An exploration of community-based training opportunities for undergraduate dental therapy students at a tertiary institution in KwaZulu-Natal.

Abstract

Introduction Dental undergraduate education has received much attention in recent years with a shift from traditional dental school clinical training to community-based clinical training to develop competencies of a new dental graduate (Yip and Smales, 2000). A new dental graduate is competent if he/she can appropriately apply knowledge, clinical skills and professional attitudes in diverse work settings (Yip and Smales, 2000). In a traditional dental school hospital setting, the student gains competency through repetitive completion of clinical procedures and the patient is seen as meeting the educational needs of the student by keeping appointments for set dental procedures (Eriksen et al., 2008). While this type of education leads to mastery in technical skills, it is fragmented, rigid and incentive driven (Eriksen et al., 2008). It does not fully prepare dental professionals to meet the rigors and demands of a diverse work environment, managing multi-cultural communities with a range of oral health care needs (Yoder, 2006). The dental therapist, a mid-level oral health care practitioner, who provides basic preventive and curative dental care, receives a similar type of training. The training includes acquisition of professional knowledge and clinical skills through intense clinical training. Clinical training occurs in a hospital-based, dental school environment. This is a secondary care setting, however, a therapist is expected to work mainly in primary care settings, in diverse communities. This poses a problem for a newly qualified therapist to adjust to a work environment different from the training facility. A strategy that can facilitate the transition from a dental school environment to a work environment is to expose dental therapy students to primary care or community-based settings while in training (Yoder, 2006). Community-based dental education (CBE) is a pedagogical approach that allows a student to develop clinical skills in a community setting so as to contextualise undergraduate training within real world settings for the student dental therapist (Yoder, 2006). Competency is built through acquisition of clinical skills by experience and reflection, and the application of critical and creative thinking in solving clinical problems (Yip and Smales, 2000). In addition, students gain a better understanding of the social, psychological, cultural and economic factors affecting oral health (Yoder, 2006). Traditional dental school training occurs in isolation from other health professionals, yet upon graduation, health professionals are expected to work in collaboration with each other, in a team-based approach, for integrated patient care. Interprofessional learning among other student health professionals is well documented in the literature, however dental student participation is minimal. Thus, to foster dental graduates with skills and ethics and a sense of social responsibility, academic institutions training dental therapy students must create learning opportunities that can facilitate acquisition of these skills and values (Yoder, 2006). The University of KwaZulu-Natal, one of two universities in South Africa, training dental therapists, in line with its mission and vision of being socially accountable, is in the process of reforming health professionals’ education (University of KwaZulu-Natal, 2017b, Essack, 2014). The university calls for all disciplines training health professionals to adopt the Primary Health Care Model (PHCM) to align clinical training to the needs of the health system and for health professionals to be more responsive to the needs of communities (University of KwaZulu-Natal, 2017b, Essack, 2014). This model enforces and facilitates training of health professionals in community health centres, district and regional hospitals within the Department of Health (DoH). However, in expanding the clinical training platforms, it is important to first determine the capacity of various sites to support dental student training. It is also important to create interprofessional community-based learning opportunities and obtain the perspectives of students on integrating community-based education into the curriculum. The purpose of this study is to explore community-based learning opportunities for undergraduate dental therapy student training, test these opportunities, and then develop a framework that can guide curriculum planning and implementation of community-based training. Aim The study aims to strengthen community-based undergraduate dental therapy training at a tertiary institution through an exploration of learning opportunities in the public, private and non-governmental health sectors, using a self-developed conceptual framework to guide this process. Objectives The objectives of the study were to determine the intended role of community-based undergraduate clinical training within the College of Health Sciences through an engagement with relevant academic leaders using semi-structured interviews, to explore opportunities for interdisciplinary community driven initiatives for dental therapy students through focus group discussions with academics from the various disciplines in the School of Health Sciences, to identify support for interdisciplinary community-based clinical training in the public health sector through semi-structured interviews with relevant stakeholders within the KwaZulu-Natal Department of Health, to explore interdisciplinary community-based learning opportunities for dental therapy training through semi-structured interviews with key role players in the non-governmental sector in KwaZulu-Natal, to explore interdisciplinary community-based learning opportunities for dental therapy training through semi-structured interviews with relevant stakeholders in the private health sector, to explore final year dental therapy students’ experiences of community-based training through self-administered questionnaires, to determine the attitudes and perspectives of undergraduate Dental Therapy and Physiotherapy students participating in an interprofessional community-based health education programme through focus group discussions and to develop a conceptual framework to guide data collection and data analysis for community based training for undergraduate dental therapy students. Methods and Materials An in-depth exploratory study design was used to obtain a better understanding of the research phenomenon. The study used predominately qualitative methods to achieve the objectives, however, elements of quantitative methods were also used, to a lesser extent. As there were several objectives to this study, it was conducted in three phases to facilitate the data collection process. An explorative, descriptive study design, with mainly qualitative methods, was used to achieve the objectives in the first phase. To achieve objectives one and two, interviews and focus group discussions were used to collect the data. Four semi-structured interviews were conducted with key role players in the university, including the Dean and Academic leader of Teaching and Learning and two other senior academics, and focus group discussions with a purposively selected sample was used. The sample for the focus group included an academic from each of the eight disciplines, in the School of Health Sciences resulting in a final sample size of 12. To achieve objective three, semi-structured interviews were conducted with the Provincial Head of Oral Health Services and clinical managers of selected clinics and hospitals within the Department of Health to identify potential sites for student training. The sites were selected on the criteria that they had three or more consulting rooms to accommodate a small group of students and provided a full range of dental services within the scope of practice of a dental therapist. The final sample size included six community health centres and twelve hospitals. A data capture sheet was used to record the resources that were available at each site. The final sample size for the interviewees was 19, including the Provincial Manager and the 18 clinical managers from the selected sites. To achieve objectives four and five, semi-structured interviews were conducted with stakeholders within the private and non-governmental sectors involved in organising community-based health care initiatives. To select interviewees, three contacts within the non-governmental sector, known to the researcher, helped to identify further participants through the use of the snowball sampling method. The final sample size was nine, with eight from the non-governmental sector and one from the private sector. In the second phase, a descriptive study design, with elements of action research and qualitative methods was used to achieve objectives six and seven. The final year dental therapy students were exposed to community-based clinical training and their perspectives of the experiences were obtained using self-administered questionnaires. A total of 32 out of 36 final year students participated in the study. In addition, students from the Disciplines of Dentistry and Physiotherapy participated in an interprofessional activity, and their views on the collaboration, were also obtained using focus group discussions. Two focus groups discussion were facilitated separately for the students, the first with six dental therapy students and the second with five physiotherapy students. In addition a third focus group discussion was held with the academic and clinical staff at the community health centre, including two academics (one from each discipline, accompanying the students), three dental clinical staff and one physiotherapy clinical staff, giving a final sample size of six. This was conducted to obtain their perspectives of the student collaboration. Five patients, randomly selected, were also interviewed, for their opinion of a student intervention. The third phase involved developing a framework for interprofessional community-based training for dental therapy students using the data collected from phase 1 and 2. In the data analysis process, the qualitative and quantitative data were analysed separately. The interviews and focus group discussion were first transcribed verbatim and then cleaned. The transcripts were read several times to identify codes. Several codes were generated and linked together in axial coding, which were then selected and collated into large themes and sub-themes. The quantitative data obtained from the data capture sheets of the site inspections were analysed using quantitative analysis through a variety of statistical techniques. The data from each sheet was extracted and captured using Excel software. All the information was collated to form a comprehensive list of available resources. A descriptive statistical method was used to comprehend the data which was presented in the form of tables and graphs. The study was conducted following the ethical guidelines of the university. Ethics approval (HSS/1060/015D) for the study was obtained before commencing the study. Results Four main themes arose from the data analysis which were aligned to objectives one to seven. These themes included: benefits of community-based training, challenges experienced, learning opportunities for community-based training and the perceived barriers to implementation. The study findings indicated that there were several benefits. The academics participating in the study believed that CBE was beneficial to students, the institution, the health system and communities. They believed that students could improve proficiency and critical reasoning by being exposed to many patients. They could also learn to connect theory to practice. Academics in the study perceived that CBE was a means for the institution to implement its goal of high impact community engagement. Benefits to the health system included building sustainable partnerships, making health care more accessible to communities and aligning the health professionals training to the needs of the health system which could make them easily employable. They also believed that communities could benefit through improved service delivery and access to services that were not previously available. Student participating in the study believed that being exposed to community-based training improved their clinical skills and self-confidence. The dental therapy students, participating in the study, reported that they benefitted from collaborating with the physiotherapy students. They perceived a better understanding of the role of the other professional, the value of peer learning and a team approach to patient education and care. The results of the study showed that there were also several challenges to community-based training. These challenges were both internal and external, with the main internal challenge being an absence of a clear operational plan for implementation of CBE at discipline level and across disciplines. Other internal challenges included a lack of support from college leaders, cooperation of other academics and funding. External challenges stemmed from the training sites, such as clinical supervisors not having a clear understanding of their roles and responsibilities in student training and the lack of communication between the two institutions. The study showed that there were several opportunities for community-based training in the public, private and non-governmental sectors. Opportunities within the Department of Health included students training at nearby community health centres which could create real life learning situations where students spend a set time, on a continual basis, treating patients as they would in a workplace. The decentralised sites offered a sustained exposure over two weeks of work experience that could allow a student the opportunity to provide more comprehensive management of a patient through a follow-up appointment system. The non-governmental and private sectors offered many learning opportunities for students through their innovative means of service delivery such as a mobile health bus, a shipping container turned into a mobile clinic and classrooms in schools converted into makeshift clinics. In addition, there were also many interprofessional community-based learning opportunities for students such as integrating oral health into general health educational talks in school and clinic settings, joining existing community projects and being part of the rehabilitation team for stroke patients. The results of the study noted that barriers did exist in the implementation of interprofessional community-based programmes. Academics in the study sample, cited finding a common time on timetables to implement interprofessional activities and funding to be their main barriers, while clinical managers perceived clinical space to accommodate large numbers of students as their main barrier. In addition to the overall themes provided, the results were discussed in relation to each objective. Objective one intended to determine the role of CBE in student clinical training. The academics, participating in the interviews and focus group discussions in the study, recognised that CBE was a valuable pedagogical approach in contextualising clinical training in settings that match the health system. They perceived CBE as being beneficial at various levels; to students, the institution, the health system and communities. However, they believed that the biggest challenge was that there was no clear guidelines on how this process had be made operational and implemented at individual and across disciplines. Objective two explored opportunities for interdisciplinary community driven initiatives for dental therapy students. Findings linked to objective two showed that academics in the focus group discussions believed that students learning in an interprofessional manner had many benefits, such as an improved understanding of the scope of practice of other professionals so that could learn to refer patients appropriately in the future to provide an integrated patient care delivery. The study further indicated that there were several interprofessional learning opportunities for dental therapy students in various settings such as schools and primary health care centres. However, barriers to collaboration as identified by the focus group participants, were a mismatch in student numbers in trying to arrange equal opportunities for all students and time-table scheduling for interprofessional activities. The results related to objective three demonstrated that the sites within the DoH could provide conducive environments for contextual student learning. The site inspection of the 18 dental clinics within the DoH revealed that the clinics in general, provided the services within the scope of the dental therapist with the exception of three, not offering restorative procedures and one, not offering scaling and polishing. They also had the necessary consumables and equipment to provide these services. The only service lacking in some of the clinics was radiography as only 61% of the clinics had an x-ray machine. The clinical managers in the study sample believed that students could benefit from learning in a real world setting. They perceived that students could master dental procedures and participate in school health programs and mobile services. They perceived that students working in such an environment facilitated their transition into the work environment. The main problem, they perceived were that students might slow down the clinicians’ work progress. The study findings in relation to objectives four and five revealed that there were many private sector and NGO community-driven projects which could provide meaningful learning opportunities for student training. Study participants indicated that students participating in their projects could benefit by adapting to different environments and working with limited resources. They believed that students could learn to treat a patient with respect and empathy, irrespective of their social, economic and cultural background and gain a deeper understanding of societal needs that could inspire volunteerism and altruism. The results of objective six showed that the dental therapy students participating in the study, believed that working in community settings improved their clinical skills and increased their self-confidence. They perceived a better understanding of the social determinants of health, social inequalities, and diversity in cultures. The main challenge experienced, was the language barrier that hindered effective communication with patients. The findings of the study in relation to objective seven demonstrated students’ openness and readiness to participate in interprofessional activities. The dental therapy and physiotherapy student participants of the study indicated that they derived several benefits of the collaborative learning experience such as respect for the other professional, an improved understanding of the role of the other professional and appropriate referral patterns. The last objective was to develop a conceptual framework for community-based training for undergraduate dental therapy students. The framework was guided by combining the formal theory obtained from literature and the empirical research findings of objectives one to seven of the study. It comprised of five components; the education system, selection of sites, student engagement, graduate competencies and the health system. The framework had a strong theoretical foundation and demonstrated the value of informed research before implementing curricula changes and new teaching pedagogies. It further demonstrated the importance of obtaining students’ input in decision making processes involving curriculum development. The framework showed the potential of being transdisciplinary as it could be used by other disciplines in the School of Health Sciences and other universities in South Africa training dental therapists, to guide community-based planning and implementation. However, it was limited only to the context of interprofessional community-based clinical training without exploring learning opportunities for a common interprofessional, classroom-based, theoretical foundational component for community-based education. Conclusion This study showed that there were several opportunities for community-based training for undergraduate dental therapy students in the public, private and NGO sectors. By taking students out of a closed university, hospital-based training centre and placing them in community settings, clinical training is contextualised in real world settings. The study reported many benefits of community-based training that could lead to the overall professional and personal development of a dental therapy student, and were reported from both the students’ and academics’ perspectives. These benefits prepared them for the work environment that they would soon enter. Barriers in the implementation of interprofessional community-based programmes were also noted and this needed to be addressed for the successful implementation of community-based training. This study also demonstrated that there was a need for a deeper engagement with theory and practice in making changes to the learning process of students and to curriculum development. The framework that was developed offered a structure for the planning and implementation of community-based training. It demonstrated the importance of student and academic engagement before adopting this pedagogical approach. It emphasised the roles and responsibilities of the education and health systems, and through this collaboration with each other, could produce relevant health professionals, including oral health care professionals, who could competently provide care to patients in diverse communities. This study also initiates exploration of further engagement for opportunities in community-based training involving multiple disciplines.