|Year : 2016 | Volume
| Issue : 4 | Page : 429-433
Challenges faced by dental undergraduates during clinical training: A qualitative study
Vaibhav Gupta1, KM Shwetha2, Pushpanjali Krishnappa2, K Sneha Shenoy2
1 Department of Public Health Dentistry, Faculty of Dental Sciences, SGT University, Gurgaon, Haryana, India
2 Department of Public Health Dentistry, M.S. Ramaiah Dental College and Hospital, Bengaluru, Karnataka, India
|Date of Web Publication||15-Dec-2016|
Department of Public Health Dentistry, Faculty of Dental Sciences, SGT University, Gurgaon, Haryana
Source of Support: None, Conflict of Interest: None
Introduction: Dental health-care professionals are expected to provide a wide range of dental care contributing to the quality of their patient's day-to-day lives, for which they are trained clinically during undergraduate (UG) course. Owing to scarcity of literature pertaining to challenges faced by dental UGs during their clinical training, research was conducted. Aim: The aim of this study was to assess challenges faced by dental UGs during the first patient encounter with patients in clinical posting. Materials and Methods: Four focused group discussions (FGDs) were conducted among 34 dental UGs using an FGD guide to facilitate the discussion process. A phenomenological approach was used to explore the lived experience of UGs. The recorded data were transcribed, translated, anonymized, and coded using Qualitative Data Analysis Miner software. Results: UGs were facing challenges related to communication, professionalism, and ethics every other day while treating patients. FGD conducted was able to explore the challenges faced by UGs during clinical posting such as language barrier, optimum utilization of material, and uphold confidentiality. Conclusions: Improving current state of UGs by taking care of all the mentioned challenges will help them become professionals with good communication skills.
Keywords: Communication barriers, education, ethics, professionalism, qualitative research, undergraduates
|How to cite this article:|
Gupta V, Shwetha K M, Krishnappa P, Shenoy K S. Challenges faced by dental undergraduates during clinical training: A qualitative study. J Indian Assoc Public Health Dent 2016;14:429-33
|How to cite this URL:|
Gupta V, Shwetha K M, Krishnappa P, Shenoy K S. Challenges faced by dental undergraduates during clinical training: A qualitative study. J Indian Assoc Public Health Dent [serial online] 2016 [cited 2020 Jul 9];14:429-33. Available from: http://www.jiaphd.org/text.asp?2016/14/4/429/195847
| Introduction|| |
Dental health-care professionals are expected to provide a wide range of dental care services contributing to the quality of their patient's day-to-day lives. It is the common goal of dental programs to produce graduates who are first, competent in basic and clinical sciences, capable of delivering quality dental care to all sectors of the population, and last but not least, committed to high moral and professional conduct. Dental graduates should be competent; having studied a specific subject in depth, this should be complemented by the development of skills that foster a commitment to lifelong learning, such as providing empathic care for all patients, including members of diverse and vulnerable populations, establishing rapport with patients, identifying their needs and expectations, and providing best treatment to them.
“The First Five Years” also presents similar arguments, noting the need for dental graduates to be competent to practice and also be committed to continuing professional development. Today, there is broad evidence that a good interpersonal communication between medical professionals and patients leads to better therapeutic outcomes, a better doctor–patient relationship, a higher patient adherence to medical advice, a higher satisfaction among patients and doctors, less burnout of medical professionals, and fewer errors in treatment and fewer regresses.
Undergraduate (UG) dental education in India is characterized by a high number of laboratory and clinical courses, resulting in numerous patient encounters during the clinical years. The dental UG course (Bachelor of Dental Surgery) in India comprises 4 years of UG dental training (2 years of preclinical training and 2 years of clinical) followed by 1 year of internship. During first 2 years of BDS program, the dental UG students undergo training in basic subjects. They are exposed to clinical setting during the 3rd year of BDS; this sudden shift from nonclinical to clinical setting without prior orientation can be threatening or challenging to them. To date, the literature does not include reports on the challenges faced by dental UGs during this change in the study setting.
Therefore, this qualitative research was conducted to explore the challenges faced by UG students during their clinical posting (student assigned to a clinic for a particular time) and also their experience while interacting and treating patient for the first time during clinical training based on which we could suggest any remedial action overcome these challenges if any.
| Materials and Methods|| |
The qualitative research was conducted in a dental institution of Bengaluru, where comprehensive treatment is provided to patients. Along with the treatment to patients, institution also educates the students for dental UG (BDS) and postgraduate (MDS) courses according to the Dental Council of India guidelines with aim to impart a high level of knowledge and skills in dentistry coupled with general education. Focused group discussion (FGD) guide was developed by a research team before carrying out the research. Approval was obtained from the Institutional Review Board, and ethical approval was obtained from the Institutional Ethical Committee. Focus group discussions were conducted in English between July 25, 2014, and August 16, 2014.
Using criterion sampling, a type of purposive nonprobability sampling, we recruited four groups of participants (dental UGs) from the dental institution. Inclusion criteria were students who are currently undergoing clinical training, who had attended at least two clinical postings, and who had experience of providing care to at least one patient. Students were selected keeping in mind that in each FGD, there should be 6–12 participants. While conducting FGD, depending on the interested and eligible participants, number of participants selected was eight in first group, six in second, and ten in third and fourth group using purposive nonprobability sampling. FGDs were carried out by the first investigator after obtaining verbal informed consent from all participants. Because of data saturation, authors stopped at four FGDs and no further FGDs were conducted. A phenomenological approach was chosen for this study because we were interested in exploring the lived experience of UGs with the first patient they interacted and the challenges faced during clinical training. We utilized focus groups as a method of data collection because they provided the opportunity for participants to elaborate on their experiences and for others to keep their opinions related to these experiences.
An FGD guide developed by research team which comprised key topics identified pertaining to experiences and challenges which UGs face during clinical training. The data collection team consisted of moderator, note taker, and observer who were trained in qualitative research. The moderator facilitated the discussion, notes were recorded by note taker, and the complete FGD was recorded using voice recorder. Note taker took field notes to record the tone of the focus group, nature of the discussion, and nonverbal communication among focus groups' participants. Observer recorded the sociogram and also observed the time. Sociogram reflects on moderator's technique of conducting FGD, offers a useful method of conceptualizing group dynamics, and is also a useful aid for displaying and interpreting data.
We assigned a number to each participant to maintain anonymity. Following brief introduction by moderator, participants were asked to introduce themselves in relation to department where they are posted currently, departments where they have already finished their posting and type of dental treatment they have provided to the patients, and after that, discussion was carried out using FGD guide. Facilitator commenced the focus group by asking broad questions about the topic of interest before asking the focal questions. Participants answered the facilitator's questions, and they were encouraged to talk and interact with each other using probes in between. After discussing all questions, participants ranked their challenges and suggestions for those challenges. All the four focus groups were audiotaped and each discussion lasted for approximately 45–55 min, followed by refreshments.
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. The transcript so prepared was coded using software Qualitative Data Analysis Miner, version 4.1.9 (Provalis Research: Montreal, Canada). We coded each focus group transcript guided by the question: What is this about? Initial coding remained data-near  to avoid premature interpretation of findings. Any issue, topic, idea, opinion, etc., that was evident in the data was identified as codes, and as many as possible, codes were enumerated. Consistency was checked by repeating the coding process for 10% of the data by second, third, and fourth investigator. Coding of data was followed by grouping of codes into segments of data on a particular issue and called as categories. These categories were further grouped into important themes which enriched our understanding of the data [Table 1]. We constructed a phenomenological summary for each focus group that identified the latent theme(s) of the group.
|Table 1: Demonstrating codes, categories for all the four focused group discussions together|
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| Results|| |
All the four focus groups were conducted by the authors for dental UGs who spoke English. First, FGD was conducted for 48 min, second for 54 min, third for 45 min, and fourth for 52 min. Because of data saturation, authors stopped at four FGDs and no further FGDs were conducted. Across all the focus groups, 21 female and 13 male UGs participated. The mean age for UGs was 23.5 years, with age ranges as follows: 20–22 years (n = 18), 23–25 years (n = 15), and >25 years (n = 1).
The first focus group (n = 8), second group (n = 6), third group (n = 10), and fourth group (n = 10) of UG students included representatives who had finished their postings in at least two clinical departments and had experience of providing care to more than two patients.
After verbatim, we were able to enumerate 64 codes, from which 16 codes were related to challenges faced by UG during clinical posting and other codes were related to their experience and suggestions. These codes were broadly classified into three different categories and these categories were grouped into one theme.
Category 1: Communication
Challenges addressed by the UGs were coded into five different codes [Table 1].
“When so ever I got Kannadiga patients, I was little uncomfortable; You are always comfortable when you can tell the patient what you going to do, instead of you telling someone and then telling the patient, as you know that message can be delivered in a right way, right manner as you wanted to be.” According to UG, it is difficult to treat over smart patients who will search information related to treatment on the internet before coming for appointment. And then, such patients will interfere at each and every step and will not let them complete treatment on time. “My patient studied from internet what is RCT, what are its complication, what all instruments we use and this become such a huge problem.”
“It is very difficult to make patient cooperate for treatment if he has been referred to two or more departments before coming. As he has gone to oral medicine and radiology, has answered all the questions. After that to periodontics and again answering all the questions, then got some treatment. Then coming to conservative dentistry, and again answering more questions. At last, he is like am just answering questions instead of getting treatment done.” Approaching attendants was challenging because of communication gap between students and attenders.
Category 2: Professionalism
Six codes related to challenges faced were grouped [Table 1].
“For edentulous patients, we are supposed to do shade and size selection for denture fabrication on basis of patients complexion, face size, etc. But most of the patients prefer white teeth and are not satisfied and will ask to fabricate denture again.”
Almost all students felt that it is very difficult to manage the resources while treating patients as most of the times they will not be able to use the material optimally to avoid wastage. “I think time management is a big deal, big issue while treating patients because you will give the patient appointment for 11:00 AM but patient will come at 12:30 PM. You can't say no to such patients in spite you are working on another patient and you I mean will be like how to treat both together by 1:00 PM.”
“There were moments when I got the airotar near to the patient tooth and patient started telling it paining. So convincing the patient that I haven't started the treatment and patient started experiencing pain because it was their fear, to get the fear out of them was very difficult but somehow managed.”
Category 3: Ethics
Challenges addressed by the UGs were coded into four different codes [Table 1].
Most of them said they know they should take informed consent before starting treatment. “I don't think, I have ever taken informed consent, I just forget to take it when patient is there.”
Gaining patient's trust while suggesting better treatment over conventional was rather challenging for UG and they were not able to follow “to do good” principle while giving priority to principle of “autonomy” as few students said, “If we keep better option for a particular disease before patients, they will not listen to us.” “They just want to get the treatment what they have heard of from their relatives, friends.”
“One thing that I feel is we always breach confidentiality as we always end up discussing patients with our colleagues, friends. You finish a clinical posting, you go back to the class, you know what happened, patient had this and we did this, and it's generally tendency that happens, so I feel confidentiality is a bit challenging that we breach a lot.”
One inductive code also emerged from the discussion. One of the UG said “My case lot of difficulties while treating patients, mainly because am a left-handed person, and only one department has left-handed dental chair. Especially when I took second quadrant, I had lot of difficulties; my chair position is like that next to spit on area, so I was not able to do properly, so I did take help, I have to take help from the staff. If possible, I think left-handed dental chair should be there.”
| Discussion|| |
Qualitative research was conducted to explore the challenges faced by UG students during their clinical posting. Group composition fulfilled the criteria for qualitative research according to consolidated criteria for reporting qualitative research guidelines, which helped in meeting our objectives. Sociogram revealed good group dynamics, i.e., good interaction between participants and moderators and also among participants. All participants were familiar with each other which encouraged them to feel comfortable in sharing their thoughts.
This study provided a unique examination of the challenges faced by dental UGs during their clinical training, with supporting evidence provided by them. The central theme of all the four focus groups intersects in several key ways.
During FGD, UGs raised a lot of challenges which they were facing every other day and language barrier was one among them. They were not able to communicate with their patients as most of them were from outside Karnataka. To communicate, one should know the language which patient can understand. There is broad evidence that a good interpersonal communication leads to better therapeutic outcomes, a better doctor–patient relationship, a higher satisfaction among patients and doctors. India is a multicultural country with 15 official languages and hundreds of dialects. Since interaction with patients starts in the 3rd year, the students have to communicate with their patients in the local dialect, which can prove to be a little difficult. Physicians and other health-care professionals who are unmindful of the potential impact of language barriers are not only unlikely to satisfy their patients but, more importantly, are also unlikely to provide their patients with optimally effective care. The language barrier, both nonverbal as well as verbal communications, poses a significant threat to the patient–physician relationship. Bridge classes for local language can be organized from the 1st year itself for UG which can make them confident to communicate with patients during their clinical training.
During FGD, all the UG echoed that they were not able to control the movements of chair for the first few patients, which made it difficult for UG to adjust the chair to correct position while providing care to the patient, which can lead to musculoskeletal problems among them. One of the participants was left handed according to whom it was quite challenging to treat patients as only one department has left-handed dental chair. To prevent musculoskeletal disorders while practicing dentistry, we have to ensure that existing equipment is functioning properly and that all dental chairs can be raised and lowered within the range, for which they were designed and light can be adjusted. Proper positioning should help reduce the static physical stresses placed on dental personnel.,
Most of them were not confident managing first patient because they were asked to give local anesthesia directly to patients; few of them suggested that local anesthesia delivery should be practiced on phantom head initially so that they can get an idea about landmarks and can deliver the anesthesia to patient easily.
There are six fundamental principles that form the foundation of the ethical code: Patient autonomy, nonmaleficence, beneficence, justice, confidentiality, and veracity. The dentist has a duty to respect the patient's rights to self-determination and confidentiality. According to UG, none of them had ever taken informed consent from their patients. Moreover, few of them have disrespected patient's confidentiality, one of the most important principles of ethics by discussing their patients in groups and on social media with their friends.
Treatment of a disease or a condition starts with its proper diagnosis and this can be done successfully only by taking a case history. According to UG, they take complete case history in all departments, but a patient waste most of his time in giving case history repeatedly in all the departments which he visits and at last he is not ready to cooperate for treatment. As a suggestion, basic case history can be recorded in first department, and later in other department, case history relevant to that department to be added.
The study was conducted in one college only which makes the generalizability of results questionable. However, as the qualitative research is conducted to frame hypothesis through which quantitative research is carried out to explore the situation in detail, such FGDs need to be conducted in all the colleges to explore challenges faced by the students and take necessary steps to refine and restructure the curriculum accordingly.
| Conclusions|| |
FGDs conducted were able to explore the challenges faced by UGs during clinical posting such as language barrier, optimum utilization of material, and uphold confidentiality. By restructuring, revising, and refining the curriculum, current challenges faced by UGs can be tackled which will help them become a professional with good communication skills.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Abu Kasim NH, Abu Kassim NL, Razak AA, Abdullah H, Bindal P, Che' Abdul Aziz ZA, et al.
Pairing as an instructional strategy to promote soft skills amongst clinical dental students. Eur J Dent Educ 2014;18:51-7.
Pau AK, Croucher R. A dental practice placement scheme: Benefits for practitioners and undergraduates. Eur J Dent Educ 2001;5:155-61.
Broder HL, Janal M. Promoting interpersonal skills and cultural sensitivity among dental students. J Dent Educ 2006;70:409-16.
Woelber JP, Deimling D, Langenbach D, Ratka-Krüger P. The importance of teaching communication in dental education. A survey amongst dentists, students and patients. Eur J Dent Educ 2012;16:e200-4.
Sangappa SB, Tekian A. Communication skills course in an Indian undergraduate dental curriculum: A randomized controlled trial. J Dent Educ 2013;77:1092-8.
Russell CK, Gregory DM. Evaluation of qualitative research studies. Evid Based Nurs 2003;6:36-40.
Warr DJ. It was fun… but we don't usually talk about these things: Analyzing Sociable Interaction in Focus Groups. Qual Inq 2005;11:200-25.
Drahota A, Dewey A. The sociogram: A useful tool in the analysis of focus groups. Nurs Res 2008;57:293-7.
Thorne S, Kirkham SR, Flynn-Magee KO. The analytic challenge in interpretive description. Int J Qual Methods 2004;3:1-21.
Sandelowski M. What's in a name? Qualitative description revisited. Res Nurs Health 2010;33:77-84.
Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): A 32-item checklist for interviews and focus groups. Int J Qual Health Care 2007;19:349-57.
Acharya S. Factors affecting stress among Indian dental students. J Dent Educ 2003;67:1140-8.
Cohen JJ, Gabriel BA, Terrell C. The case for diversity in the health care workforce. Health Aff (Millwood) 2002;21:90-102.
Coombs AA, King RK. Workplace discrimination: Experiences of practicing physicians. J Natl Med Assoc 2005;97:467-77.
Gupta S. Ergonomic applications to dental practice. Indian J Dent Res 2011;22:816-22.