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ORIGINAL ARTICLE
Year : 2016  |  Volume : 14  |  Issue : 3  |  Page : 332-337

Perceptions, concerns, and experiences of dental interns after accident and emergency posting: A qualitative study


Department of Public Health Dentistry, M S Ramaiah Dental College and Hospital, (Faculty of Dental Sciences, MSRUAS), Bengaluru, Karnataka, India

Date of Web Publication6-Sep-2016

Correspondence Address:
K Sneha Shenoy
Department of Public Health Dentistry, M S Ramaiah Dental College and Hospital, (Faculty of Dental Sciences, MSRUAS), MSR Nagar, Bengaluru - 560 054, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2319-5932.189840

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  Abstract 

Introduction: Most dentists will, at some point in their career, be faced with an in-office emergency. Dental staff must undergo training in the management of emergencies to a level based on their clinical responsibilities. Aim: To explore the perceptions, concerns, and experiences of interns after their accident and emergency posting. Materials and Methods: Focus group discussions were conducted among interns in English language in a dental college in Bangalore. Participants individually answered the facilitator's questions and measures were taken not to miss out any question with the help of probes. Both focus groups were audiotaped and lasted approximately 90 min. Audio recordings and focus group notes from the sessions were transcribed, analyzed using qualitative data analysis miner software. Results: Two focus groups were conducted by the authors among interns. After verbatim, the transcript was coded into one hundred and thirty different codes which were broadly classified under eight different categories and these categories were grouped into four different themes. Interns had good and bad experiences during their posting. They said that this experience was once in a lifetime and exposure like this will help them in future to manage emergency cases in the dental clinic. Conclusions: Dental interns were aware about their shallow knowledge of medical emergencies, and they felt there is room for improvement regarding self-estimation of competence in emergency management. Hence, they suggested that emergency postings should be introduced early in their curriculum.

Keywords: Dentist, emergencies, focus groups, qualitative research


How to cite this article:
Shenoy K S, Pallavi H N, Pushpanjali K, Gupta V. Perceptions, concerns, and experiences of dental interns after accident and emergency posting: A qualitative study. J Indian Assoc Public Health Dent 2016;14:332-7

How to cite this URL:
Shenoy K S, Pallavi H N, Pushpanjali K, Gupta V. Perceptions, concerns, and experiences of dental interns after accident and emergency posting: A qualitative study. J Indian Assoc Public Health Dent [serial online] 2016 [cited 2019 Dec 6];14:332-7. Available from: http://www.jiaphd.org/text.asp?2016/14/3/332/189840


  Introduction Top


Emergencies can and do happen. Most dentists will, at some point in their career, be faced with an in-office emergency. We simply cannot prevent every emergency; therefore, we must be prepared to recognize and appropriately manage medical emergencies when they occur. The dentist has a responsibility to recognize them and initiate primary emergency management procedures in an effort to reduce morbidity and mortality when such adverse events arise. The more common problems include vasovagal syncope (faints), hypoglycemic episodes, angina, seizures, choking, asthmatic attack, and anaphylaxis. Serious medical emergencies are fortunately a rare occurrence in the dental practice environment;[1] however, if an emergency situation is encountered a delay in treatment may result in potentially avoidable consequences. The risk of mortality or serious morbidity can be reduced by ensuring that basic emergency equipment and medications are in place and that the dental team is appropriately trained in basic life support (BLS) measures.

Dental staff must undergo training in the management of emergencies to a level based on their clinical responsibilities. Skills learned should be refreshed annually, and training can be undertaken within the general practice or at designated training centers. All new staff members must undergo resuscitation training as part of their induction. A questionnaire survey among the UK dentists reported that one in five interns deemed themselves “not very well” or “not at all” prepared to manage medical emergencies should they arise in their surgeries, and majority of them expressed a need for further training.[2] The need for continued training was also expressed by Australian dentists, where just over half deemed themselves proficient in cardiopulmonary resuscitation (CPR).[3] In Ireland, there also appears to be an inadequate availability of refresher courses in this important area.[1] The management of medical emergency situations should therefore be a core subject in the proposed continued professional development program.

Accordingly, Dental Council of India has set regulations dated August 26, 2011, that interns shall have 15 days posting in emergency services of a dental/general hospital with extended responsibilities in emergency dental cares in the wards. During this period, they shall attend emergencies under the direct supervision of oral surgeon during any operation. Emergencies could be (i) toothache, (ii) trigeminal neuralgia, (iii) bleeding from mouth due to trauma. Postextraction bleeding disorder or hemophilia (iv) airway obstruction due to fracture mandible and maxilla tooth fracture postintermaxillary fixation after general anesthesia.[4]

In our institution, interns are posted in accident and emergency (A&E) department for a period of 21 days. Hence, a qualitative research was conducted with the main aim of the study was to explore the perceptions, concerns, and experiences of interns after their posting. We also wanted to explore their suggestions to overcome these challenges.


  Materials and Methods Top


A phenomenological approach was chosen for this study because we were interested in exploring the lived experience of interns after their postings.[5] We utilized focus groups as a method of data collection because they provided the opportunity for participants to explain their ideas and to build off of the ideas of others who held some shared experiences.[6] Specifically, we selected a culturally appropriate form of focus groups to explore participant's perceptions, concerns, and experience after the posting and suggestions for the betterment.

The study took place in a dental college in Bangalore where the dental interns are posted in A&E department for a period of 20 days as a part of their compulsory rotating internship. The study recruitment process and group discussion protocol was approved by the Institutional Review Board, and ethical approval was obtained from the Institutional Ethical Committee. Using criterion sampling a type of purposive nonprobability sampling,[7] we recruited two groups of interns from the college. Inclusion criteria for both the groups were they should have completed their A&E posting. Cases accomplishing above-mentioned inclusion criteria were total 12 in number; six in both the groups. Focus group discussions (FGDs) were carried out after obtaining informed consent from all participants.

FGDs were conducted in English language at the Department of Public Health Dentistry. After obtaining informed consent, we assigned a number to each participant to maintain anonymity. Following a brief introduction by group moderator/facilitator ( first author), patients were asked to introduce themselves and after that discussion was carried out using FGD guide which was pilot tested. Facilitator commenced the focus group by asking broad questions about the topic of interest, before asking the specific questions. Participants individually answered the facilitator's questions; they were encouraged to talk and interact with each other. Measures were taken not to miss out any question with the help of probes. Both focus groups were audiotaped (primary method) and lasted approximately 90 min. One co-facilitator took field notes to record the tone of the focus group, the nature of the discussion, and nonverbal communication among focus groups participants. Data saturation was obtained after two FGD sessions.

Audio recordings and focus group notes from the focus group sessions were transcribed verbatim by the first author and reviewed by the second and third author for accuracy. Codes were then reread and grouped into patterned categories [8] addressed in individual focus groups. We constructed a phenomenological summary for each focus group that identified the latent theme (s) of the group.


  Results Top


Two focus groups were conducted by the authors among interns. Across both focus groups, eight female, and four male interns were participated. The mean age for interns was 24.5 years (n = 12), 23–25 years. Both the groups had interns who were doing their internship but completed their A&E posting for a period of 21 days.

After verbatim, the transcript was coded into 130 different codes which were broadly classified under eight different categories and these categories were grouped into four different themes [Table 1].
Table 1: Representation of codes, categories, and themes of focus group discussions conducted

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Theme 1: Perceptions

Under this theme, there was just one category “Perception” with two codes supporting it.

Interns had a perception that A&E posting was going to be scary and they had to perform many procedures which they had never done in dental setup.

Theme 2: Experience in accident and emergency posting

Under this theme, there are four categories, i.e., “experiences” which includes 42 codes, “duties of a dental intern” which includes fifteen codes, “cases seen” which includes nine codes, and “confidence gained” with four codes.

Interns provided valuable information regarding their experiences in A&E posting. They felt that 21 days of posting was adequate, and most of them were excited as they had never worked in a hospital setup. They felt that they got better exposure to emergency situations which otherwise would not be possible in dental college. They felt the opportunity to learn new things was vast; however, it depends on individual if they want to make the best use of it. Few of them felt that Basic Training in Life Support (BTLS) course was not quite useful before attending the posting, rest felt otherwise. They learned the basic emergency protocols to be followed. Interns felt that they learned something new out of nothing, and it was a lifetime experience for them.

They got an opportunity to interact with the super specialty doctors and learned a lot from them as to how they diagnose and case and what kind of treatment they provide. They performed few procedures such as CPR, Ryle's tube, and catheterization which they had never seen earlier. Hence, they were quite scared. They also had to do patient examination, send them for X-ray and documentation work. They had seen different kinds of cases such as burns cases, road traffic accident, poisoning, and trauma. They also got an exposure of medicolegal cases.

Regarding night posting they felt that it was a good experience as they got to see more trauma cases and drunken driving accident cases. After A&E posting, they feel more potent and confident to handle the emergency cases. They feel more responsible and confident to prescribe drugs.

Overall, they felt it was a good learning experience, and they gained knowledge.

Theme 3: Concerns

Concerns addressed by the interns were coded into 43 different codes which were grouped into two different categories, i.e., concerns with 38 codes and night postings with five codes.

Interns felt that they had a limited knowledge regarding how to handle cases in A&E. They also felt that they were not given the first preference to attend the cases, and medical interns were preferred over them for the same. They felt that the duration of posting was too short because by the time they settled, it was time to leave. They also felt the brothers and nurses are better trained than them. They were very scared because they would be seeing deaths for the first time and they were worried if they would mess up the whole thing. Interns were of the opinion that they should be posted as maxillofacial interns and should be on call for maxillofacial cases only as their knowledge was limited regarding other cases.

Another category of concern was the night postings and the 24 h postings. As a dental intern, they were never exposed to such situations earlier and they found it difficult to manage.

Theme 4: Suggestions

Under this theme, there are two categories, i.e., suggestions with 13 codes and certification with two codes.

Interns felt that a proper prior orientation is necessary before the A&E posting. The orientation provided for them for 1 h is not sufficient. Orientation should be pertaining to cases encountered in A&E and not just related to documentation work. They also suggested that they could be posted as observers for a week and then allowed to carry out the procedures.

They also suggested that a dental faculty should be posted throughout there, which will help interns in handling the cases with more confidence. Few interns suggested that it is better to complete BTLS course prior to A&E posting. However, they said that working on patients is much different than working on dummies. Few felt that even without BTLS course, they could manage the cases properly. When asked about certification for attending the posting, they said just with 21 days of experience we cannot be certified, and it requires immense training for a longer duration.


  Discussion Top


Through this FGD we were able to explore many new areas. We got a clear view of the perception, concerns, and experiences of dental interns after A&E posting. Interns had good and bad experiences during their posting. They said that this experience was once in a lifetime and exposure like this will help them in future to manage emergency cases in a dental clinic, “It was a lifetime experience we had, like actual emergency situations. Different thing other than dental setup.” However, the night postings had taken a toll in their lives. They were very scared to handle the cases as their knowledge was limited, “night posting has a lot of these accident cases see most of these drunken driving, accident cases, and all happens at night so obviously; those patients come at night, so we got to see more of those.” Sociogram revealed good group dynamics, i.e., good interaction between participants and moderators and also among participants [Figure 1] and [Figure 2]. All participants were familiar with each other which encouraged them to feel comfortable in sharing their thoughts.
Figure 1: Sociogram depicting good group dynamics in the first focus group discussion

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Figure 2: Sociogram depicting good group dynamics in the second focus group discussion

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The students were scared before joining this posting as they felt they had a limited knowledge and mess up, “What we know we are studying up till the head and neck so something asked about leg and stomach and all how are we supposed to know?”. When asked about their experience in A&E posting, interns said they had a limited knowledge to manage emergency conditions which are similar to Brazilian students [9] and New Zealand dentists [10] and they strongly desire to improve their knowledge. They felt that the training they received during their undergraduate days is not sufficient and expressed the need for further training.[2],[10] This finding was similar to study done among dental and medical interns in Mangalore where the level of BLS knowledge was not satisfactory, especially in those who had not received any prior training (BLS work shop), lack of professional training of BLS was regarded as the most common hindering factor responsible for poor BLS knowledge by interns.[11] There was disparity among interns when asked about BLS course. Few of them felt that it was necessary prior to A&E posting as its better to do the CPR on dummies first and then do it on patients as it will improve their life supporting skills.[12] Structured training of BLS was opposed by few interns. BTLS courses are designed to review, organize and prioritize the skills, and didactic information needed to manage a multitude of traumatic situations. Upon completion of a BTLS course, prehospital care providers should be able to perform a rapid, organized primary survey, recognize and treat life-threatening injuries, and rapidly package trauma patients for transport. An excellent course for advanced level care providers who deal with trauma in the course of their prehospital care activities. On the other hand, they also felt that it was a good learning experience, and they gained knowledge and got to learn a lot of new things which is comparable to findings from another study where students felt that emergency course reported was a valuable educational experience, and better prepared them for handling office-based emergencies.[13]

Interns described the different kind of cases seen during their postings and also the procedures they performed such as suturing and catheterization. They feel more confident to perform these activities as they received hands-on experience which is similar to a study where the suturing skills of undergraduate students were assessed and they felt introducing a number of changes to dental curriculum including observation of senior students at an early stage of the course, regular formative assessment of suturing on the clinic as the patient needs arise should be done.[14] Interns expressed their concerns regarding a limited knowledge to manage trauma cases “…heard from the previous batches that you know we have to do all this catheterization, intravenous and all you know something which we hadn't really seen” which was comparable to a study in New Zealand where it was reported that overseas graduates were more likely to describe their undergraduate training as satisfactory but were more likely to feel unprepared for emergencies.[10] They were also worried about night postings as this was the first time they would work at odd hours. Dental interns felt that A&E postings should be included earlier in their curriculum which is similar to the findings from the study done in Buffalo dental school where they suggested that the dental curriculum should be re-evaluated to determine if enough emphasis is placed on those areas most commonly resulting in medical emergencies, particularly cardiovascular disease and diabetes. Adequate emphasis must also be given to the management of acute events.[15]

Limitations

The FGDs were conducted among only one batch of dental interns as previous batches had passed out from the college. More FGDs can be conducted among the future batches of interns to explore the issue more in depth.

Recommendations

  • A&E posting can be extended for more than 21 days as students will be more competent to handle emergency situations and inclusion of formative assessment component will better prepare interns toward competency
  • The compulsory inclusion of BTLS in the BDS curriculum.



  Conclusions Top


Dentistry is a health science profession that should focus on the whole patient, instead of being limited to the oral cavity. As health care improves and life expectancy increases, dentists and dental students are treating a growing number of elderly and medically compromised patients, increasing the likelihood of a medical emergency during treatment. However, students' limited knowledge about them leads to incompetence. Dental students were aware about their shallow knowledge of medical emergencies and they felt there is room for improvement regarding self-estimation of competence in emergency management. Hence, they suggested that emergency postings should be introduced early in their curriculum so that they will build the confidence to handle any emergency situation avert any mishap. This should include regular participation in life support courses, as well as standardization of courses, specially designed for dentists.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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