping strategies of planning and seeking social support for instrumental purposes have also been found to be significantly related to self-efficacy, at least among first-year undergraduate students. 22 When individuals are not able to successfully cope with a demanding task, the experience of stress can affect their self-efficacy perceptions. Feeling a state of aversive arousal, as occurs in stress responses, could be taken as a sign of potential failure and decrease the individual s self-efficacy perceptions. 10,11 Taking these previous findings into account, the aim of this study was to propose a possible model to explain the relation between test anxiety and dental student performance. The strategies students use to cope with the stress experienced during the examination period, as well as their self-efficacy assessments, were expected to modulate the relation between test anxiety and grades. In this regard, this study aimed to test a number of hypotheses: 1) there would be a relation between the type of coping strategies that dental students used and their examination-related self-efficacy assessments; 2) the association between coping strategies and examination-related selfefficacy would be mediated, at least partially, by the differing effectiveness of coping strategies (rational vs. emotional) to reduce students perceived stress during the examination period; 3) the extent to which students experienced stress during the examination period would be associated with grade averages, with lower grades expected for those students reporting more stress; and 4) the association between stress and grade averages would be explained at least partially by the students self-efficacy in undertaking examinations. Materials and Methods The Rey Juan Carlos University Review Board approved this study. The participants were a sample of undergraduate dental students at the Faculty of Health Sciences, Rey Juan Carlos University, Madrid, Spain. A cross-sectional design was used to test the hypotheses. Data collection was carried out by means of an online survey consisting of measures of stress during examination periods, coping strategies, examination-related self-efficacy, and academic performance. Gender and age of the participants were also recorded. Students enrolled in dental courses were sent an email asking them to collaborate in a research study focused on examination-related stress. This email was sent through a university web service that guaranteed invitations reached the target population, and only registered members of the university could access the questionnaire. The invitation email included a link to the online survey, instructions to complete the questionnaire, and an informed consent form. Participants were informed that, by submitting their responses, they agreed to participate in this study. All data were collected anonymously from students. Data collection started in February 2014, two weeks after a period of examinations, and students were allowed to complete the questionnaire over the course of one week. No remuneration was offered for participating in the research, and filling out the survey was voluntary. A previously validated Spanish version of Cohen s four-item version of the Perceived Stress Scale (PSS-4) was used. 23,24 This scale measures the extent to which a person assesses an event as stressful. For the purposes of our study, all items referred to the students most recent period of examinations. An example was How often have you felt unable to control the important things in your life during the last exams period? Participants responded on a four-point scale, with response options of never=1, sometimes=2, often=3, and very often=4. Total scores for each participant were calculated by averaging response scores across the four items (range 1 to 4). Internal reliability as measured by Cronbach s alpha was 0.72, which was acceptable for a questionnaire of this nature. Coping strategies were measured with the Coping Strategies Questionnaire (Cuestionario de Afrontamiento al Estrés, CAE) developed by Sandín and Chorot in Spanish. 25 This instrument consists of 42 items on possible ways of coping with stressful events. A five-point response format indicates how frequently each was used, from never=0 to almost always=4. This questionnaire was designed to assess seven basic coping styles: problem-solving coping, negative auto-focused coping, positive reappraisal, overt emotional expression, avoidance coping, social support seeking, and religious coping. According to Sandín and Chorot, two general measures of coping can be calculated from the respondents answers: rational coping (comprising coping styles 1, 3, and 6, with a total of 18 items) and emotional coping (comprising coping styles 2 and 4, with a total of 12 items). Of the 42 items on the CAE questionnaire, six referring to avoidance-based coping and six referring to the use of religion as a coping strategy were not used, following the authors instructions. 166 Journal of Dental Education Volume 80, Number 2

Rational coping represents problem-focused positive ways of coping, whereas emotional coping refers to negative strategies directed against other people or oneself. For our study s purpose, prior to filling out this measure, participants were asked to think of possible problematic academic-related events during the examination period. An example of a rational coping item is I tried to analyze the causes of the problem in order to be able to cope with it, while an example of emotional coping item is I got angry with some people. For each participant, scores of rational coping use and emotional coping use were obtained by averaging responses to the corresponding items, producing scores ranging from 0 to 4. The Cronbach s alpha was 0.87 for the rational coping measure and 0.75 for the emotional coping measure, which are very good and acceptable internal consistency, respectively. The Personal Efficacy Beliefs Scale (PEBS) was used to measure the students perceptions of their efficacy in taking examinations. 26 This scale consists of items measured with a six-point Likert scale, with options ranging from 1=strongly disagree to 6=strongly agree. Intermediate points of the response scale are not labeled. An example item is I have confidence in my ability to do exams. Items were translated into Spanish following a forward- and back-translation method. The Cronbach s alpha was 0.84 for this scale, which indicated very good internal consistency. Due to privacy issues, student grades were not available from the university. In keeping with the Spanish university system, students were provided with instructions to calculate their grade averages (between 0 and 10) for the last examination period. Descriptive statistics (means and standard deviations) were calculated, and gender groups were compared using independent samples t-tests. Our hypotheses were tested by means of two series of multiple linear regression analyses. Prior to analysis, statistical requirements for using this technique (linearity, homoscedasticity, independence, and normality of residuals) were checked, indicating that the data were suitable for the analyses planned. To avoid possible multicollinearity problems, variables were standardized (i.e., converted to Z-scores) prior to running the regression analyses. First, a hierarchical multiple linear regression model, with two models (method: forced entry), was carried out. Model 1 aimed at testing our first hypothesis, and self-efficacy was regressed on gender, age, and both rational and emotional coping strategies. As stated in Hypothesis 2, we expected that a possible relation between coping and self-efficacy could be partially explained by the students perceived stress during the exams period. Accordingly, in Model 2, the participants stress scores were added to the model, which allowed testing whether this variable assumed part of the variance in self-efficacy that was previously explained by coping strategies. In a separate multiple linear regression analysis, stress scores were regressed on gender, age, and coping strategies in order to test the association between coping strategies and perceived stress. A second series of multiple linear regression analyses aimed at testing the relation between stress and students grade averages (Hypothesis 3) and whether this association was partially explained by exam-related self-efficacy (Hypothesis 4). Grade averages were therefore regressed on gender, age, and students stress scores in the first model of a hierarchical multiple regression model (method: forced entry). In Model 2, self-efficacy was added to the model to identify whether this variable explained part of the variance in the students grades previously found to be accounted for by the stress scores. A separate linear regression analysis tested whether stress was significantly associated with self-efficacy, after controlling for gender and age. Finally, the complete model including all the hypothesized relations among variables was tested by means of structural equation modeling. For the mediation models, the proportion of the total effect that is mediated was computed following the procedure described by Alwin and Hauser. 27 Statistical analyses were carried out using SPSS 19 software (IBM Corp., Armonk, NY, USA). AMOS software (IBM Corp., Armonk, NY, USA) was used to build and test the structural equations model. Results Of the 275 dental students invited to participate in the study, 201 responded for a response rate of 73.6%. Among the participants, 68.7% were female, and the mean age was 21.2 years (SD=2.90), with a range from 18 to 40 years. Only 17 students (8.5%) were over the age of 25 years. Table 1 shows descriptive statistics for the study variables. Overall, students reported fair average grades, moderate levels of perceived stress during the exam period, and moderate scores in exam-related self-efficacy. On these variables, no statistically February 2016 Journal of Dental Education 167

Table 1. Descriptive statistics (mean and standard deviation) for study variables, by total (n=201), males (n=63), and females (n=138) Total Male Female Mean (SD) Range Mean (SD) Mean (SD) t Age 21.21 (2.90) 18-40 20.70 (2.58) 21.44 (3.02) 1.69 Grade average (range 0-10) 6.50 (1.10) 4-9 6.40 (1.17) 6.54 (1.07) 0.88 Perceived stress (range 1-4) 2.21 (0.62) 1-4 2.02 (0.61) 2.30 (0.60) 3.04* Exam-related self-efficacy (range 1-6) 3.84 (0.87) 1.5-6 4.17 (0.78) 3.69 (0.87) -3.74* Rational coping (range 0-4) 2.62 (0.64) 1-3.9 2.54 (0.58) 2.66 (0.67) 1.15 Emotional coping (range 0-4) 1.40 (0.59) 0-3.33 1.26 (0.63) 1.47 (0.56) 2.43* *p<0.05 significant gender differences were found. However, females compared to males reported significantly higher perceived stress scores, lower exam-related self-efficacy, and greater use of emotional coping Table 2. Perceived stress regressed on gender, age, and coping strategies B S.E. b Gender -0.21 0.08-0.16* Age 0.09 0.04 0.14* Rational coping -0.15 0.04-0.25** Emotional coping 0.21 0.04 0.34** Note: Dependent variable was perceived stress. Gender was coded as 0 (female) and 1 (male) and used as a control variable; beta for this variable was not interpreted; R 2 =0.25. *p<0.05, **p<0.01 Table 3. Exam-related self-efficacy regressed on gender, age, coping strategies, and perceived stress B S.E. b R 2 Model 1 0.15 Gender 0.42 0.13 0.22** Age -0.07 0.06-0.07 Rational coping 0.14 0.06 0.16* Emotional coping -0.19 0.06-0.22** Model 2 0.22 Gender 0.33 0.12 0.18** Age -0.03 0.06-0.03 Rational coping 0.07 0.06 0.09 Emotional coping -0.10 0.06-0.12 Perceived stress -0.26 0.06-0.30** Note: Dependent variable was exam-related self-efficacy. Gender was coded as 0 (female) and 1 (male) and used as a control variable; beta for this variable was not interpreted. Model 1 and Model 2 were run separately (method: forced entry). *p<0.05, **p<0.01 strategies. The use of coping strategies was associated with the students levels of stress during the exam period after controlling for gender and age (Table 2). Using emotional coping strategies was positively associated with perceived stress, whereas a negative relation was found between using rational coping strategies and stress scores. In support of our first hypothesis, coping strategies were associated with the students examrelated self-efficacy after controlling for gender and age (Table 3, Model 1). Both rational and emotional coping strategies were significant predictors of the students self-efficacy assessments. The more the students reported the use of rational strategies, the greater exam-related self-efficacy expectancies they reported, whereas using emotional strategies to cope with academic stressful events was associated with lower perceptions of self-efficacy. The students perceived stress was included in Model 2 of the regression model, yielding a significant beta coefficient. However, both coping strategies (rational and emotional) were attenuated and no longer statistically significant when the stress scores were added to the model. A statistically significant negative association between students stress and self-efficacy was found, with higher perceived stress during the exam period associated with lower reported exam-related self-efficacy (Table 3, Model 2). Consistent with our second hypothesis, coping strategies were associated with exam-related self-efficacy beliefs, at least to some extent, through the students stress-related perceptions. The indirect path involving rational coping, perceived stress, and self-efficacy accounted for 46% of total effects in this mediation, whereas the indirect path for emotional coping strategies represented 45.4% of the total effects (Figure 1). 168 Journal of Dental Education Volume 80, Number 2

Figure 1. Path model representing complete set of hypothesized relations among variables Note: Gender and age effects were controlled for; to provide a clear graphical representation, paths for these variables are not shown. Numbers represent standardized regression weights. Percentage of total effects accounted for by indirect paths are calculated as follows: for the indirect path from rational coping to exam-related self-efficacy through perceived stress, we computed (-0.25*-0.30)/ [(-0.25*- 0.30)+0.09]=45.4%; for the indirect path emotional coping to exam-related self-efficacy through perceived stress, we computed (0.34*- 0.30)/[(0.34*-0.30)-0.12]=46.0%; for the indirect path from perceived stress to average grades through exam-related self-efficacy, we computed (-0.30*0.26)/[(-0.30*0.26)-0.13]=37.5%. *p<0.01 Students stress scores significantly predicted their academic performance, with lower semester grade averages associated with greater perceived stress during the exam period (Table 4, Model 1). However, when added to the model, exam-related self-efficacy was a statistically significant and stronger predictor of the students grade averages in comparison to stress scores (Table 4, Model 2), which indicates a mediation effect. The indirect path (i.e., that in which stress is connected with grades through self-efficacy) accounted for 37.5% of total effects in this mediation (Figure 1). A structural equations model, which included all the proposed relations among variables, was tested to confirm the pattern of results found in regression analyses (Figure 1). Perceptions of stress were proposed to mediate the relation between use of coping strategies and exam-related self-efficacy. Moreover, exam-related self-efficacy was expected to mediate the relation between perceived stress and average grades. Results indicated that the model adequately fit the data (χ 2 =1.97; df=2; p=0.37; RMR=0.02; AGFI=0.96; CFI=1.00; RMSEA=0.00), supporting the proposed chain from coping strategies to grade averages through stress perceptions and self-efficacy. Discussion This study aimed to explore the associations between stress experienced during exam periods and academic performance among dental students. By Table 4. Grade averages regressed on gender, age, perceived stress, and exam-related self-efficacy B S.E. β R 2 Model 1 0.04 Gender -0.25 0.17-0.11 Age 0.00 0.08 0.00 Perceived stress -0.23 0.08-0.21* Model 2 0.09 Gender -0.35 0.17-0.15* Age 0.01 0.08 0.08 Perceived stress -0.13 0.08-0.12 Exam-related self-efficacy 0.26 0.08 0.23* Note: Dependent variable was grade averages. Gender was coded as 0 (female) and 1 (male) and used as a control variable; beta for this variable was not interpreted. Model 1 and Model 2 were run separately (method: forced entry). *p<0.01 including other variables connected with stress and performance, this research also allows a more complex view of the processes that may lead to an academic result under potentially stressful conditions. Consistent with our first hypothesis, and in line with previous research, 21,22 the coping strategies used by students were differently connected with their perceptions of exam self-efficacy. Rational coping strategies were associated with higher exam-related self-efficacy, whereas the use of emotional coping strategies was linked to lower self-efficacy perceptions. As suggested in our second hypothesis, the relation between coping strategies and self-efficacy February 2016 Journal of Dental Education 169

was partially mediated by the level of stress students experienced during the exam period. Previous research has reported that different coping strategies lead to different outcomes concerning an individual s perceived stress. 28,29 For instance, Carver et al. found that strategies such as focusing on and the venting of emotions, as well as behavioral and/or mental disengagement, might be of limited usefulness. 28 In comparison, problem-focused coping (e.g., active coping, planning, suppression of competing activities, restraint coping, seeking of instrumental social support) and emotion-focused coping (e.g., seeking of emotional social support, positive reinterpretation, acceptance, denial, turning to religion) were found to be relatively more effective. Supporting this theory, Dwyer and Cummings reported that the use of avoidance-focused coping strategies was significantly associated with stress among university students. 29 Consistent with previous findings in the classical transactional approach to stress, 8,9 our study found that rational strategies were associated with reductions in the students stress, whereas emotional strategies were associated with increases in perceived stress during the exam period. Previous studies have found that academic stress was associated with poorer academic performance, 1-4 a result that was also found in our study (Hypothesis 3). However, going a step further, our fourth hypothesis was that the link between stress and academic results would be partially mediated by the students perceived self-efficacy concerning exam completion. Adding self-efficacy and perceived stress as predictors of academic performance into the same regression model reduced the strength of the association between perceived stress and grade averages to non-significance, whereas self-efficacy was significantly associated with the students grades. The relation between stress scores and students grades was therefore mediated, to some extent, by their exam-related self-efficacy assessments. In this regard, we found that exam-related self-efficacy was a more robust and consistent predictor of academic success than stress, which is consistent with a previous study. 30 As expected, higher levels of stress were connected with poorer average grades through lower exam-related self-efficacy, and this was consistent with Bandura s social-cognitive theory, which holds that physiological states influence appraisals of selfefficacy. 10-12 On the contrary, lower levels of stress were associated with higher self-efficacy perceptions and better academic outcomes. The associations between the variables explored in this study were analyzed using structural equation modeling (SEM). This analysis showed that rational coping strategies were associated with reduced stress perceptions and therefore with higher exam-related self-efficacy, which was in turn associated with better student grades. Using emotional coping strategies, on the other hand, was associated with increased stress levels, which may be interpreted as a signal of lower self-efficacy to successfully complete exams and poorer academic results. This study had some limitations. First, a convenience sample was used, and we cannot therefore assume that the participants were representative of a broader population. Another potential limitation is that our sample included students in different years of their formative program, and they were therefore taking different exams, which may involve different coping challenges. In particular, there may have been different stressors for students taking preclinical compared to clinical exams. However, the formative program of dental students introduces practice from early career years in a progressive manner, and it was therefore not possible to differentiate purely clinical students from those not having clinical experience. Concerning sample size, it is important to note that our study aimed at identifying possible relations among variables, for which convenience samples of medium size are commonly used. Sample size could have, however, limited the power of regression analyses involving a greater number of predictor variables; therefore, replication of this study in larger samples would be advisable. A second potential limitation is that the use of self-report measures may have resulted in memory errors and social desirability bias. This could have especially affected the students recall of their past levels of stress and the strategies they used to cope throughout the exam period. However, the period of time selected to administer the survey was close to an exam period, which would have helped to minimize this possible bias. Overall, internal reliability of the instruments used was good, with the rational coping measure yielding a better internal consistency than the emotional coping measure. The greater number of items comprising the rational coping measure and a possible greater heterogeneity of the items describing emotional strategies could be at the basis of these differences. Gathering data after the exam period could help to avoid bias related to the impact of stress and negative emotions on self-evaluations. However, students self-reported their academic re- 170 Journal of Dental Education Volume 80, Number 2

sults, as their records at the dental school were not available, and self-reports could be affected by recall errors or social desirability responding (although the anonymous reporting may have minimized this possible bias). Another possible limitation, as shown in the results, is that participants had obtained only fair academic results overall with a rather low variability in average grades. In this regard, academic-related characteristics of participants may have influenced the results, and generalization of the results might be difficult. However, previous research has found that dental students usually obtain good grades, with 80% of them passing their semester exams. 31 Past experience could also be a possible confounding factor as regards the use of coping strategies. However, we tried to control this possible source of error by including participant age in our analyses, as this variable may account for some of the variance due to past experience (not only in a university context but also concerning past life events). A final potential limitation is that regression and path analyses are not able to confirm causal relations among variables, so directions of causality alternative to those we have proposed could also be plausible. In fact, the transactional approach to stress and coping assumes a recursive process, depending on coping strategies effectiveness to reduce felt stress. Coping strategies aim to reduce the perceived stress, but perceptions of stress may also activate coping strategies, in a feed-forward and feedback process. In any event, all the paths we hypothesized were theoretically driven and based on previous empirical evidence and therefore represent at least a plausible explanation of the associations found in this study. Future research is suggested using a longitudinal approach to clarify possible causal relations among variables and increase the validity of conclusions with new evidence. Conclusion In spite of its limitations, the results of this study provide a better understanding of how psychological and behavioral variables, such as stress and the use of coping strategies, could have an impact not only on dental students self-efficacy but also on their grades. Moreover, our research combines inputs from transactional framework to stress and self-efficacy theory, which is a novel approach to the topic of academic performance. Psychological aspects, such as coping strategies for stress management and academic self-efficacy, may play a relevant role in academic success. In this regard, promoting the use of adequate coping strategies, such as problem-solving focused coping, positive reappraisal, and looking for social support, could have a positive impact on student performance. 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