Perceptions of a simulated general dental practice facility - reported experiences from past students at the Maurice Wohl General Dental Practice Centre 2001–2008

Key Points

• A co-operative approach to team learning in a dedicated primary dental care setting is shown to be highly regarded by past cohorts of undergraduates.

• Experienced and committed general dental practitioners were seen to be very effective in the delivery of this style of learning.

• Findings confirm that a close simulation of a real working environment enhances later experiences in vocational training.

Abstract

This article assesses the perceived value of a simulated general dental practice centre as reported by past undergraduates over five years. Various aspects of teaching and related outcomes are explored based on responses received from anonymous questionnaires. A team based approach to cooperative learning led by current practitioners experienced in primary dental care was seen as pivotal to the huge success of the teaching model. Moreover the role of cooperative learning and its influence on building individual clinical confidence and acumen was considered highly beneficial as part of the transition from novice to expert.

Methodology An anonymous questionnaire was distributed to students six months after qualification for a period of five years. The last registered postal address held by the Institute was used for this purpose. The years surveyed were: 2001-2002, 2002-2003, 2003-2004, 2005-2006 and 2007-2008. The questionnaire provided for both qualitative aspects of feedback and a quantitative representation of the overall perception of effectiveness of the General Dental Practice Centre, as expressed by a visual analogue scale.

Results In total 135 questionnaires were returned representing a return rate of 53%. From the responses received 99% of the students reported that they enjoyed their sessions at the Centre with 96% expressing satisfaction with the teaching regime. The mean visual analogue scale rating the centre overall was reported as 83%, with a year on year increase ranging from 76-92%. Rich qualitative data were derived from free text responses.

Conclusion A simulated general dental practice centre was highly rated by past dental students in terms of the overall learning experience received and its relevance to later vocational training. By far the most consistently reported attribute was the opportunity to practise close support four handed dentistry with a nurse. Training in practice management and organisational skills were viewed as important with effective teamwork and a friendly environment seen as conducive to building up knowledge and confidence. The role of experienced current primary care practitioners as teachers was seen to be very effective in this setting.

Introduction

Ever since the General Dental Council published its document The first five years – a framework for undergraduate education¹ there have been a number of innovative approaches to establishing primary care dental education within the current curriculum.^2,3 Over 85% of dental students will become primary care practitioners⁴ and therefore appropriate recognition of their needs in this regard has long been recognised.

Outreach teaching forms a significant part of many of the present initiatives and has been widely reported in the literature.^5,6 In this paper, we discuss the model of the Maurice Wohl General Dental Practice Centre (Fig. 1), a multi surgery facility that opened in 1987 where two former private houses were converted into eight self-contained dental units, situated near to King's College London Dental Institute.

Figure 1

The Maurice Wohl GDP Centre

Primarily focused on developing the role of the undergraduate as team leader, a cooperative approach to teaching and learning, led by current primary care practitioners, has been shown to be hugely successful with past students.

Feedback from five years of anonymous questionnaires is unequivocal in terms of the very high approval ratings consistently reported.

Outline of the centre

As part of the Department of Primary Dental Care, the Maurice Wohl General Dental Practice Centre provides pre-graduation students with a year's experience of adult comprehensive whole patient care, in a setting that closely resembles a modern dental practice. Each student is assigned a fully equipped surgery together with individual nursing and reception support. The nurses are a mix of both qualified and experienced, together with trainees from the School of Dental Nursing. Patients identified as suitable for the Centre are referred from the dental hospital. The underpinning rationale is to provide as real an exposure to team led primary care dentistry as possible, within the scope and limitations of the undergraduate curriculum. The students adopt the role of a trainee clinical team leader working closely alongside a dental nurse (Fig. 2). Two student hygienists also support each clinical session, working to agreed treatment plans and prescriptions. Separate commercial laboratories provide technical services. A clinical director oversees the Centre together with a senior nurse manager, supported by nursing, reception and administrative staff. Ultimate responsibility for the facility lies with the Head of Primary Dental Care. This arrangement permits most day-to-day activities to be carried out within the Centre, but with ready access to specialist services such as oral surgery available from the adjacent main hospital. Two fortnightly sessions over three academic terms allow for approximately one third of the present intake of 180 students to use the Centre. In order to meet an increased undergraduate and patient demand, the Centre underwent a complete refurbishment in 2005 (Figs 3, 4) to include two further surgeries.

Figure 2

Four-handed dentistry at the Centre

Figure 3

A typical surgery before renovation

Figure 4

A typical surgery after renovation

A small team of experienced part-time practitioners are exclusively assigned to teaching. Most hold dental postgraduate qualifications and undergone in-service teacher training within the Institute. The nurse manager and her staff, principally through individual chairside interactions, deliver important adjunctive teaching for example cross infection control issues.

The students are randomly selected from the final year cohort and pre-organised into groups of eight. Each clinical session is preceded by half an hour of small group learning, which can vary from teacher led tutorials to student centred projects. Currently this is confined to dental students with occasional nurse input. A list of relevant topics and subject areas is provided for guidance at the beginning of each term. The teacher can use this facility flexibly in order to foster close interaction with the students throughout their time at the Centre. The emphasis is on building an effective knowledge sharing process through cooperative learning.⁷

The teaching at the Centre firmly embraces the stated aims and objectives of the Department of Primary Care Dentistry, which are included in Table 1. The Centre also delivers specialist teaching in rotary endodontics, practice management, clinical governance together with career advice.

Table 1 Primary care departmental aims and objectives

Methodology

Six months post graduation an anonymous questionnaire was distributed to students using the last registered postal address held by the Institute. The years surveyed were: 2001-2002, 2002-2003, 2003-2004, 2005-2006 and 2007-2008. Closure, renovations, new commissioning and later cross infection issues were thought prejudicial to meaningful feedback; consequently no surveys were carried out in years 2004-2005 and 2006-2007.

The design of the questionnaire allowed for both qualitative and quantitative aspects of feedback based on an instrument that has been previously piloted and used in other studies. Simplicity of use and ready understanding were sought in order to encourage an adequate response rate. Both open and closed questions were set, together with a visual analogue scale to give an overall percentage rating for the centre (very poor - excellent), as used in previous studies.⁷ A rich source of qualitative data was generated from the open questions, which allowed for a thematic approach to analysis.

In total 136 questionnaires (Fig. 5) were collected giving an overall response rate of 53%.

Figure 5

Maurice Wohl GDP Centre Graduate Questionnaire

Results

The results are presented in Tables 2, 3, 4, 5, 6, 7, 8.

Table 2 Responses to the questionnaires

Table 3 Approval ratings for the general questions

Table 4 The Centre's main areas of strength as identified by the respective percentages of respondents (n = 136)

Table 5 Identified areas of strength

Table 6 The Centre's main areas for improvement as identified by the respective percentages of respondents (n = 136)

Table 7 Identified areas for improvement

Table 8 Percentage overall rating for the Centre (n = 136)

A total of 283 students attended the Maurice Wohl GDP Centre during the study period. Of these, 256 qualified in June of the corresponding year and formed the cohort for this study.

The total number of received questionnaires was (n = 136) from 256 distributed giving a response rate of 53%.

One hundred and thirty-three out of the 136 respondents (98%) at the time of survey were undertaking VT/GPT while the remaining respondents were all House Officers.

The analyses of the findings from the respondents are shown in Tables 3, 4, 5, 6, 7, 8. An overwhelming majority of ex-students were satisfied with the teaching provided and enjoyed their learning experience at the Centre.

Discussion

It is clear from the survey responses that the overwhelming majority of students enjoyed the experience of being at the Centre and were very satisfied with the teaching received. Looking at the thematic responses by far the most reported observation was the ability to work with a nurse in a close support environment (75%).⁷ Before 2004-5 exclusive access to one to one nursing was not consistently available for every student treatment session and this was reflected in the general feedback. Since that time better nursing distribution has largely eliminated this feature (Table 6). Students appreciated the 'total care' team based approach to treatment. This is perhaps not to be unexpected and has been commented on elsewhere.⁸ Training in the art of practice management and organisation was seen as the second most important factor (57%). The advice and guidance given by individual clinical teachers was perceived as being both relevant and important to future career development. It is clear from the feedback received that the teachers were especially identified as strong positive role models, exerting significant influence over their students. The fact that consistency of chairside teaching was possible under this regime is thought to be a major contributor to the success of the model.

The natural role for a simulated general dental practice is to smooth the transition from dental school to vocational training and this aspect is commented on favourably in the survey. As part of the so-called continuum of dental education,⁹ the centre prepares the undergraduate for the working conditions they will encounter next. It is not meant to reflect a hospital or clinic environment and is readily identified as a familiar dental practice. It does share many of the attributes of an outreach setting, but would best fit the description of being an extended clinical environment. The learning environment itself appears to have featured strongly in the feedback (41%). From our experience as clinical teachers we have observed that effective team based learning takes place in a setting that is perceived as nurturing, supportive and non-threatening.¹⁰ In our view a significant role in developing crucially important individual clinical skills is linked to acquiring appropriate levels of personal confidence, allied to a sense of judgement. These attributes are often difficult for many students to acquire when undergraduates.¹¹ Most of the clinical teaching takes place on a one to one basis within the surgery confines, allowing for a more personalised and potentially more in depth encounter than perhaps would be the case on a busy open clinic. This style of teaching can legitimately be described as 'relationship teaching'.¹² It also provides considerable scope to involve trainee dental nurses in the cooperative learning process, particularly in regard to the enhancement of close support skills and compliance with cross infection control measures. Thus the learner becomes a stakeholder in the learning process.¹³ The success of the cooperative strategy is heavily dependent on encouraging both students and nurses to think and to take ownership and responsibility for their decision-making. This in turn requires the teacher to adopt a slightly less hands-on approach to overall supervision. Interventions are indicated more where issues relating to specific learning points or patient safety are deemed important. The role of the teacher in this setting is thus more likened to that of a guide and trusted colleague, allowing for a more natural development along the pathway of novice to expert.¹⁴

The physical layout of the Centre also tends to foster a sense of personal ownership and belonging. We would postulate that in our experience the closer a teaching model simulates real working conditions, the more team performance tends to reflect that encountered in real life.¹⁵ The emphasis is on creating a positive learning platform whereby all members of the dental team can flourish.¹⁶

Areas for improvement were generally focused either on upgrading the existing equipment (61% before the renovation, 2% after) or for the opportunity to have more sessions at the centre (36%). More seminars on practice management were seen as desirable as well as the opportunity to treat more advanced cases.

Access to these facilities by the entire student body is not possible under existing arrangements. The small increase in numbers of surgeries is insufficient to accommodate the training needs of the whole dental team within the existing building. There is a lack of physical potential to further expand the site sufficiently in order to address these issues. As a response to this the Dental Institute together with the University of Portsmouth in 2010 will be jointly opening an expanded outreach facility in that city. This will provide a further 20 chairs as part of a developing programme of outreach teaching between the two institutions. In years to come the opportunity to make comparisons between the two modes of delivery can be considered.

Conclusions

A simulated practice environment as evidenced by feedback received from five years of past students strongly confirms the success of this teaching model. It works well because of the team approach to delivering high quality comprehensive adult care, led by current primary care practitioners. Considerable efforts have been made to achieve an optimum learning environment in which the undergraduate can safely develop and progress with confidence to the next stage in their professional development.