Description of material (questionnaire)
Some studies in the medical and dental literature are known to discuss similar topics, and the findings of some of these studies were used to develop the questionnaire. In a few cases, it was possible to adopt proven and validated survey instruments. Furthermore, findings from the focus groups were incorporated in the survey.
Corresponding to the end points of the study, the questionnaire is composed of three subject areas (Table
1).
Table 1
Dimensions of the questionnaire
- self-perception |
Härlen and Kultermann, 2000 [ 28] | - employment/establishment of own practice |
Hartmannbund, 2012 [ 23] ; Jacob et al. , 2015 [ 22] | - weighting work life/private life |
Abele et al. , 2006 [ 33] ; Abele et al. , 2009 [ 36] ; Abele and Hagmaier, 2011 [ 34] |
- reasons for studying dentistry |
Härlen and Kultermann, 2000 [ 28] | - requirements |
Hartmannbund 2012 [ 23] ; Jacob et al. 2010 [ 21] | - demand-control | |
- satisfaction with profession |
Jacob et al. , 2010 [ 21] ; BMA, 2009 [ 29] | - working regions | | - effort-reward imbalance | |
- challenges |
Bergmann-Krauss et al. Die Fortbildung des niedergelassenen Zahnarztes. Nutzen und Bewertung, unpublished. Schneller and Micheelis, 1997 [ 30] ; Micheelis et al. , 2010 [ 4] ; Oberlander, 2008 [ 31] | - further training and specialisation |
Micheelis et al. , 2010 [ 4] | - overcommitment | |
| | - personal and career goals |
Abele et al. , 2006 [ 33] ; Abele and Hagmaier, 2011 [ 34] | - depression | |
| | - job expectations |
Abele et al. , 2006 [ 33] ; Abele and Hagmaier, 2011 [ 34] | | |
| | - knowledge of career paths | | | |
| | - preparation for career | | | |
| | - occupational self-efficacy expectations | | | |
The first dealt with questions regarding the (1) professional identity of future dentists.
To assess
self-perception as a specific type of dentist, a typology of the forms of “dental professionalism”, e.g., “passionate craftsman” or “specialised health professional” by Härlen and Kultermann from 2001 provided a basis [
28]. Findings from the focus groups were used to refine this typology, as more types had been identified and some were a specification of the primary types described by Härlen and Kultermann.
Reasons for studying dentistry had been described by Härlen and Kultermann as well and were also supplemented by findings from the focus groups for the questionnaire.
Satisfaction with the chosen profession was a topic in a few of the previous surveys: a question regarding willingness to study the subject again was adopted from a nationwide survey with medical students [
21]. Another question was based on a survey with postgraduate students in England who had been asked about the strength of their desire to practise medicine [
29].
Challenges of the profession are a recurring subject in dental health profession research. One question in our survey inquired about pleasant and unpleasant issues in dentistry, and a similar question was part of nationwide surveys conducted 10 (Bergmann-Krauss et al: Die Fortbildung des niedergelassenen Zahnarztes. Nutzen und Bewertung, unpublished) and 19 years [
30] ago. Challenges might also result from the conditions of the health system, which can restrict autonomy. A corresponding question was modified from a regional [
31] and a national survey [
4] according to the results of the qualitative pre-study and incorporated in the questionnaire.
The second subject area focused on (2) career paths, preparation for career, and career conditions.
The main career paths in dentistry in Germany include either
employment or establishment of one’s own practice. For long-term needs and demand-based planning, knowledge on the intended career choices of young dentists is crucial. Therefore, the questionnaire included four questions on this topic based on national surveys with medical students [
22,
24] and modified according to the results of the focus groups.
To determine which factors are seen as
requirements for the decision to establish a practice or work as an employee, prerequisites were discussed in the focus groups. Similar requirements had been observed in medical students [
21,
24] and two questions were appropriately modified for the dental students’ questionnaire.
In parts of Germany, a shortage of general medical doctors can be observed [
32]. Loosely based on a question in a nationwide survey with medical students [
22], we therefore inquired regarding the willingness to live and work in different
regions and areas of Germany.
Further regular training is required for dentists in Germany, and some take the opportunity to prioritise one or more fields of activity. Questions on
further training and
specialisation were adopted and modified from a previous national survey with dentists conducted in 2009 [
4].
One question inquired about
personal and career goals and was influenced by the results of the focus groups and the findings from open questions regarding goals in a long-term cohort study by Abele et al., which accompanied alumni of the University of Erlangen-Nuremberg [
33,
34].
The students were asked about their short-term
expectations regarding the next career-step, i.e., their assistantship. This question was inspired by the results of the group discussions and findings of the longitudinal studies of Abele et al. [
33,
34].
Based on a German survey with medical students [
22] and the results of the focus groups, one question focused on the
knowledge of career paths. A question regarding
preparation for career by the university courses was based on a question in a postgraduate survey of medical students in England [
29]. In line with the findings of the focus groups, this question focused less on soft skills, as in the postgraduates’ survey, but rather on the contents of lectures and courses.
In 2000, Abele et al. developed a scale to measure
occupational self-efficacy expectations to predict success in career start of university graduates [
35]. This scale was adopted in the questionnaire.
The third subject area engaged in (3) conditions and strains during dental studies. Different approaches exist to measure the extent of strain in work or study environment.
To measure
weighting between the domains of
work life and private life, Abele et al. created a scale for their long-term study [
33,
34,
36] focussing on private life in general rather than family life [
33]. As the focus groups implied, only a few dental students had started a family, yet the question from Abele et al. was adopted in a shortened version for the dental student survey. A perceived weighting of the work life and private life domains was conducted with a graphical illustration [
33](p. 36), which was adapted to the dental students’ situation.
One approach to measure the extent of strain is the
demand-control model. According to Karasek, imbalance between demand resulting from and control of the practised job may result in strain, which may lead to health problems. In this study, demand and control during dental studies was measured with a short version of Karasek’s Job Content Questionnaire [
37]. This scale permits the identification of a person who experiences an imbalance between demand and control and therefore shows high strain.
In Siegrist’s
effort-reward-imbalance model [
38], reward or gratification are bestowed during work life, whereas effort can be of either a personal or circumstantial nature. The circumstantial or extrinsic effort refers to job conditions. Effort-reward-imbalance was measured with a scale containing 14 items, which had been tested previously with medical students [
39]. The personal or intrinsic effort is called
overcommitment [
40]. Overcommitment is measured with a six-point-scale, which was also applied in this questionnaire.
Imbalance between demand and control or between reward and effort and a high overcommitment cause a higher risk of disease [
41]. Disease might manifest as mental disease, for example, disposition to
depression. A nine-item scale to measure depression was taken from the Personal Health Questionnaire (PHQ), which was found to be a reliable scientific screening tool [
42] and can indicate the manifestation of acute psychological disorder.
Furthermore,
sociodemographic data questions regarding age, gender, and family background were included. Focus group discussions supported the idea that family planning and planning of the professional career are closely related. Therefore, a question on family planning was integrated in the questionnaire based on questions from surveys with medical students [
21,
22,
24].
The final questionnaire comprised 34 questions: 6 regarding the professional profile, 14 regarding the career, 6 conditions and strains, and 8 sociodemographics.
1
The questionnaires are to be applied during the assistantship and 2 years later in employment or self-employment and will be based on this first questionnaire but adapted to the altered work-environment and optimised due to experience of the first wave.
Data collection methods and management
In October 2014, each local contact person was individually contacted to discuss the study procedure at the universities regarding the number of questionnaires and the methods of allocation. They were asked to provide information on the number of students attending courses of the 9th and 10th semester at their university and an anonymous listing of the ages and genders of these students to generate an overview of the target study population. Packages with envelopes and additional material supporting the study procedure were sent to each university in November 2014. The envelopes were distributed to the students between the last week in November 2014 and the second week in January 2015. At most universities, semester representatives handed out the envelopes in a compulsory lecture, whereas some favoured distribution in seminars or in a particular treatment course.
The questionnaire for the first wave was handed out as a paper version, which was to be sent back to the IDZ via mail. Each student received an envelope containing one white questionnaire, one large, white, post-free envelope addressed to IDZ, one blue letter of consent, and one small, blue, post-free envelope addressed to the National Association of Statutory Health Insurance Dentists (KZBV). Different colours were chosen to simplify correct dispatch of the questionnaire to IDZ (white) and the letter of consent to KZBV (blue).
The letter of consent asked for the students’ permission to be contacted again and for their e-mail address for contacting them after two and 4 years. Information on the e-mail address was optional only for those who wished to be surveyed again and/or receive an incentive. Consent to being surveyed again was not required for receipt of the incentive for participation in the first wave.
The field phase took 6 months, and the students were given several opportunities to return all of the documents: either sending the questionnaire and the letter of consent to IDZ and KZBV, respectively, or by central collection at the universities. In many universities, this option was provided via a locked collection box or the mailbox of the students’ representative body. Some of the questionnaires were handed in to the semester representatives or contact persons, and some of them were collected personally.
The return to two different addresses (IDZ and KZBV) was chosen for data protection: e-mail address and responses in the questionnaire were recorded at different sites. The linkage between the questionnaire and the e-mail address is only possible via the personal code on both documents. The personal code on each returned questionnaire was registered at IDZ. The e-mail address, consent to participate again, and the code were registered at KZBV. The return of the questionnaire was checked via personal code. If the e-mail address had been provided and the questionnaire had been sent back, the appropriate student received an incentive (online voucher).
Student representative bodies received a financial recompense for their assistance when the anonymous listing of the number, age, and gender of the students had been provided, all questionnaires had been handed out, and the method of dispatch of the questionnaires had been settled.
Statistical methods
Entry of the collected data was provided by an external company (AFEK Analysen, Forschung, Engineering, Kommunikationstechnik, Aachen, Germany). The statistical analyses were conducted at IDZ with the Statistical Package for the Social Sciences (IBM SPSS Statistics, version 22, IBM Germany, Ehningen).
The analysed subgroups were grouped according to gender (male/female), target working condition (employed/self-employed), and primary socialisation (parents dentists/parents not dentists). In the latter question‚ the responses “one parent” and “both parents” for the question regarding dental background were combined for statistical analysis because we presumed that similar anticipation of ideals and moral concepts of the profession during primary socialisation occurred in both cases.
All of the questions were analysed using descriptive statistics as a first step. The significance of inference statistics was evaluated with Pearson’s Chi-Square test; p ≤ 0.05 was set to indicate statistical significance.
The following questions were subjected to further analysis:
(1)
Professional identity: a factor analysis was conducted with the items for reasons for studying dentistry. The method of extraction was principal component analysis, and the method of rotation was varimax with Kaiser’s normalisation. The identified factors were subjected to reliability analysis to evaluate their adequacy.
(2)
Career: Univariate statistics of the mean, standard deviation, and a 95% confidence interval were calculated for the question regarding preparation for career. The Kolmogorov-Smirnov test showed that the variable preparation for career was not normally distributed, and differences in the mean for gender and primary socialisation regarding data of preparation for career and life-domain balance were tested with the Mann-Whitney U-test for significance.
(3)
Conditions and strains: The variable for life-domain balance was analysed in an analogous manner to the variable for preparation for career.
The median of both the demand and control scale was calculated, and individuals with a demand value above the median and a control value below the median were considered to be in the high-strain condition. Questions regarding effort-reward imbalance and overcommitment were analysed with a reliability analysis (Cronbach’s α).
Questions regarding depression were analysed categorically and dimensionally. For categorical analysis, the pattern of provided answers enables assignment to one of three categories‚ “major depressive syndrome”, “other depressive symptoms”, or “no depressive symptoms”. With dimensional analysis, the severity was measured by adding definite scores for the given answers. The total score ranged from 0 to 27, and the corresponding categories are mild, moderate, moderately severe and severe depression.