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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 in-
volved in this association. This study aimed to analyze how other variables such as coping strategies and exam-related self-effica-
cy could be related to academic stress and performance for dental students. An online survey, including measures of coping strat-
egies, 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 strate-
gies (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 me-
diated 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

A
cademic stress may lead to reduced or com- The way students cope with academic-related
promised performance for students. Previous stress and their examination-related self-efficacy may
research has found that greater academic affect the association between stress experienced
stress is associated with lower grades1 and student during the exam period and academic achievement.
burnout and is negatively associated with academic The strategies individuals select to cope with prob-
achievement.2 A longitudinal study of medical stu- lematic events affect levels of perceived stress, with
dents concluded that reported levels of stress were stress persisting if the way of coping is ineffective.8,9
negatively related to their academic performance be- Self-efficacy, which is one’s perception of his or her
fore and during medical school.3 Research with dental capacity to successfully carry out a course of action
students has yielded comparable findings. Silverstein that leads to a desired outcome,10-12 may also affect
and Kritz-Silverstein, for example, found that stress achievement in educational contexts. Students re-
increased over time for first-year dental students, porting higher exam-related self-efficacy have been
with negative effects on academic performance and found to attain better academic achievement.13-20
health.4 While stress-provoking events are common Interestingly, self-efficacy expectations appear
throughout dental education, examinations are often connected with both coping strategies and stress
perceived by students as particularly stressful.5,6 Hav- perceptions. For instance, previous research has
ing some degree of test anxiety appears as a wide- found that active-coping efforts are linked to higher
spread emotion among university students as well.7 self-efficacy scores and good dissertation grades.21

February 2016  ■  Journal of Dental Education 165


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

166 Journal of Dental Education  ■  Volume 80, Number 2


Rational coping represents problem-focused stated in Hypothesis 2, we expected that a possible
positive ways of coping, whereas emotional coping relation between coping and self-efficacy could be
refers to negative strategies directed against other partially explained by the students’ perceived stress
people or oneself. For our study’s purpose, prior during the exams period. Accordingly, in Model
to filling out this measure, participants were asked 2, the participants’ stress scores were added to the
to think of possible problematic academic-related model, which allowed testing whether this variable
events during the examination period. An example assumed part of the variance in self-efficacy that
of a rational coping item is “I tried to analyze the was previously explained by coping strategies. In a
causes of the problem in order to be able to cope with separate multiple linear regression analysis, stress
it,” while an example of emotional coping item is “I scores were regressed on gender, age, and coping
got angry with some people.” For each participant, strategies in order to test the association between
scores of rational coping use and emotional coping coping strategies and perceived stress.
use were obtained by averaging responses to the cor- A second series of multiple linear regression
responding items, producing scores ranging from 0 analyses aimed at testing the relation between stress
to 4. The Cronbach’s alpha was 0.87 for the rational and students’ grade averages (Hypothesis 3) and
coping measure and 0.75 for the emotional coping whether this association was partially explained by
measure, which are very good and acceptable internal exam-related self-efficacy (Hypothesis 4). Grade
consistency, respectively. averages were therefore regressed on gender, age,
The Personal Efficacy Beliefs Scale (PEBS) and students’ stress scores in the first model of a
was used to measure the students’ perceptions of hierarchical multiple regression model (method:
their efficacy in taking examinations.26 This scale forced entry). In Model 2, self-efficacy was added to
consists of items measured with a six-point Likert the model to identify whether this variable explained
scale, with options ranging from 1=strongly disagree part of the variance in the students’ grades previ-
to 6=strongly agree. Intermediate points of the re- ously found to be accounted for by the stress scores.
sponse scale are not labeled. An example item is “I A separate linear regression analysis tested whether
have confidence in my ability to do exams.” Items stress was significantly associated with self-efficacy,
were translated into Spanish following a forward- and after controlling for gender and age.
back-translation method. The Cronbach’s alpha was Finally, the complete model including all the
0.84 for this scale, which indicated very good internal hypothesized relations among variables was tested
consistency. Due to privacy issues, student grades by means of structural equation modeling. For the
were not available from the university. In keeping mediation models, the proportion of the total effect
with the Spanish university system, students were that is mediated was computed following the pro-
provided with instructions to calculate their grade cedure described by Alwin and Hauser.27 Statistical
averages (between 0 and 10) for the last examina- analyses were carried out using SPSS 19 software
tion period. (IBM Corp., Armonk, NY, USA). AMOS software
Descriptive statistics (means and standard de- (IBM Corp., Armonk, NY, USA) was used to build
viations) were calculated, and gender groups were and test the structural equations model.
compared using independent samples t-tests. Our
hypotheses were tested by means of two series of
multiple linear regression analyses. Prior to analy- Results
sis, statistical requirements for using this technique
(linearity, homoscedasticity, independence, and Of the 275 dental students invited to participate
normality of residuals) were checked, indicating in the study, 201 responded for a response rate of
that the data were suitable for the analyses planned. 73.6%. Among the participants, 68.7% were female,
To avoid possible multicollinearity problems, vari- and the mean age was 21.2 years (SD=2.90), with a
ables were standardized (i.e., converted to Z-scores) range from 18 to 40 years. Only 17 students (8.5%)
prior to running the regression analyses. First, a were over the age of 25 years.
hierarchical multiple linear regression model, with Table 1 shows descriptive statistics for the
two models (method: forced entry), was carried study variables. Overall, students reported fair aver-
out. Model 1 aimed at testing our first hypothesis, age grades, moderate levels of perceived stress during
and self-efficacy was regressed on gender, age, and the exam period, and moderate scores in exam-related
both rational and emotional coping strategies. As 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, strategies. The use of coping strategies was associ-
females compared to males reported significantly ated with the students’ levels of stress during the
higher perceived stress scores, lower exam-related exam period after controlling for gender and age
self-efficacy, and greater use of emotional coping (Table 2). Using emotional coping strategies was
positively associated with perceived stress, whereas
a negative relation was found between using rational
Table 2. Perceived stress regressed on gender, age, and coping strategies and stress scores.
coping strategies
In support of our first hypothesis, coping
B S.E. b strategies were associated with the students’ exam-
Gender -0.21 0.08 -0.16* related self-efficacy after controlling for gender and
Age 0.09 0.04 0.14* age (Table 3, Model 1). Both rational and emotional
Rational coping -0.15 0.04 -0.25** coping strategies were significant predictors of the
Emotional coping 0.21 0.04 0.34** students’ self-efficacy assessments. The more the
Note: Dependent variable was perceived stress. Gender was students reported the use of rational strategies, the
coded as 0 (female) and 1 (male) and used as a control vari- greater exam-related self-efficacy expectancies they
able; beta for this variable was not interpreted; R2=0.25.
reported, whereas using emotional strategies to cope
*p<0.05, **p<0.01
with academic stressful events was associated with
lower perceptions of self-efficacy. The students’
perceived stress was included in Model 2 of the
Table 3. Exam-related self-efficacy regressed on gen- regression model, yielding a significant beta coeffi-
der, age, coping strategies, and perceived stress
cient. However, both coping strategies (rational and
B S.E. b R2 emotional) were attenuated and no longer statistically
Model 1 0.15 significant when the stress scores were added to the
Gender 0.42 0.13 0.22** model. A statistically significant negative associa-
Age -0.07 0.06 -0.07 tion between students’ stress and self-efficacy was
Rational coping 0.14 0.06 0.16* found, with higher perceived stress during the exam
Emotional coping -0.19 0.06 -0.22** period associated with lower reported exam-related
Model 2 0.22 self-efficacy (Table 3, Model 2).
Gender 0.33 0.12 0.18** Consistent with our second hypothesis, cop-
Age -0.03 0.06 -0.03 ing strategies were associated with exam-related
Rational coping 0.07 0.06 0.09 self-efficacy beliefs, at least to some extent, through
Emotional coping -0.10 0.06 -0.12
the students’ stress-related perceptions. The indirect
Perceived stress -0.26 0.06 -0.30**
path involving rational coping, perceived stress, and
Note: Dependent variable was exam-related self-efficacy.
Gender was coded as 0 (female) and 1 (male) and used as a self-efficacy accounted for 46% of total effects in this
control variable; beta for this variable was not interpreted. mediation, whereas the indirect path for emotional
Model 1 and Model 2 were run separately (method: forced
entry). coping strategies represented 45.4% of the total ef-
fects (Figure 1).
*p<0.05, **p<0.01

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 Table 4. Grade averages regressed on gender, age,
grade averages associated with greater perceived perceived stress, and exam-related self-efficacy
stress during the exam period (Table 4, Model 1). B S.E. β R2
However, when added to the model, exam-related
Model 1 0.04
self-efficacy was a statistically significant and
Gender -0.25 0.17 -0.11
stronger predictor of the students’ grade averages in Age 0.00 0.08 0.00
comparison to stress scores (Table 4, Model 2), which Perceived stress -0.23 0.08 -0.21*
indicates a mediation effect. The indirect path (i.e.,
Model 2 0.09
that in which stress is connected with grades through Gender -0.35 0.17 -0.15*
self-efficacy) accounted for 37.5% of total effects in Age 0.01 0.08 0.08
this mediation (Figure 1). Perceived stress -0.13 0.08 -0.12
A structural equations model, which included Exam-related self-efficacy 0.26 0.08 0.23*
all the proposed relations among variables, was tested Note: Dependent variable was grade averages. Gender was
to confirm the pattern of results found in regression coded as 0 (female) and 1 (male) and used as a control vari-
able; beta for this variable was not interpreted. Model 1 and
analyses (Figure 1). Perceptions of stress were pro- Model 2 were run separately (method: forced entry).
posed to mediate the relation between use of coping *p<0.01
strategies and exam-related self-efficacy. Moreover,
exam-related self-efficacy was expected to mediate
the relation between perceived stress and average including other variables connected with stress and
grades. Results indicated that the model adequately performance, this research also allows a more com-
fit the data (χ2=1.97; df=2; p=0.37; RMR=0.02; plex view of the processes that may lead to an aca-
AGFI=0.96; CFI=1.00; RMSEA=0.00), supporting demic result under potentially stressful conditions.
the proposed chain from coping strategies to grade Consistent with our first hypothesis, and in line
averages through stress perceptions and self-efficacy. with previous research,21,22 the coping strategies used
by students were differently connected with their
perceptions of exam self-efficacy. Rational coping
Discussion strategies were associated with higher exam-related
self-efficacy, whereas the use of emotional coping
This study aimed to explore the associations strategies was linked to lower self-efficacy percep-
between stress experienced during exam periods and tions. As suggested in our second hypothesis, the
academic performance among dental students. By relation between coping strategies and self-efficacy

February 2016  ■  Journal of Dental Education 169


was partially mediated by the level of stress students The associations between the variables ex-
experienced during the exam period. plored in this study were analyzed using structural
Previous research has reported that different equation modeling (SEM). This analysis showed
coping strategies lead to different outcomes concern- that rational coping strategies were associated with
ing an individual’s perceived stress.28,29 For instance, reduced stress perceptions and therefore with higher
Carver et al. found that strategies such as focusing exam-related self-efficacy, which was in turn associ-
on and the venting of emotions, as well as behavioral ated with better student grades. Using emotional cop-
and/or mental disengagement, might be of limited ing strategies, on the other hand, was associated with
usefulness.28 In comparison, problem-focused cop- increased stress levels, which may be interpreted as a
ing (e.g., active coping, planning, suppression of signal of lower self-efficacy to successfully complete
competing activities, restraint coping, seeking of exams and poorer academic results.
instrumental social support) and emotion-focused This study had some limitations. First, a con-
coping (e.g., seeking of emotional social support, venience sample was used, and we cannot therefore
positive reinterpretation, acceptance, denial, turning assume that the participants were representative of
to religion) were found to be relatively more effec- a broader population. Another potential limitation is
tive. Supporting this theory, Dwyer and Cummings that our sample included students in different years
reported that the use of avoidance-focused coping of their formative program, and they were therefore
strategies was significantly associated with stress taking different exams, which may involve different
among university students.29 Consistent with previ- coping challenges. In particular, there may have been
ous findings in the classical transactional approach different stressors for students taking preclinical
to stress,8,9 our study found that rational strategies compared to clinical exams. However, the formative
were associated with reductions in the students’ program of dental students introduces practice from
stress, whereas emotional strategies were associ- early career years in a progressive manner, and it was
ated with increases in perceived stress during the therefore not possible to differentiate purely clinical
exam period. students from those not having clinical experience.
Previous studies have found that academic Concerning sample size, it is important to note that
stress was associated with poorer academic perfor- our study aimed at identifying possible relations
mance,1-4 a result that was also found in our study among variables, for which convenience samples of
(Hypothesis 3). However, going a step further, our medium size are commonly used. Sample size could
fourth hypothesis was that the link between stress have, however, limited the power of regression analy-
and academic results would be partially mediated ses involving a greater number of predictor variables;
by the students’ perceived self-efficacy concerning therefore, replication of this study in larger samples
exam completion. Adding self-efficacy and perceived would be advisable.
stress as predictors of academic performance into A second potential limitation is that the use of
the same regression model reduced the strength of self-report measures may have resulted in memory
the association between perceived stress and grade errors and social desirability bias. This could have
averages to non-significance, whereas self-efficacy especially affected the students’ recall of their past
was significantly associated with the students’ grades. levels of stress and the strategies they used to cope
The relation between stress scores and students’ throughout the exam period. However, the period of
grades was therefore mediated, to some extent, by time selected to administer the survey was close to an
their exam-related self-efficacy assessments. In this exam period, which would have helped to minimize
regard, we found that exam-related self-efficacy was this possible bias. Overall, internal reliability of the
a more robust and consistent predictor of academic instruments used was good, with the rational coping
success than stress, which is consistent with a previ- measure yielding a better internal consistency than
ous study.30 As expected, higher levels of stress were the emotional coping measure. The greater number
connected with poorer average grades through lower of items comprising the rational coping measure
exam-related self-efficacy, and this was consistent and a possible greater heterogeneity of the items
with Bandura’s social-cognitive theory, which holds describing emotional strategies could be at the basis
that physiological states influence appraisals of self- of these differences. Gathering data after the exam
efficacy.10-12 On the contrary, lower levels of stress period could help to avoid bias related to the impact
were associated with higher self-efficacy perceptions of stress and negative emotions on self-evaluations.
and better academic outcomes. 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 as coping strategies for stress management and
available, and self-reports could be affected by recall academic self-efficacy, may play a relevant role in
errors or social desirability responding (although academic success. In this regard, promoting the use of
the anonymous reporting may have minimized this adequate coping strategies, such as problem-solving
possible bias). focused coping, positive reappraisal, and looking
Another possible limitation, as shown in the for social support, could have a positive impact on
results, is that participants had obtained only fair student performance. On the contrary, coping strat-
academic results overall with a rather low variability egies such as negatively auto-focusing and venting
in average grades. In this regard, academic-related negative emotions should be discouraged as a way
characteristics of participants may have influenced of coping with academic stress. Furthermore, by re-
the results, and generalization of the results might ducing stress perceptions, positive coping strategies
be difficult. However, previous research has found could increase students’ exam-related self-efficacy,
that dental students usually obtain good grades, with which in turn could lead to obtaining better grades.
80% of them passing their semester exams.31 Past
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172 Journal of Dental Education  ■  Volume 80, Number 2