Junaid Sarfraz Khan1, Saima Tabasum2, Osama Mukhtar3
How to CITE:
Khan J S, Tabasum S, Mukhtar O. Towards a Competency-Based Dental Education Framework: Defining Competencies. J Pak Dent Assoc. 2012: 21 (02): 71 – 77
The objective of this studywas the validation of competencies by all stakeholders and to group them intomanageable,measurable, reproducible and identifiable dental graduate capabilities.METHODOLOGY
Dental faculty, students of all academic years in institutions affiliated with University of Health Sciences and the public were administered a 30 item questionnaire listing the graduate dental competencies in 2011. Data was entered into Statistical Package for Social Sciences (SPSS) v.16 and nalyzed by using Confirmatory FactorAnalysis (CFA)withVarimaxRotation under the conditions of Eigenvalues > 1 and loadings ≥ 0.2. Parametric tests were applied to the responses of all stakeholders. ‘Agree’ response was given a score of ‘1’ and ‘disagree’ was given a score of ‘0’ for each uestion/characteristic. These scores were added up to compute a new variable as total score of the respondents. p 0.05was considered as significant.
2037 questionnaires were collected (1789 from students, 88 from faculty and 160 from the public. The value ofKaiser-Meyer-Olkin (KMO) was 0.924, where Bartlett’s Test of Sphericitywas significant (p-value<0.05). In Confirmatory Factor analysis (CFA), five components were extracted with Kaiser Eigenvalues greater than 1 accounting for 40.58% of variance. Total 30 items had internal consistency reliability of 0.876 (Cronbach'sAlpha). Analysis of Variance (ANOVA) showed a significant difference in Response scores of various stakeholders (F=113.2, p<0.05). Post Hoc Tukey Test revealed that General public scored significantly lower than the students and faculty.
Graduate dental outcomes are not wholly generic; there are cultural, societal and structural variations that affect the desired regional final competencies. It is therefore important for Pakistan to design its own outcomes for the programrather than to import themfromtheWest.
Competency-based dental education, outcome-based curriculum, competencies, baccalaureate of dental surgery
urriculum broadly falls into two categories, prescriptive and outcome-based. In the outcome-based curriculum the competencies that are required to be achieved by the candidates in the cognitive, psychomotor and affective domains are clearly defined and so are the means to achieve those competencies.
French et al define Competency-Based Medical Education (CBME) as an approach to preparing physicians for practice that is fundamentally oriented to graduate outcome abilities and organized around competencies derived from an analysis of societal and patient needs. It de-emphasizes time-based training”, [as seen in the prescriptive models]”and promises greater accountability, flexibility and learner-centeredness”.
CBME frameworks have been applied previously to post-graduate specialist training, because of the relative ease of applying a competency-based model in their training and learning as well as in the assessment methodologies in a more specific competency-based environment of postgraduate education. However, over the last two decades, increasing public, peer and industry accountability, rising cost of higher education, information overload and an emphasis on improving healthcare delivery in an ever-deficient global healthcare system, there has been considerable pressure to apply competency-based medical education reform models to undergraduate education aswell.
Harden in defining CBME as an orientation towards curricular outcome presented his three circle model representing educational outcomes shown in figure 1. Central to the model of competency-based undergraduate dental education is the identification of independent competencies that a graduate dental practitioner should possess and their presentation in a manner that could fully represent these capabilities as they reside in integrated professional performance.
Once these competencies or outcomes of the undergraduate dental program are defined, the entire curriculum can be modeled around them. The curricular outcome no longer is a time-based acquisition of subject and discipline knowledge, skills and behavior attributes disconnected with each other, but rather it becomes a framework in which the aim of all training and learning from day one of dental education is to attain the final competencies. The paths taken (i.e. various curricular models) towards that ultimate goal could be varied but all have the same objective.
In Pakistan, the dental undergraduate curriculum is wholly prescriptive. The curricular document is nothing more than a list of topics. In an attempt to develop outcomes for the four-year Baccalaureate of Dental Surgery program (BDS), Khan et al developed the graduate dental competencies, thirty in all, which they broadly divided into ‘professional behavior’ and ‘clinical skills’ outcomes . This study attempts to validate the findings of Khan et al and to group their broad competencies into manageable, measurable, reproducible and identifiable dental graduate themes/capabilities. These then, can be stated to be a requirement of all dental graduates to be described as a “safe dental practitioner”, and a necessary acquisition, before they can be registered as dental practitioners in the community.
In our study,we set a questionnaire based on the thirty characteristics of the Junior Dental doctor in an effort to validate the general most important characteristics/traits that should be present in a junior dental doctor graduating from the University of Health Sciences, Lahore, BDS program. The population of the study included students of all ProfessionalYears of Baccalaureate of Dental Surgery (BDS) of 2011, their faculty and the general public. Students of all professional years of BDS program were included in the study to validate the characteristics for students at different levels of education and academic exposure. The faculty and general public were included in the study to determine their perception about the characteristics of a junior dental doctor. The research study was conducted in THREE public and SEVEN privatemedical colleges i.e. all the colleges affiliatedwith theUniversity.
Approximately 2000 questionnaires were collected anonymously from all three stakeholders.The samplewas adequate enough for the FactorAnalysis,which required a minimum, 10 samples per item. All the data was entered into Statistical Package for Social Sciences (SPSS) v.16 and analyzed by using Confirmatory Factor Analysis (CFA) with Varimax Rotation under the conditions of eigenvalues > 1 and loadings ≥ 0.2. Questions that loads <0.2 on the expected factor, loaded on two factors or were grouped within an unexpected factor were thoroughly examined. Chi-Square Test and Analysis of Variance (ANOVA) were applied to the responses of all stakeholders to determine the association amongst them. 'Agree' responsewas given a score of '1' and 'disagree'was given a score of '0' for each uestion/characteristic. These scores were added up to compute a new variable as total scores of the respondent. p<0.05 was considered as
Overall 2037 questioners were collected from three stakeholders (1789 fromstudents, 88 fromfaculty and 160 from the public). Of these, 1466 respondents (72%) were female and 571 (28%) were male. The value of Kaiser- Meyer-Olkin (KMO) was 0.924, where Bartlett’s Test of Sphericity was significant (p-value<0.05). In Confirmatory Factor analysis (CFA), five components were extracted with Kaiser Eigenvalues greater than 1 accounting for 40.58% of variance. Total 30 items had internal consistency reliability of 0.876 (Cronbach's Alpha).The results of CFAare presented inTable 1.
Fig. 2- Percentage of ‘agree’ responses for each question by different stakeholders Table 2 shows the relationship between the general outcomes, competencies, and Harden’s three circle model shown in Fig ‘1’.
A significant association was found amongst the re spons es of diffe rent s t akeholder s in all questions/characteristics (p<0.05). In all the questions, 'disagree' response to the questions was higher amongst the General Public. The percentage of 'agree' responses for each question by different stakeholders is shown in Fig.2. Analysis of Variance (ANOVA) showed a significant difference in Response scores of various stakeholders (F=113.2, p<0.05). Post Hoc Tukey Test revealed that General public scored significantly lower than the students and Faculty. It may be because the general public is less familiar with the dental traits/characteristics required in a junior dental practitioner and in their inability to 'understand' the traits and their contextual relevance. Mean response score of three stakeholders are presented in Fig.3.
University of Health Sciences is striving to bring dental education in the country in line with the Best Evidence Medical Education practices worldwide . In order to do that, it has to set things right from the beginning. The curriculum needs to be redesigned into a competency framework. With competencies defined clearly as the outcomes of the 4 years BDS program, systems and methodologies can be developed to ensure that these objectives aremet and the assessment can focus at all levels of education in achieving these competencies Khan et al, in their study identified 30 graduate dental competencies,which they grouped into ‘clinical skills’ and ‘professional behavior’ . In this study, these 30 competencies were validated by the faculty, the dental tudents (at all academic levels) and the general public as important minimum requirements/capabilities possessed by a graduate dental practitioner, one who can safely practice in the community.This study is important, since it is the first of its kind in Pakistan and one that involves the entire cohort of dental students in all academic year in the province of Punjab.Moreover, all the stakeholders i.e. the students, the faculty and the general public were included in the competency-validation process.
The internal consistency reliability of 0.88 (Cronbach’s alpha) in the study is much higher than the 0.70 or 0.80 thresholds generally considered acceptable for scales . Through analysis, the 30 competencies were grouped into five final outcomes/ competencies of the BDS program i.e. clinical competence, confidence and a multidisciplinary approach; role of dental house officer in the health sciences; treatments planning; attitude, ethical stance and legal responsibilities and, communication skills, information handling and teaching. Applying Harden’s three circle model of curriculum outcomes (Fig 1), within these 5 final competencies, the general competencies can then be grouped into performance of tasks, approaches to tasks and professionalism, giving the entire framework a hierarchical structure. This is because any competency identified as level-1 (performance of tasks) is by default associated with the higher theme of approach to that task which in turn is associated with the larger concept/competency of professionalism.
To give an example, as seen in table 2, the competency ‘understands the importance of post-treatment follow-up’ is grouped under ‘Treatment Planning’. It is identified as an ‘Approach to task’ competency i.e. level-2, and is associated with level-3 i.e. Professionalism competencies in all the groups. This unique matrix-framework can then be used to develop the dental curriculum in a top-down approach using disciplines and subjects in all academic years to represent these competencies. The curricular framework then becomes a road-map from day one of education in a systematic, thought-out approach to attaining these competencies.
Competency based dental education (CBDE) does not specify any particular teaching methodology . CBDE requires, that students should be directly engaged in their education, faculty should support students in gaining these competencies, the goals should be realistic and the framework to achieve them clearly defined, there should be adequate feedback and student-support mechanisms in place, education and assessment should be aligned with the competencies to be gained, the program should not be limited by time but by the outcomes and their achi evement s , and f inal ly a const ruct ivi s t methodology/process should be established for development of cognitive, affective and psychomotor domains. These principles can be adopted within any curricular methodology, problem-based learning, hybrid learning methodology, task/care-based education etc., as long as the aimof teaching and learning is to finally arrive at the desired, pre-defined competencies through a process of valid and reliable assessment.
In our study, the fact that the general public ‘agree’ responses to the items were significantly lower than the students and the faculty, can be due to their lesser familiarity with the dental traits/characteristics required by the junior dental practitioner and in perhaps their inability to ‘understand’ the traits and their contextual relevance. This could be identified as a limitation of this study. An ‘Urdu-version’ of the questionnaire could have been developed or the public could have been interviewed in which case, each item could have been explained to them clearly before eliciting their responses against it. Nevertheless, this study provides a clear platformtomove to the next stage of a competency-based-dental-education (CBDE) framework that could be applied to dental education inPakistan.
Graduate dental outcomes are not wholly generic; there are cultural, societal and structural variations that affect the desired regional final competencies. When constructing the educational framework around their competencies, this regional variability needs to be factored in. It is, therefore, important for Pakistan to design its own outcomes for the program rather than to import themfromtheWest.
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