|Year : 2021 | Volume
| Issue : 1 | Page : 90-94
An assessment of the efficacy of clinical skills simulation using standardized patient in teaching behavior management and modification skills in Pediatric Dentistry to dental undergraduate students: A double-blinded, randomized, controlled trial
Madhu Santhakumar, R Vidhya
Department of Pediatric and Preventive Dentistry, Government Dental College, Kozhikode, Kerala, India
|Date of Submission||27-Nov-2020|
|Date of Acceptance||02-Mar-2021|
|Date of Web Publication||22-Apr-2021|
Dr. Madhu Santhakumar
Department of Pediatric and Preventive Dentistry, Government Dental College, Kozhikode, Kerala
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Clinical skills simulation (CSS) is an important tool in teaching and learning. The literature review showed a scarcity of research data regarding the use of CSS,in teaching, especially in dentistry. The use of CSS in dental teaching was found restricted to the use of low fidelity typhodonts fitted to phantom heads used in teaching cavity preparation and crown cutting. Aim: The aim of the study was to determine the efficacy of CSS using standardized patient in teaching behavior management and modification skills to dental undergraduate students. Settings and Design: This double-blinded, randomized controlled trial was undertaken among 3rd year dental undergraduate students, and the study was undertaken at the Department of Pediatric and Preventive Dentistry. Materials and Methods: Fifty, 3rd year BDS students were randomly allotted to simulation and nonsimulation groups. Baseline data regarding their knowledge in the behavior management of child patients were assessed. Simulation group was further divided into group of six students and underwent CSS with standardized patient. Pretest and posttest knowledge regarding behavior management was assessed in the simulation group using questionnaires approved by an expert committee. The results were analyzed to see if there is any improvement in their knowledge after CSS. Students in simulation and nonsimulation groups were assessed for their behavior management skills during patient management, by an independent observer, using a checklist. Statistical Analysis: Mean, standard deviation (SD), and unpaired student t-test were done to assess the baseline knowledge of students who participated in the study. Mean, SD, and paired t-test were used to compare the pretest and posttest score of students who underwent simulation. Mean, SD, and unpaired t-test were used to compare the behavior management skills of both groups of students. Results and Conclusions: The knowledge of students in both groups before the study was comparable with no statistically significant differences. There was a statistically significant improvement in the knowledge of students who underwent CSS regarding behavior management of child patients. The unpaired Student's t-test showed a significant difference in the behavior management skill of dental undergraduate students when treating a child patient. The students who underwent CSS fared better compared to students who were taught behavior management methods by traditional methods only. Clinical skill simulation using standardized patient is an effective adjunct to be used along with traditional method of teaching while teaching behavior management and modification skills to dental undergraduate students.
Keywords: Clinical skills simulation, simulated patient, standardized patient
|How to cite this article:|
Santhakumar M, Vidhya R. An assessment of the efficacy of clinical skills simulation using standardized patient in teaching behavior management and modification skills in Pediatric Dentistry to dental undergraduate students: A double-blinded, randomized, controlled trial. J Indian Soc Pedod Prev Dent 2021;39:90-4
|How to cite this URL:|
Santhakumar M, Vidhya R. An assessment of the efficacy of clinical skills simulation using standardized patient in teaching behavior management and modification skills in Pediatric Dentistry to dental undergraduate students: A double-blinded, randomized, controlled trial. J Indian Soc Pedod Prev Dent [serial online] 2021 [cited 2021 Aug 2];39:90-4. Available from: https://www.jisppd.com/text.asp?2021/39/1/90/314366
| Introduction|| |
Clinical skills simulation (CSS) is an effective tool in learning affective, psychomotor, and cognitive domains.,,,, Only simulators used in dentistry at present in dental colleges in India are probably low fidelity, typhodont fitted to phantom head used in learning cavity preparation and crown cutting., All other procedures in dentistry are learned by students practicing directly on patients. Soft skills such as communication, behavior management, and modification are extremely important in pediatric dentistry. Although the students have theoretical knowledge about this topic, their practical experience is limited.
In health care, a simulated patient (SP),,,,, also known as a standardized patient, sample patient, or patient instructor, is an individual trained to act as a real patient to simulate a set of symptoms or problems. SPs have been successfully utilized in medical education, research, and evaluation of health-care professionals. Although there is a huge potential for using SP methodology in dentistry, especially in pediatric dentistry, to teach communication, behavior management and modification skills, only limited number of studies could be found in the literature regarding its application in dentistry. SP is a widely used method in CSS. This method can be attempted to teach basic behavior management and communication skill to the dental undergraduate students.,,
This study was conducted to determine the efficacy of this method as an adjunct to traditional method of teaching, while teaching behavior management and modification methods to dental undergraduate students.
| Materials and Methods|| |
The aim of this study was to determine the efficacy of clinical skill simulation using standardized patient, in teaching behavior management and modification skills to dental undergraduate students.
Double-blinded randomized controlled trial.
This study was conducted at the department of pediatric and preventive dentistry among 3rd BDS students. Theory classes were taken for all the students in the subject of child psychology and nonpharmacological methods of behavior management. An informed written consent was obtained from all the participants including the senior resident who was to become the SP. The study was approved by the scientific committee and Institutional Ethics Committee of the concerned college (IEC no: 168/2019/DCC dtd 14/11/2019) and registered under (clinical trial registry of India/2020/05/025017).
The inclusion criteria were third BDS students willing to participate in the study and who have attended theory classes on behavior management and child psychology. The exclusion criteria were students who could not attend simulation session (in simulation group) or who could not attend clinical posting in the department. Sample size was calculated based on a published study on the effectiveness of CSS. Fifty, 3rd year BDS students were divided randomly into Group A (theory class + clinical instructions + simulation) and Group B (theory class + clinical instructions). Randomization was done with simple randomization method with computer-generated random numbers and allocation concealment. One student who could not attend simulation session and one student who could not attend departmental posting in nonsimulation group were excluded from the study. Twenty-four students of simulation group were further divided into four groups of 6 students.
Baseline data regarding their knowledge in the behavior management of child patients were assessed using a pretest after the theory classes on the subject. CSS followed the predetermined simulation protocol. Simulation group underwent clinical skill simulation with standardized patient under the guidance of principal investigator who was trained in techniques of clinical skills simulation. Clinical skills simulation include briefing, [Figure 1] simulation [Figure 2]a and [Figure 2]b, and debriefing [Figure 3] sessions.,,,,, Briefing session includes a brief discussion on the learning objectives of this exercise [Figure 1]. The participants were to divide among themselves as parents of the patient, receptionist, dental surgeon, dental assistant, and dental nurse. The SP was the senior resident of the department who was briefed to perform like an uncooperative 5 year old child who comes for restoration of her decayed tooth [Figure 2]a and [Figure 2]b. The SP was told to become cooperative only as the dental team does proper behavior management protocol with pretreatment communication, tell-show-do technique, etc., before and during cavity preparation. The behavior management during cavity preparation was to be performed as the dental surgeon does cavity preparation on typhodont (hybrid method of CSS). Debriefing session [Figure 3] is the stage at which the participants analyze the scenario retrospectively and discuss about their experiences, the aspects they have learned by performing, the mistakes they have committed, etc.. This step is most important in storing information in long-term memory.
Pretest and posttest knowledge regarding behavior management was assessed in the simulation group using questionnaires approved by an expert committee. The results were analyzed to see if there is any improvement in their knowledge after CSS. Students in simulation and nonsimulation groups were assessed for their behavior management skills during patient management, by an independent observer, using a checklist [Figure 4].
Procedure selected to assess CSS involve, the behavior management/modification technique to be used in a 4–6 year old child (Frankel's negative) who needs to undergo cavity preparation with an air rotor for the first time. Written consent was obtained from the parents after explaining all the details. The following five components were assessed, namely:
- Basic communication skills (with the parent and the child)
- Behavior management of the child prior treatment
- Behavior management and modification before the procedure (desensitizing by the tell-show-do technique),,,
- Behavior management and modification during procedure (voice control and desensitization)
- Behavior management after the procedure (positive reinforcement and instructions).
Outcome measure and statistical analysis
Students in the simulation group (Group A) underwent a pretest and posttest in which there were five questions. Satisfactory answer got 2 marks (fulfilling 2 criteria). Partially, satisfactory answer got 1 mark (fulfilling 1 criteria) and no knowledge about the subject got zero marks. The comparison was drawn within the batch before and after simulation by mean, standard deviation (SD), and Student's paired t-test, which gave an insight into the change in the knowledge of the students due to simulation. Level of significance was set at 0.05.
A comparison between simulation group (theory + clinical instruction + simulation) and the group which has not undergone simulation (theory + clinical instruction) will suggest if simulation in the pediatric dentistry with SP is an effective tool in teaching behavior management and modification skill. While comparing the clinical behavior management skill of two groups, independent observer observed 48 students with checklist while treating children in 4–6 years' age group (Frankel's negative). The comparison was drawn then using mean, SD, and unpaired t-test.
| Results|| |
The students in both groups had comparable baseline knowledge level in the subject of behavior management, initially, and there was no statistically significant difference among them (P = 0.220) [Table 1],
The difference in the mean value of the marks in simulation group in pretest and posttest was found to be statistically significant (P = 0.007) [Table 2] by the paired t test.
|Table 2: Pre and posttest comparison in simulation group (before and after simulation)|
Click here to view
The difference in mean scores obtained while the students treated the Frankel's negative children was found to be statistically highly significant (P = 0.000) with simulation group students performing better compared to nonsimulation group [Table 3].
|Table 3: Simulation - nonsimulation group comparison during patient management|
Click here to view
| Discussion|| |
The literature review showed a very limited amount of research studies on teaching methodology with CSS, especially in dentistry. Most of the studies and review articles were regarding simulators. The CSS using SP was found much lesser, and no study could be found reported from India.
There are different methods of CSS. It ranges from simple low fidelity mannequins to high fidelity ones which respond to your treatment., They can be used alone or multiple methods can be employed like a hybrid method. Simulated or standardized patient(SP) is a very useful tool in clinical skills simulation where the SP mimics the signs ,symptoms and behavior of the real patient. In the present study, although a hybrid method of CSS was used in which the procedure was done on the typhodont fitted to phantom head, the behavioral management was exclusively assessed using a simulated patient. The aspect of the procedural quality was not checked here rather we focused exclusively on behavior management aspect.
The SP needed to react according to the situation. Hence, instead of selecting a 3rd year student in each group as an SP, we selected our senior resident as SP in all the groups; hence, the response of the SP was standardized.
Knowledge regarding behavior management was assessed with a pretest and posttest, which showed a significant improvement. However, it was interesting to note that higher evidence of the efficacy of the CSS was obtained when they actually performed the procedure on the patient. The significance was high during the clinical procedure which proved that more than the theoretical knowledge, it was the practical aspect of actually performing the behavior management which showed a higher improvement with CSS.
A double blinding was done in this RCT since it was not possible to blind the student since they underwent simulation. Although the whole process of simulation was done under the guidance of principal and co-investigator the evaluation of the pretests and posttests and the evaluation during clinical procedure with a checklist was done by an independent observer who was blinded. The statistician was also blinded in this study.
A previous study assessed the long-term retention and effectiveness of this method. The results showed that the simulation experience did not result in significant improvement in student-patient communication. However, the simulation group included all treatment options more frequently compared to nonsimulation group. This current study also will be repeated when the students reaches internship to know whether this method has any advantage in long-term retention or beneficial only during the study period as in the 3rd year.
| Summary and Conclusions|| |
- CSS using standardized patient is an effective tool in teaching behavior management and modification aspect in pediatric dentistry to dental undergraduate students
- There is a significant improvement in the knowledge of dental undergraduate students regarding behavior management and modification aspect after CSS
- The clinical skill of behavior management of the dental undergraduate students who underwent CSS were found better than those who underwent training in traditional method only while managing unco-operative dental patients.
Clinical skill simulation using standardized patient is an effective adjunct to traditional method of teaching of dental undergraduate students while teaching behavior management and modification of a child dental patient.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
The authors would like to express their gratitude to Dr. Kannan Vadakkepurayil, Professor and Head, Department of Pediatric and Preventive Dentistry, Government Dental College, Kozhikode for all the support, Dr. Biju George, Associate Professor, Department of Community Medicine, Govt. Medical College, Kozhikode for the statistical inputs and Kerala University of health Sciences for providing training in Clinical skills simulation.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Perry S, Bridges SM, Burrow MF. A Review of the Use of Simulation in Dental Education. Centre for Enhancement of Teaching Learning,S.M.B University of Hong Kong, and Melbourne Dental School (M.F.B), The University of Melbourne, Australia: Society for Simulation in Health Care; 2015. p. 1-7.
Fugill M. Defining the purpose of phantom head. Eur J Dent Educ 2013;17:e1-4.
Wallace P. Following the threads of an innovation: The history of standardized patients in medical education. Caduceus 1997;13:5-28.
Qutieshat AS. Assesment of dental clinical simulation skills: Recommendations for implementation. J Dent Res Rev 2019;5:116-23.
Bray BS, Schwartz CR, Odegard PS, Hammer DP, Seybert AL. Patient simulation. Assessment of human patient simulation based learning. Am J Pharm Educ 2011;75:1-10.
McKenzie CT, Tilashalski KR, Peterson DT, White ML. Effectiveness of standardized patient simulations in teaching clinical communication skills to dental students. J Dent Educ 2017;81:1179-86.
Cederberg RA, Bentley DA, Halpin R, Valenza JA. Use of virtual patients in dental education: A survey of U.S. and Canadian dental schools. J Dent Educ 2012;76:1358-64.
Anders PL, Scherer YK, Hatton M, Antonson D, Austin-Ketch T, Campbell-Heider N. Using standardized patients to teach interprofessional competencies to dental students. J Dent Educ 2016;80:65-72.
Fraser KL, Ayres P, Sweller J. Cognitive load theory for the design of medical simulation. Simul Health J Soc 2015;10:295-307.
Reedy GB. Using coagnitive load theory to inform simulation design and practice. Clin Simul Nurs 2015;11:355-60.
Carvalho IP, Pais VG, Silva FR, Martins R, Figueiredo-Braga M, Pedrosa R, et al
. Teaching communication skills in clinical settings: Comparing two applications of a comprehensive program with standardized and real patients. BMC Med Educ 2014;14:92.
Papadopoulos L, Pentzou AE, Louloudiadis K, Tsiatsos TK. Design and evaluation of a simulation for pediatric dentistry in virtual worlds. J Med Internet Res 2013;15:e240.
Nestel D, Bearman M. Simulated Patient Methodology: Theory, Evidence and Practice. West Sussex, UK: Wiley-Blackwell; 2014.
Stephenson E, Poore J. Tips for conducting the pre-brief for a simulation. J Contin Educ Nurs 2016;47:353-5.
Tyerman J, Luctkar-Flude M, Graham L, Coffey S, Olsen-Lynch E. Pre-simulation preparation and briefing practices for healthcare professionals and students: A systematic review protocol. JBI Database System Rev Implement Rep 2016;14:80-9.
Fanning RM, Gaba DM. The role of debriefing in simulation-based learning. Simul Healthc 2007;2:115-25.
Frankl S, Shiere F, Fogels H. Should the parent remain in the operatory? J Dent Child 1962;29:150-63.
Dieckmann P, Molin Friis S, Lippert A, Ostergaard D. The art and science of debriefing in simulation: Ideal and practice. Med Teach 2009;31:e287-94.
Sawyer T, Eppich W, Brett-Fleegler M, Grant V, Cheng A. More than one way to debrief: A critical review of healthcare simulation debriefing methods. Simul Healthc 2016;11:209-17.
Adelson R, Goldfried MR. Modelling and the fearful child patient. J Dent Child 1970;37:476-89.
Roberts JF, Curzon ME, Koch G, Martens LC. Review: Behaviour management techniques in paediatric dentistry. Eur Arch Paediatr Dent 2010;11:166-74.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3]