1 Volume 22 2023 e233737 Original Article Braz J Oral Sci. 2023;22:e233737http://dx.doi.org/10.20396/bjos.v22i00.8673737 1 School of Medicine, University of Concepción, Concepción, Chile. 2 School of Dentistry, University of Concepción, Concepción, Chile. Corresponding author: Ricardo Cartes-Velásquez. University of Concepción, School of Medicine. Barrio Universitario, Concepción. Phone: +56412204362 Email: cartesvelasquez@gmail.com Editor: Dr. Altair A. Del Bel Cury Received: April 18, 2023 Accepted: September 20, 2023 Students’ perception of instructors and burnout levels in chilean dental students Ricardo Cartes-Velásquez1,* , Javiera Cárdenas Retamal2 , Valeria Campos2 Aim: The educational environment affects dental students’ well-being and academic achievement, with unclear impact from clinical instructors on burnout levels. This study is aimed to determine the impact of students’ perception about their clinical instructors in its burnout levels in a sample of Chilean dental students. Methods: A cross-sectional study was conducted among fourth and fifth-year dental students at the University of Concepción (Chile), collecting data on various variables including demographics, effective teaching hours, instructor treatment, knowledge delivery, student appreciation, and burnout assessed using Maslach’s Burnout Inventory (MBI). Data were gathered through a self-administered survey and analyzed using STATA 10/SE software (p<0.05). Results: One-hundred and seventy students participated, high levels of emotional exhaustion (51.76%), depersonalization (56.47%), and personal accomplishment (60.59%) were found. Female students (p=0.0008), those who perceive inadequate treatment from instructors towards patients (p=0.0496), and those who rate the instructor as obstructionist (p=0.0208) reported higher levels of emotional exhaustion. 5th year students (p=0.0142), students who perceive indifferent treatment from instructors towards students (p=0.0002), and those who rate the instructor as obstructionist (p=0.0026) exhibited higher levels of depersonalization. 4th year students (p=0.0475) and those who perceive indifferent treatment from instructors towards students (p=0.0221) showed lower levels of personal accomplishment. There was a correlation between depersonalization and effective teaching hours (rho=-0.2166, p=0.0046). Conclusion: Students’ perception about their clinical instructors as indifferent towards the students, obstructionist in the teaching process, with inadequate treatment towards the patients, and less effective teaching hours is associated with higher students’ burnout levels. Keywords: Students, dental. Burnout, psychological. Health education, dental. https://orcid.org/0000-0001-5831-7324 https://orcid.org/0000-0001-8208-6415 https://orcid.org/0000-0003-0697-1345 2 Cartes-Velásquez et al. Braz J Oral Sci. 2023;22:e233737 Introduction Burnout, characterized by physical and mental exhaustion, arises from chronic inter- personal stressors at work and includes emotional exhaustion, depersonalization, and reduced personal accomplishment1. It is associated with depression, suicidal- ity, and negative outcomes such as decreased patient satisfaction, increased medi- cal errors, and higher costs. Both organizational and individual factors contribute to burnout, including resource-workload imbalances and resilience practices2. Among dentists, burnout prevalence is considerable, with emotional exhaustion being prom- inent at 13%3,4. Subscale breakdown shows high levels of emotional exhaustion in 25%, depersonalization in 18%, and low personal accomplishment in 32%4. Prevalence varies geographically, with higher rates in Europe and lower rates in the Americas, and longitudinal studies report higher burnout than cross-sectional surveys, with a decreasing trend over time3. Dental student burnout varies widely, ranging from 7% to 70.4%, with emotional exhaustion being the most prevalent subscale at 10% to 66.2%. Stressors for den- tal students include study years, clinical components, and demanding academic courses, emphasizing the need for early identification and interventions to prevent negative consequences5. Factors associated with burnout include younger age, male gender, student status, high job strain/working hours, enrollment in clinical degree programs, and specific personality types6. Depression is significantly asso- ciated with all burnout subscales, while suicidal ideation specifically relates to the lack of personal accomplishment7. As expected, educational environment is associated with academic achievement, quality of life, resilience, positive attitudes, mindfulness, preparedness for practice, less psychological distress, and greater peer support8. While negative perceptions of the learning environment are associated with increase the odds of stress, depres- sion, and anxiety among dental students9. However, evidence regarding the impact of students’ perceptions of their clinical instructors on burnout levels is lacking, despite this association between the learning environment and the psychological well-being of students. The aim of this paper is to determine the impact of students’ perception about their clinical instructors in its burnout levels in a sample of Chilean dental students. Materials and Methods Study design, settings, and participants This research utilized a cross-sectional study design to examine burnout among dental students and its relationship with their perception of clinical instructors. The study was conducted during the first semester of 2019 at the University of Concepción, focusing on fourth and fifth-year dental students who were beginning their clinical courses during these academic years. The University of Concepción, located in Concepción, Chile, is a reputable institution known for its longstanding academic excellence. 3 Cartes-Velásquez et al. Braz J Oral Sci. 2023;22:e233737 All enrolled students who were undertaking clinical courses, regardless of any pre- vious course failures, were included in the study. However, exchange students were excluded due to their exposure to different risk factors and potential language and cultural barriers that could affect the validity of the instrument used. In total, the eligible population consisted of 194 students, and as the entire population was included, there was no need for sample size calculation. The participation of stu- dents in the study was voluntary, and they provided their informed consent prior to their involvement. Variables and data collection The data collection for this study included the following variables: sex (female/male), age (in years), course (4th, 5th), effective teaching hours (in hours), instructor treat- ment towards patients (adequate, inadequate), instructor treatment towards students (indifferent, empathic), knowledge delivery (verbal only, practical only, both), student’s appreciation of the instructor in the teaching process (facilitator, neutral, obstruction- ist), and burnout measured using Maslach’s Burnout Inventory (MBI). The MBI, which has been previously validated In Chile10, was utilized for assessing burnout. It captures the three main aspects of the syndrome: emotional fatigue, depersonalization, and personal fulfillment. The emotional exhaustion subscale consists of seven questions and evaluates the experience of feeling emotionally drained due to work demands, with a maximum score of 42 points. Similarly, the depersonalization subscale comprises seven questions and assesses the extent to which individuals exhibit attitudes of coldness and detachment, with a maximum value of 42 points. Finally, the lack of personal fulfillment subscale includes eight items that assess feelings of self-efficacy and personal satisfaction at work, with a maximum score of 48 points. The data collection process involved two researchers who gathered sociodemo- graphic information and administered the survey instrument through a self-admin- istered survey format. The researchers approached the students in the classroom setting, either during theory or clinical activities, within the first two months of the second semester. To ensure inclusivity, each course was visited twice to account for any absences during the initial visit. Participation in the study did not entail any form of monetary or academic compensation and was completely voluntary. Statistical analysis The collected data were tabulated using Microsoft Excel (Microsoft Corp., USA) and subsequently analyzed using STATA 10/SE (Stata Corp., USA). Descriptive statistics were employed to summarize the quantitative variables. For normally distributed variables, the mean and standard deviation were calculated, while for non-normally distributed variables, the median and interquartile range were utilized. Categorical variables were analyzed by calculating the frequency and percentage distributions. The normality of the MBI-SS and its subscales was assessed using the Shapiro-Wilk test, confirming their non-normal distribution. Statistical differences among cate- gorical variables were evaluated using the Mann-Whitney and Kruskal-Wallis tests. 4 Cartes-Velásquez et al. Braz J Oral Sci. 2023;22:e233737 Correlations between variables were examined using the Spearman correlation coefficient. Statistical significance was set at p < 0.05. Ethics This study was ethically conducted based on the Helsinki Declaration and obtained ethical approval from the Bioethics Committee of the School of Dentistry at the Uni- versity of Concepción (C.E.C. N°016/18). Results One-hundred and seventy dental students answered the survey, the characteristics of the sample is shown in Table 1. One-hundred and four (61.2%) students pertain to 4th year, and sixty-six (38.8%) to 5th year. Table 1. Characterization of the sample Variable 4th year 5th year General Sex Female, n (%) 73 (70.19) 39 (59.09) 112 (65.88) Male, n (%) 31 (29.81) 27 (40.91) 58 (34.12) Age, years (SD) 22.70 (2.19) 23.83 (2.58) 23.14 (2.41) Effective teaching hours (SD) 1.98 (0.54) 1.93 (0.39) 1.96 (0.49) Instructor treatment to patient Adequate, n (%) 100 (96.15) 63 (95.45) 163 (95.88) Inadequate, n (%) 4 (3.85) 3 (4.55) 7 (4.12) Instructor treatment to student Indifferent, n (%) 32 (30.77) 27 (40.91) 59 (34.71) Empathic, n (%) 79 (69.23) 39 (59.09) 111 (65.29) Knowledge delivery Verbal only, n (%) 38 (36.54) 31 (46.97) 69 (40.59) Practical only, n (%) 9 (8.65) 7 (10.61) 16 (9.41) Both, n (%) 57 (54.81) 28 (42.42) 85 (50) Instructor appreciation Facilitator, n (%) 81 (77.88) 41 (62.12) 122 (71.76) Neutral, n (%) 13 (12.50) 15 (22.73) 28 (16.47) Obstructionist, n (%) 10 (9.62) 10 (15.15) 20 (11.76) SD: standard deviation. The distribution of scores for each subscale is as follows: for emotional exhaustion, 16.47% have low scores, 31.76% have moderate scores, and 51.76% have high scores; for depersonalization, 18.82% have low scores, 24.71% have moderate scores, and 5 Cartes-Velásquez et al. Braz J Oral Sci. 2023;22:e233737 56.47% have high scores; and for personal accomplishment, 7.65% have low scores, 31.76% have moderate scores, and 60.59% have high scores. Table 2 presents the scores of the MBI subscales based on sex, course, and students’ perceptions of their clinical instructors. The analysis revealed that female students, those who perceive inadequate treatment from instructors towards patients, and those who rate the instructor as obstructionist reported higher levels of emotional exhaustion. Additionally, 5th year students, students who perceive indifferent treatment from instructors towards students, and those who rate the instructor as obstruction- ist exhibited higher levels of depersonalization. Furthermore, 4th year students and those who perceive indifferent treatment from instructors towards students showed lower levels of personal accomplishment. A statistically significant correlation was only found for depersonalization and effec- tive teaching hours (rho = -0.2166, p = 0.0046). Table 2. MBI subscales’ scores by categorical socioeducational variables Variable EE score (IQR) DP score (IQR) PA score (IQR) Course p = 0.8930 p = 0.0142 p = 0.0475 4th 27 (22-32) 10 (6-16) 33 (28-36) 5th 25 (21-33) 13.5 (7-20) 30.5 (24-35) Sex p = 0.0008 p = 0.5714 p = 0.1793 Female 28 (23-34) 10.5 (6-19) 31 (25.5-36) Male 24 (15-29) 12 (6-17) 33 (29-36) Instructor treatment to patient p = 0.0496 p = 0.0697 p = 0.2280 Adequate, n (%) 27 (21-32) 11 (6-18) 32 (27-36) Inadequate, n (%) 29 (28-40) 20 (11-24) 28 (23-33) Instructor treatment to student p = 0.0504 p = 0.0002 p = 0.0221 Indifferent, n (%) 29 (23-34) 15 (9-22) 30 (25-35) Empathic, n (%) 26 (20-31) 9 (6-17) 33 (28-36) Knowledge delivery p = 0.4719 p = 0.1681 p = 0.6693 Verbal only, n (%) 28 (22-34) 12 (8-18) 33 (25-36) Practical only, n (%) 24.5 (17-30.5) 14 (6.5-19) 31.5.5 (27-35) Both, n (%) 27 (22-31) 9 (6-18) 31 (28-36) Instructor appreciation p = 0.0208 p = 0.0026 p = 0.1520 Facilitator, n (%) 25 (20-31) 9 (6-17) 32.5 (28-36) Neutral, n (%) 29 (24-33.5) 13.5 (9.5-21) 29.5 (26.5-35) Obstructionist, n (%) 31.5 (24-34.5) 16.5 (10.5-22.5) 30 (22.5-35.5) SD: standard deviation. IQR: interquartile range. EE: emotional exhaustion. DP: depersonalization. PA: personal accomplishment. MBI: Maslach’s Burnout Inventory. 6 Cartes-Velásquez et al. Braz J Oral Sci. 2023;22:e233737 Discussion The study found high levels of emotional exhaustion and depersonalization among dental students, influenced by gender, perceptions of inadequate treatment, indif- ference, and instructor ratings. 4th-year students and those perceiving indifference reported lower personal accomplishment. A negative correlation was observed between depersonalization and effective teaching hours. Burnout represents a significant concern within the realm of dental education, prompting extensive research endeavors to identify risk factors and explore inter- ventions aimed at mitigating its impact11. The academic environment significantly influences the well-being of dental students, who often face considerable stress- ors throughout their education8,9. Moreover, a positive perception of the learning environment has been found to correlate with increased academic achievement, as students who perceive their learning experiences favorably are more likely to excel academically. Conversely, when students perceive problems in the atmosphere and social life, it is associated with lower achievement and a higher likelihood of aca- demic failure12. Research has shown that stress symptoms are prevalent in this stu- dent population. Factors such as class size, leisure time, assessment procedures, relationships with peers and faculty, ethical climate, and access to extracurricular opportunities all contribute to students’ experiences. It is important for institutions to implement targeted strategies and support services to help students effectively manage stress and promote their overall well-being13. Despite the well-established link between the learning environment and students’ psychological well-being, there remains a dearth of research investigating the influence of students’ perceptions of their clinical instructors on burnout levels. The findings of this study align with the limited existing evidence in this domain12,14-17, underscoring the pivotal role that students’ perceptions of their instructors play in shaping the psychological well-being of aspiring dentists. Previous investigations have demonstrated that a supportive learning environment and positive teacher-stu- dent interactions have a beneficial impact on the teaching of undergraduate dental students, particularly during the crucial transition from pre-clinical to clinical edu- cation14. The establishment of a comprehensive care teaching clinic environment, where students engage in collaborative group work, has been found to enhance stress coping mechanisms and yield improved student experiences; conversely, negative teacher behaviors can significantly impair student well-being, emphasizing the importance of positive and supportive teacher supervision in addressing chal- lenges related to perfectionism and stress15. Additionally, the presence of collegiality between teachers and students and the development of effective communication skills with patients emerge as critical factors in alleviating stress levels among den- tal students16. Moreover, students’ perceptions of their clinical learning environment identified three key themes: feedback processes, assessments and grading, and tutor interactions. Their feedback highlighted areas of dissatisfaction, including the need for improved feedback practices, consistency in grading, and consideration of different teaching styles. These findings emphasize the importance of enhanc- ing student-teacher relationships in the clinical learning environment to create an optimal teaching and learning environment and improve student outcomes17. The 7 Cartes-Velásquez et al. Braz J Oral Sci. 2023;22:e233737 presence of faculty caring behavior plays a pivotal role in providing support to dental hygiene students throughout their rigorous dental and allied dental curricula. Rec- ognizing and cultivating effective caring behaviors among faculty members holds great significance in mitigating student worry and fostering an environment condu- cive to learning18. The available evidence underscores the importance of improving the student-instruc- tor relationship in dental education14-18, particularly in relation to clinical feedback. The presence of incongruity between dental students and instructors regarding the quality of clinical feedback provided highlights the need for improved communication and understanding between the two parties. Promoting effective communication chan- nels between instructors and learners is crucial to enhance the level of understanding and clarity of the feedback given by clinical instructors19. One approach to alleviate this situation is to cultivate a caring educational environ- ment, particularly during the demanding clinical years of dental training. This aligns with research in other healthcare professions, such as nursing, where faculty mem- bers play a crucial role in students’ intent to graduate by fostering confidence, com- passion, and competence in a supportive learning environment. Faculty members who demonstrate caring behaviors, including respect, empathy, and effective commu- nication, contribute significantly to students’ perception of the learning environment, sense of belonging, and motivation to pursue their studies. Therefore, the nurturing and supportive capacity of faculty caring positively influences students’ academic success and retention20. This study is subject to several noteworthy limitations that warrant acknowledg- ment. Firstly, the sample size utilized was relatively modest, originating exclusively from a single dental school. As such, caution must be exercised when generalizing the findings to other dental institutions. Moreover, the assessment of students’ per- ceptions regarding their clinical instructors was predicated on a restricted set of closed-ended questions, which may have neglected a more comprehensive explora- tion of their experiences and viewpoints. Furthermore, the study primarily focused on students’ subjective perceptions, neglecting a direct evaluation of the objec- tive behaviors exhibited by the clinical instructors. To address these limitations, future research endeavors should strive to encompass larger, multicenter samples, employing comprehensive assessment methodologies that encompass both quali- tative and quantitative approaches. By adopting such an inclusive approach, a more nuanced understanding of the intricate interplay between students’ and instructors’ perceptions and behaviors can be attained. Additionally, it is imperative that forth- coming investigations consider implementing environment and community-based interventions that extend beyond mere burnout prevention, and instead, prioritize the cultivation of holistic well-being throughout the entire dental community. In conclusion, students’ perception about their clinical instructors as indifferent towards the students, obstructionist in the teaching process, with inadequate treat- ment towards the patients, and less effective teaching hours is associated with higher students’ burnout levels. 8 Cartes-Velásquez et al. Braz J Oral Sci. 2023;22:e233737 Data availability Datasets related to this article will be available upon request to the corresponding author. Acknowledgments None. Declaration of interest None. Author Contribution RCV, JCR and VC designed the study. JCR and VC completed the data collection and RCV performed the statistical analysis. RCV and VC wrote the first draft of the article. All authors read and approved the final manuscript and actively participated in the discussion of the manuscript’s findings. References 1. Rodrigues H, Cobucci R, Oliveira A, Cabral JV, Medeiros L, Gurgel K, et al. Burnout syndrome among medical residents: a systematic review and meta-analysis. 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