Stress and Academic Performance in Dental

Students: The Role of Coping Strategies and

Examination-Related Self-Efficacy
Antonio Crego, PhD; Mara Carrillo-Diaz, PhD; Jason M. Armfield, PhD;
Martn 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 (=-0.25,
p<0.01), whereas emotional coping strategies (venting negative emotions, negative auto-focus) were linked to increased academic
stress (=0.34, p<0.01). Moreover, rational and emotional coping strategies were, respectively, positively (=0.16, p<0.05) and
negatively (=-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 (=-0.30, p<0.01). Experiencing higher levels of stress during the examination period was
found to be associated with poorer average grades (=-0.21, p<0.01), but students exam-related self-efficacy partially mediated
this relation (=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

cademic stress may lead to reduced or compromised performance for students. Previous
research has found that greater academic
stress is associated with lower grades1 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

February 2016 Journal of Dental Education

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 ones 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

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 individuals 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.

166

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
Cohens 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 Cronbachs 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 Estrs, CAE) developed by Sandn
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
Sandn 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.

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 studys 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 Cronbachs 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 Cronbachs 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

February 2016 Journal of Dental Education

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

167

Table 1. Descriptive statistics (mean and standard deviation) for study variables, by total (n=201), males (n=63), and
females (n=138)
Total

Mean (SD)
Range
Age
Grade average (range 0-10)
Perceived stress (range 1-4)
Exam-related self-efficacy (range 1-6)
Rational coping (range 0-4)
Emotional coping (range 0-4)

21.21 (2.90)
6.50 (1.10)
2.21 (0.62)
3.84 (0.87)
2.62 (0.64)
1.40 (0.59)

18-40
4-9
1-4
1.5-6
1-3.9
0-3.33

Male
Mean (SD)
20.70 (2.58)
6.40 (1.17)
2.02 (0.61)
4.17 (0.78)
2.54 (0.58)
1.26 (0.63)

Female
Mean (SD)
21.44 (3.02)
6.54 (1.07)
2.30 (0.60)
3.69 (0.87)
2.66 (0.67)
1.47 (0.56)

t
1.69
0.88
3.04*
-3.74*
1.15
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

Gender
Age
Rational coping
Emotional coping

B S.E. b
-0.21 0.08 -0.16*
0.09 0.04 0.14*
-0.15
0.04
-0.25**
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; R2=0.25.
*p<0.05, **p<0.01

Table 3. Exam-related self-efficacy regressed on gender, age, coping strategies, and perceived stress

S.E.

R2

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

168

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).

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 (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

February 2016 Journal of Dental Education

Table 4. Grade averages regressed on gender, age,

perceived stress, and exam-related self-efficacy

S.E.

R2

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

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 individuals 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 Banduras 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.

170

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-

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

February 2016 Journal of Dental Education

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. On the contrary, coping strategies such as negatively auto-focusing and venting
negative emotions should be discouraged as a way
of coping with academic stress. Furthermore, by reducing stress perceptions, positive coping strategies
could increase students exam-related self-efficacy,
which in turn could lead to obtaining better grades.

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Journal of Dental Education Volume 80, Number 2