The evaluation of a continuing professional development package for primary care dentists designed to reduce stress, build resilience and improve clinical decision-making.

Introduction Stress and burnout are widely accepted as a problem for primary care dental practitioners. Previous programmes to address this issue have met with some success. Burnout is associated with poor coping skills and emotion regulation, and increased rates of clinical errors. Anxiety is associated with poor decision-making and is thought to be associated with poor clinical decision-making. Attempts to improve decision-making use increasing meta-awareness and review of thinking processes. Bibliotherapy is an effective method of delivering cognitive behavioural therapy as self-help or guided self-help (with some therapist input) formats.Objective To evaluate the efficacy of a specially designed CPD package which was designed to improve coping skills, build resilience and reduce the impact of anxiety on dentists' clinical decision-making.Design A multi-centred quasi-experiment.Setting Lincolnshire and Nottinghamshire (England) 2014.Materials and methods Thirty-five volunteer primary care dentists used two versions (self-help [SH] and guided self-help [GSH], which included a 3 hour workshop) of a specially written cognitive behavioural therapy bibliotherapy programme designed to improve well-being and decision-making.Main Outcome Measures The main outcome measures were dentists' burnout, depression, anxiety, stress and decision-making style. Data were also collected on use and evaluation of the programme.Results At 6 weeks there was a clinically and statistically significant reduction in depression, anxiety and stress levels, a statistically significant reduction in burnout (emotional exhaustion) and hypervigilant decision-making, and an increase in personal achievement. The improvements in depression, stress, emotional exhaustion and hypervigilant decision-making were maintained at 6 months. Dentists were overwhelmingly positive in their evaluation of the project and used most of its contents.Conclusion With the caveat of small numbers and the lack of a no-treatment control, this project demonstrated that a self-help package can be highly acceptable to dentists and, in the short-to-medium term, improve dentists' well-being and decision-making with implications for patient safety.

A study to explore if dentists' anxiety affects their clinical decision-making.

Aims To develop a measure of dentists' anxiety in clinical situations; to establish if dentists' anxiety in clinical situations affected their self-reported clinical decision-making; to establish if occupational stress, as demonstrated by burnout, is associated with anxiety in clinical situations and clinical decision-making; and to explore the relationship between decision-making style and the clinical decisions which are influenced by anxiety.Design Cross-sectional study.Setting Primary Dental Care.Subjects and methods A questionnaire battery [Maslach Burnout Inventory, measuring burnout; Melbourne Decision Making Questionnaire, measuring decision-making style; Dealing with Uncertainty Questionnaire (DUQ), measuring coping with diagnostic uncertainty; and a newly designed Dentists' Anxieties in Clinical Situations Scale, measuring dentists' anxiety (DACSS-R) and change of treatment (DACSS-C)] was distributed to dentists practicing in Nottinghamshire and Lincolnshire. Demographic data were collected and dentists gave examples of anxiety-provoking situations and their responses to them.Main outcome measure Respondents' self-reported anxiety in various clinical situations on a 11-point Likert Scale (DACSS-R) and self-reported changes in clinical procedures (Yes/No; DACSS-C). The DACSS was validated using multiple t-tests and a principal component analysis. Differences in DACSS-R ratings and burnout, decision-making and dealing with uncertainty were explored using Pearson correlations and multiple regression analysis. Qualitative data was subject to a thematic analysis.Results The DACSS-R revealed a four-factor structure and had high internal reliability (Cronbach's α = 0.94). Those with higher DACSS-R scores of anxiety were more likely to report changes in clinical procedures (DACSS-C scores). DACSS-R scores were associated with decision-making self-esteem and style as measured by the MDMQ and all burnout subscales, though not with scores on the DUQ scale.Conclusion Dentists' anxiety in clinical situations does affect the way that dentists work clinically, as assessed using the newly designed and validated DACSS. This anxiety is associated with measures of burnout and decision-making style with implications for training packages for dentists.

Understanding emotionally relevant situations in primary dental practice. 3. Emerging narratives.

BACKGROUND AND AIMS: Dentists experience considerable occupational stress. Stressful clinical situations can provoke high levels of negative emotions, and situations which are associated with positive emotions tend to be overlooked by practitioners. Reflection regarding difficult situations is encouraged to facilitate learning. Cognitive behavioural therapy (CBT) formulations may be applied to situations appraised both positively and negatively. Analysis and interpretation of the dentist's coping behaviour and the consequent outcomes facilitate learning and reflection upon individual interactions with patients. METHOD: Twenty primary care dental practitioners in the greater Lincoln area participated in a semi-structured interview which explored their stressful and positive clinical experiences. Some of the episodes were analysed to create CBT formulations. RESULTS AND DISCUSSION: CBT formulations are presented and the learning points highlighted by this structured presentation are discussed. In particular, it is suggested that this structured reconstruction of events, which highlights dentists' emotions, responses and the transactional effects of coping responses, might well facilitate objective reflective learning either individually or as part of peer to peer support. It should facilitate dentists' emotional processing of events and may thus contribute to stress reduction. CONCLUSION: CBT formulations of positive and negative dental scenarios may be constructed. It is proposed that this is a useful technique to foster reflection and learning in clinical situations and should lead to improved communication skills and shared decision-making, resulting in fewer complaints and thereby reduced stress. It should also improve dentists' emotional processing.

Understanding emotionally relevant situations in primary care dental practice: 1. Clinical situations and emotional responses.

BACKGROUND AND AIMS: The stressful nature of dental practice is well established. Much less information is available on the coping strategies used by dentists and the emotions which underlie the stressful experience. Previous research has been almost exclusively questionnaire-based, limiting the range of emotions explored. This study used qualitative methods to explore the full extent of emotions and coping strategies associated with stressful events in primary dental practice. METHOD: Semi-structured interviews were conducted with 20 dentists in Lincoln and the surrounding area. Verbatim transcriptions were analysed using thematic analysis. RESULTS: Participants reported a wide variety of stressful situations, consistent with the existing literature, which were associated with a diverse range of negative emotional responses including anxiety, anger and sadness. Dentists tended to have more difficulty identifying positive events and emotions. The designation of a situation as stressful or otherwise was dependent on the dentist's personal interpretation of the event. Data relating to the effects of stressors and the coping strategies used by dentists will be presented in subsequent papers. CONCLUSION: The situations which dentists find difficult are accompanied by a diverse set of emotions, rather than omnipresent 'stress.' This has implications for stress management programmes for those in dental practice.

Understanding emotionally relevant situations in primary dental practice. 2. Reported effects of emotionally charged situations.

BACKGROUND AND AIMS: Dentistry is widely reported to be a stressful profession. There is a limited body of research relating to the coping strategies used by dentists whilst in clinical situations. This study aims to use qualitative methods to explore the full extent of the coping strategies associated with stressful events in primary dental practice. METHOD: Semi-structured interviews were conducted with 20 dentists within a 50 mile radius of Lincoln. A thematic analysis was conducted on verbatim transcriptions thereby identifying six themes and 35 codes. RESULTS: Participants described both problem-focussed and emotion-focussed strategies. The strategies used had a variety of outcomes in the context of use. Most dentists denied that their emotions affected their decision-making, but then proceeded to describe how they were influential. DISCUSSION AND CONCLUSION: Dentists use a wide variety of coping strategies some of which are maladaptive. Training in the development and recognition of appropriate coping decisions would be appropriate as they would, potentially, improve practitioner decision-making and well-being.

Factors associated with carer strain in carers of people with multiple sclerosis.

PURPOSE: To examine the factors associated with strain in carers of people with multiple sclerosis (MS). METHOD: People with MS were recruited from an MS management clinic. Demographic information, memory, executive function, attention/concentration, mood, disability and health of the person with MS, the carer's opinion of the care-recipient's memory and disability, and the carer's mood were recorded. A postal questionnaire to identify factors associated with carer strain was sent to carers. A further questionnaire was sent to carers to examine the association between memory problems in people with MS and carer strain. RESULTS: Problems with everyday memory and activities of daily living were found to be associated with carer strain. Strained carers perceived strain to be a consequence of the memory problems (p < 0.01). Aspects of the memory problems related to carer strain were the amount of time a carer could spend alone (p = 0.01), the carer's mood and less sympathetic feelings towards the person with MS (p < 0.05). Strained carers had more desire for other people to help the person with MS deal with the memory problems by themselves than carers who were not under strain (p = 0.03). CONCLUSION: Carer strain was associated with memory problems experienced by people with MS.

A survey of the effects of fatigue on driving in people with multiple sclerosis.

PURPOSE: To examine the effect of fatigue on driving in patients with multiple sclerosis (MS). METHOD: A questionnaire on driving was sent to 192 people with MS and 192 controls who were relatives or close friends of the people with MS. RESULTS: Replies were received from 75 MS patients (39%) and 63 controls (32%). MS patients' ability to drive was more often affected by fatigue, leg problems, numbness and eye problems than controls. The MS group reported driving shorter distances and shorter times than controls, and that fatigue had a significant effect on their ability to drive. The driving plans of MS patients were affected by fatigue. CONCLUSION: Fatigue affected the driving of MS patients, but it was not the only factor and should be considered in relation to other symptoms of MS.

Measuring fatigue in people with multiple sclerosis.

OBJECTIVE: To compare methods of assessing fatigue. DESIGN: Cross sectional. SETTING: Community. SUBJECTS: Forty Multile Sclerosis (MS) patients and 20 healthy controls. MAIN OUTCOME MEASURES: Fatigue questionnaires, SDSA dot cancellation test, finger tapping test, TEA Lottery. RESULTS: The MS patients had significantly higher levels of fatigue than the controls on the Task Induced Fatigue Scale, Fatigue Severity Scale and Fatigue Impact Scale. The Task Induced Fatigue Scale completed whilst imagining oneself driving and the Fatigue Assessment Instrument did not differentiate between MS patients and controls. Finger tapping differentiated between MS patients and controls but there was no significant difference between MS patients and controls on visual and auditory concentration tests. A factor analysis indicated that questionnaire measures of fatigue were interrelated but independent of objective test performance. CONCLUSIONS: Questionnaire measures can be used to assess fatigue in people with MS. The FSS differentiated MS patients from controls and is relatively short. It was therefore recommended for clinical use.

Heel ulcers don't heal in diabetes. Or do they?

AIM: To obtain information on outcome of heel ulcers in diabetes. METHODS: Data were recorded prospectively on all patients with heel ulcers who were referred to a specialist multidisciplinary clinic between 1 January 2000 and 30 November 2003. Outcomes were assessed on 31 March 2004. RESULTS: There were 157 heel ulcers in the patients referred in the period. Three ulcers were excluded from analysis because of associated osteomyelitis. Of 154 remaining ulcers (121 limbs; 97 patients, 55 male; mean age 68.5 +/- 12.8 sd years), 101 (65.6%) healed after a median (range) 200 (24-1225) days. Of 53 non-healed ulcers, 11 (7.1% of 154) were resolved by major amputation, 30 (19.5% of 154) were unhealed at time of patient's death, and 12 (7.8% of 154) remained unhealed. Ulcers healed in 59 of 97 affected patients (60.8%). Twenty-six patients (26.8% of 97) died during the period, of whom 20 died with ulcers unhealed. Worse outcomes were observed in larger ulcers (P = 0.001, Mann-Whitney U-test = 1883.5) and limbs with clinical evidence of peripheral arterial disease (P = 0.001, Mann-Whitney U-test = 1163.00). Backward step-wise logistic regression analysis showed 70.1% of healing could be predicted from these two baseline characteristics. CONCLUSIONS: The common perception that 'heel ulcers don't heal' is not reflected in clinical practice. Outcome is generally favourable even in a population often affected by serious comorbidity and with limited life expectancy. These data can be used to help define management plans, as well as a basis for counselling of the individual patient.