Undergraduate dental education aims to create dental professionals to meet societal needs and improve the overall population’s oral healthcare. To achieve this goal educational institutions must ensure that new dental graduates are competent as safe independent practitioners. They also need to be committed to continuing to development of their professional knowledge, understanding, and skills after graduation. Traditionally dental education has been taught in a bottom up orientation throughout several disciplines with the goal of producing a dental professional with a prescribed package of knowledge (Chuenjitwonga et al., 2018; Yip & Smales, 2000).
Competency based education (CBE) employs an educational perspective with a significant focus on judgement, patient centred care, and the medical aspects of dentistry. This is achieved by formative continuous learning and testing strategy throughout the program (Chambers, 1999; Chimea et al., 2020). Academic programs based upon CBE strive to provide students with learning experiences that allow the integrated development of multiple components of overall competence, rather than the isolated development of individual skills. Assessments focus on the students’ ability to perform generalized competencies in an increasingly wide variety of situations as they transition from a novice to competent practitioner (Chuenjitwonga et al., 2018; Hendricson & Kleffner, 1998). This shift to CBE from the previous traditional dental curriculum requires a significant shift in faculty philosophies, as well as entire program renewal (Hendricson & Kleffner, 1998).
The process of developing a CBE curriculum involves several steps and levels. An initial ser of competencies is created by identifying learning outcomes based on analysis of job responsibilities and tasks of practitioners currently working in the profession. These overarching competencies are then used to develop a curriculum that is focused on the information students require to learn to perform these overarching tasks/responsibilities. Hierarchal sequenced interdisciplinary learning modules are then developed and linked to specific competencies. Finally individual competency assessment techniques are developed and assessed. CBE also employs the importance of formative, lower stake assessments compared to summative one time testing (Hendricson & Kleffner, 1998).
Throughout the literature, there have been few studies completed on the faculty and student perspectives of CBE, with the results generally in favour of a CBE perspective to produce competent dental professionals.
An initial literature search including only dental hygiene did not yield a substantive number of references, therefore the search criteria was widened to include dentistry as a whole. A literature search of PubMed, Google Scholar, and ProQuest was conducted using terms including Competency based dental hygiene education, and competency based dental education. Article reference lists were examined to identify any additional relevant articles. Articles from the year 1995-2021(October) were included. During the 90s and early 2000s there was a surge in research interest surrounding CBE in dentistry, which coincides with the period that many dental curriculums were in the lengthy period of transition. Only articles that met the criteria of ‘English only’, and ‘full text’ were considered. Articles utilized are primarily from the Journal of Dental Education, Journal of Dental Hygiene, and the European Journal of Dental Education.
Competency Based Education
Competence is a global, multifaceted, blended construct consisting of; knowledge, experience, problem solving, experience/reflection, intellectual maturity, self-confidence, professional, ethical values, and fine motor skills in dentistry (Hendricson & Kleffner, 1998). Competencies themselves are defined as a specific set of performance, supported by understanding and appropriate professional values, necessary to begin independent practice and assume responsibility for continuing one’s professional growth (Chambers, 1998). Clinical competencies are tested via several forms; multiple choice questions, progress testing, objective-structured clinical examinations (OSCE), triple jump exams, critically appraised topic summaries, simulations, self-assessments, portfolios, and continuous formative assessment. These assessments are all based upon the stage of learning (Chimea et al., 2020).
In general, CBE asks three questions. What knowledge, skills, and values should an entry-level practitioner have when they graduate? What curriculum and learning experiences will help students to acquire this competence? How do we know if students have attained these competencies, and what proof is needed to certify competency? (Hendricson & Kleffner, 1998).
Stages of Learning
Becoming a competent healthcare professional is not a simple start and endpoint, it is a transition from a novice to competent learner (Chambers, 1998). The underlying philosophy of CBE is that students pass through the stages of competency. Through these stages they understanding, skills, and values on their way to becoming an independent practitioner. Each stage has differing learning requirements and testing strategies (Licari & Chambers, 2008). There are five stages of learning: novice, beginner, competent, proficient, and expert (Chuenjitwonga et al., 2018). The primary learning objective is for the learner to become progressively autonomous and for self-directed learning to take over from instructor teaching (Yip & Smales, 2000). This continuum of the learner discusses that knowledge is not assumed to precede performance, the two should interact and be present at the same time, increasing as the learner becomes more competent (Chambers, 1998).
Novice
All learners begin as a novice. At this stage, the learner is considered ‘unconsciously incompetent’. They are enthusiastic and excited to be entering the professional training, but unaware of their own limitations (Hendricson & Kleffner, 1998). During this stage learning and development rely heavily on well-structured learning and direct support from faculty (Chuenjitwonga et al., 2018). The learner observes demonstrations, obtains knowledge and guided instruction from expert educators, often in a simulation lab. During this guided instruction the learner benefits from constant coaching and feedback in a non-graded manner and can begin to self-assess (Hendricson & Kleffner, 1998; Tucker et al., 2018; Yip & Smales, 2000). Often during this stage learners are expected to demonstrate comprehension of foundational elements by written tests, and essays (Hendricson & Kleffner, 1998). Novice learners require great structure, clarity of goals, external rewards, and single, clearly defined approaches. They are extremely concrete in their thinking and are hesitant to deviate from specific learned rules and guidelines. They are reluctant to contemplate abstractions or alternatives, desiring instead precise prescriptions from instructors (Hendricson & Kleffner, 1998) (Chambers, 1998).
Beginner
Once the learner begins to develop foundation knowledge and skills, they can transfer this to different contexts. During this stage students gain some control and are now able to demonstrate this control in an ideal, simulated situation (Yip & Smales, 2000). During these first two stages students gradually take more responsibility in their learning (Chuenjitwonga et al., 2018).
Competent
Learners reach the competent stage at their end of their program (Chuenjitwonga et al., 2018). Instructors become less involved because the learner is considered to be at the skill level of an entry level practitioner (Tucker et al., 2018). Testing is exclusively performance based, meaning that the learner performs a competency under observation by trained evaluators without assistance. During this stage indirect measures of competence, such as multiple choice testing and essays are not appropriate. Execution of tasks are not as fluid and seemingly effortless as the expert practitioner. However, with adequate preparation, time and a limited number of distractions the learner can perform the task (Hendricson & Kleffner, 1998).
Proficient
Learners are at the proficient stage after working in practice for two to three years. At this point they have gained a more in-depth understanding, and now have the skills to handle a wide range of professional problems (Chuenjitwonga et al., 2018). Students are now able to understand the basis for their decisions and possess appropriate professional values and the ability to provide the dental needs of most patients (Yip & Smales, 2000).
Expert
This stage is achieved after more than ten years from the beginning of their training, this stage involves the integration and internalisation of professional practice (Chuenjitwonga et al., 2018).
Competency Based Education in Dentistry
The American Dental Education Association’s Compendium of Curriculum Guidelines state that every skill routinely performed by a dental professional need to be taught to competency within dental education (Tucker et al., 2018). The clinical portion of dental education in the United States typically accounts for 40-45% of curriculum hours within the program. Learners are often assigned a ‘family’ of patients with a variety of treatment requirements. Dental students are expected to diagnose, treat, and manage these patients under the supervision of faculty members within the school's clinic (Chambers, 1999). Traditionally, assessment of clinical skills were based on final products and outcomes. However, when looking at clinical outcomes alone there is little difference between novice or expert on operative dentistry techniques. The difference between these levels can be distinguished when considering the steps that are taken, the use of feedback, the definition of task, and the environmental conditions (Chambers, 1998). This displays the need for observational assessments rather than outcomes only.
Within the literature, there are several proposed approaches to defining competency based education in dental education. A behaviourist approach focuses on measurable behaviour, and that competence is the ability to successfully perform a task (Chuenjitwonga et al., 2018). A constructivism approach emphasizes that the learner should not only be evaluated at their current level of achievement but reflect upon their potential development (Chimea et al., 2020). A holistic approach incorporates the information the learner knows, the skills the learner possesses, the learner's disposition, and the execution of patient treatment. This approach considers a combination of context and underlying attributes including knowledge, skills, attitude, and performance (Tucket et al., 2018). (Chuenjitwonga et al., 2018).
History of CBE in Dental
CBE first began in the 1950s as a result of demand for better outcomes, and more accountability within public school systems. Shortly after, in the 1970’s it began being employed within various health disciplines, and later in the 1990s began within dental education (Licari & Chambers, 2008). While many educational institutions have transitioned to a more CBE approach, there are still many programs, and many educators who are resistant to the change and still teach in a more traditional way.
Teaching
Historically dental education has been built on accumulating didactic knowledge and then learning clinical skills. This didactic knowledge has primarily been measured by the number of isolated facts a learner can recite, and the number of procedures a student completes before graduation. It had been assumed that this didactic knowledge was a prerequisite for clinical performance, and this knowledge transfers spontaneously throughout clinical practice. The overall aim was to produce a dental professional with a prescribed package of knowledge upon graduation (Chambers, 1998; Yip & Smales, 2000). This traditional system has many weaknesses. It causes fragmented care, clinical inefficiency, and students thinking of their patients in terms of requirement numbers rather than patient needs and well being (Shiloah et al. 2016).
Traditional dental education had been shaped in a bottom-up orientation. Layers of instruction are superimposed on top of foundations with each discipline building their own vertical column of courses, independent of other specialty areas. This creates a vertically organized, compartmentalized curriculum, with each course being built upon prerequisites of preceding courses' knowledge (Hendricson & Kleffner, 1998). Students learned what teachers chose to teach them. Teachers were often specialists in certain fields, only teaching about their specialty and their passion (Yip & Smales, 2000). Compared to a bottom-up orientation in traditional dental educational models, CBE curriculum is more commonly developed in a top down orientation. Faculties begin with a set of well-validated competencies for the entry level practitioner and work backwards to create a logical sequence of performance-based learning activities and individual assessments that prepare learners for unsupervised practice after graduation (Hendricson & Kleffner, 1998).
Testing
Historically summative one-time high stakes assessments have been used to evaluate dental learners in a numerical format (such as board exams). This traditional approach leads to a superficial appearance to learning involving basic memorization and recall. Much of the content studied and reviewed is forgotten shortly after the examination. Rather than guide learning, summative approaches reflect a learners study habits and test taking ability (Chimea et al., 2020). Summative forms of education have the challenge of assuring that the directly observed assessment at a single point in time is an accurate indication of a student’s competence and a predictor of their future behaviour (Chimea et al., 2020). While summative testing in dental education does have high reliability, it has low generalizability and predictive validity. This is because summative assessments stress single measurements in very standardized circumstances, which is not indictive of real life practice (Chambers, 1999). The traditional evaluation criteria in dental education of the number of tasks completed are often insufficient to reliably distinguish the level of learning. Assessment based on outcomes only shows no difference between those in a novice stage, or in a competent stage. Rather the steps involved, and the critical thinking process needs to be involved within the assessment process to truly assess competence (Chambers, 1998).
Formative assessments provide a relaxed environment with instructors providing detailed immediate feedback and assistance when necessary. Formative assessments are utilized when learning is the focus. They provide often unmarked feedback to guide the learning process (McCann et al. 2001; Tucker et al. 2018). If earning is to be meaningful, it must engage the student in a deeper understanding of the content, which leads to long-term retention. Formative assessments are also numerous and non-graded (or carry low weight), which helps to reduce learner anxiety. (Chimea et al., 2020). Within dental CBE, numerous competencies place less emphasis on technical skills and more on judgement, patient centred care, and medical aspects of dentistry (Chambers, 1999). It has also been noted that during the novice & beginner stages excessive formal grading can decrease student's confidence, cause frustration and defensiveness in learners. Therefore, formative evaluations should remain predominately formative. Encouraging, practical suggestions, non-judgemental assistance and praise for accomplishments are essential for learner success (Hendricson & Kleffner, 1998). Within formative testing, reliability is lower as testing is not standardized, testing mimics that of real life practice. This mimic of real life practice also increased the generalizability of testing results. Depending on the testing tools developed, validity can differ (Chimea et al., 2020).
CBE utilizes a continuous assessment approach with both summative and formative in a holistic approach in which the triangulation of data from multiple methods, a variety of assessments at appropriate intervals within individuals learning. This multisource assessment data provides a more accurate representation of student competence (Chimea et al., 2020). Typically, formative education is early in the learning process (novice), and summative assessment occurs later, when the learner is entering the competent stage. Both summative and formative evaluation is utilized to assess performance against a standard to determine readiness to advance to the next level, or the need for constructive feedback and remediation (Fancher, 2000; McCainn et al 2001).
Development of a CBE program
Converting an existing traditional disciplined-based dental program into a competency-based program requires a significant philosophical shift among faculty and significant alterations in the overall curriculum structure (Hendricson & Kleffner, 1998). Development of CBE also involves gathering a dedicated panel of experts/stakeholders to assume responsibility for development (Fanger, 2000).
When developing a CBE program societal and patient needs are utilized to define a set of competencies and characteristics of an ideal graduate. These pre-defined overarching competencies and characteristics are then used to develop interdisciplinary curriculum, content, modes of teaching, and specific learning modules. Individual assessment competencies are then developed with these overarching competencies in mind and are then incorporated into both clinical and didactic teaching throughout every program course from the beginning to the end of the curriculum. The goal of individual assessments are to be educational, formative in nature, and to have the ability to provide a reliable measurement of student capacity while predicting future clinical performance (Chuenjitwonga et al., 2018; Yip & Smales, 2000).
Miller's pyramid (Figure 1) has been used to guide the assessment strategies, and practices in the education of those within the health profession. This pyramid represents the differing levels of clinical competence and the appropriate testing strategies for each level. At the base is “knows”, which represents the knowledge of basic facts. This is tested via factual questions, essays, and multiple-choice testing. Often used within the early stages of novice learning to test basic didactic knowledge. The second level is “knows how”. This involves learners applying their knowledge to analyze and solve problems presented in standardized case-based scenarios. This level also incorporates essays, oral questions, multiple choice questions, along with triple jump examinations, and clinical context-based questions. At the “shows” level, learners demonstrate the application of skills within authentic conditions that allow for supervised interactions between learner and healthcare patient. This level can be compared to the beginner stage, where skills can be transferred to demonstration within controlled, ideal situations. The “does” top level involves the learner being able to perform core competencies and responsibilities under various conditions with limited support from instructors. During these last two levels, learners are assessed via OSCE’s, high-fidelity simulations, direct observations, self-assessments, portfolios, longitudinal evaluations, and clinical competency examinations (Chimea et al., 2020). When developing a CBE based curriculum these levels are considered to determine what learners are capable of and what testing strategies are appropriate at differing stages within their learning.
An important aspect of individual competency assessment tools is their reliability and validity. The reliability of assessments refers to the consistency and reproducibility of the results. Consistency of learner performance rating, with the use of multiple examiners across a broad sampling of cases, is essential. The validity of an assessment instrument refers to its ability to measure what it is intended to measure. This is achieved in the development of assessment programs to minimize the sources of error/bias when evaluating assessments (Chimea et al., 2020).
Rather than a traditional bottom down teaching approach, courses should simultaneously teach learners core curriculum competencies throughout the entire program. Learning modules within CBE are structured in a stair-step orientation working from the ground up acquiring foundational skills before proceeding to more complex competencies across different disciplines. Testing procedures require learners to demonstrate mastery of the competency embedded in each learning module before moving on to the next (Hendricson & Kleffner, 1998). These learning modules are continuous, not subsequent.
Effectiveness of CBE
Throughout the literature, there were few, but well done studies that evaluated the effectiveness of implementing a CBE curriculum within an individual dental hygiene or dentistry program.
Student Perspective
McCann et al (2001) investigated CBE being introduced into an individual dental hygiene program, the six years following development and implementation were followed closely. From 1995 when CBE was introduced, until the final year of the study in 2000, there was an exponential increase in the percentage of students passing a senior exit exam (SEE) on their first attempt. Which translates to an increase of competence as a result of implementation. During the first year of the study, prior to implementation of CBE, period the majority of students passed only four of eleven sections. Then after in the final years of the program, after implementation the majority of students passed all 11 sections. Table 1 displays the improved test scores over the years following the development of the CBE program.
A study by Tucker et al (2018) evaluated the implementation of a competency based dental hygiene clinical program from a traditional grade based program at the University of Arkansas for Medical Sciences by gaining both student and faculty perceptions. The students involved in this study experienced two semesters of traditional grade based evaluation and two semesters of competency based education. The student survey revealed that they were favourable to the change to CBE (table 2) The majority (80%) of students involved in the CBE portion of the course agreed, or strongly agreed, that they feel as if the CBE portion of the course better prepared them to be competent dental professionals.
Faculty Perspective
The Faculty at the University of the Pacific’s School of Dentistry have expressed for years that with their current grading system there were certain students that “everyone knew were incompetent” who were not being flagged within the grading system and were being pushed through. At the time their grading system was typical for dental education throughout the United States and Canada. Minimal productivity requirements were set in each discipline (endodontics, fixed/removable prosthodontics, etc). Grades on daily technical work were averaged and combined with that of productivity. Daily grades tended to range from satisfactory to excellent, as faculty focused primarily on the technical properties of the finished dental procedure. No clinically unacceptable work was allowed to leave the clinic, which resulted in the majority of work being in the ‘C’ range or better regardless of the student's level of ability, and instructor amount of instructor involvement. This resulted in final grades being based primarily on productivity alone, and only one third being based on daily assessments. Once developed, the school implemented a competency rating form, which is noted in figure 2. This form focused on the learners understanding the foundations of clinical procedures, diagnostic ability, recognizing and working within the limits of one's competency, placing patients overall treatment needs above the opportunity to meet clinical requirements, effective organization/use of time, and respect for patients, and good professional relations. These aspects were each scored on a scale of 1-9. Students who are progressing satisfactorily receive a 5,6 or 7. If faculty feeds that students are excelling and need an enriched experience (more challenging case, or greater freedom from faculty observation) the student gets an 8, or a 9. The ‘not becoming competent’ category is a 3 or a 4. If these marks are received the learner will receive feedback and remediation. Once a faculty member had worked with a student and found that progress is still not improving, the student would be given a 1 or a 2 signalling that the student needs to repeat or be counselled out of the program. Once implemented, in the first year these marks overwhelmingly concentrate in the 5-7 range of ‘becoming competent’ range, with 4% of learners requiring significant remediation. Within the second year, there was a greater dispersion, 75% having an appropriate level of experience, 6% in need of remediation, and 1% where there was significant doubt of year completion. After implementation grade inflation had been brought under control, and for the first time faculty were able to dismiss a student who was a danger to patients based on overall patient management and lack of clinical judgement. The implementation of this also allowed for the identification of students who were not progressing appropriately and provided more information about what their difficulties involved so that appropriate assistance could be provided. (Chambers, 1999).
Licari and Chambers (2008) developed a questionnaire to assess the perceptions and understanding of faculty regarding competency based dental education and to determine the extent to which it is being applied within schools across the United States. This questionnaire measured opinions regarding competency and foundation knowledge, use of competencies in the school’s educational program, and impact of competency-based education. Overall, a significant number of schools responded, 94% of schools responded. The surveyors used the accepted definition of competency as “a set of skills, knowledge, and values that characterize beginning dentists”. This definition was correctly recognized by fewer than half of the respondents. The respondents noted that the concept of CBE was understood and valued among school administration and others responsible for curriculum development. However, faculty members had mixed feelings about the approach. Only 27% reported that CBE had improved the quality of students graduating from dental school, and 60% reported that it improved curriculum management. 23% reported that competency is just a new way of talking, and not a change in education. 18% stated that it got their school through accreditation with no actual changes to the curriculum being made. While there are many cases where CBE has led to more competent students, better patient care, better diagnostic and clinical judgement skills, and an overall improved education throughout a wide variety of professions. It also needs to be recognized that some faculty are frustrated with a change to the traditional education model. It is important to note that these results can differ based upon dental educators who frame their work in terms of improving learning outcomes, and those that frame their work in terms of their technical skill, or time clocked in. Faculty dedicated to the process of learning are more likely to report that CBE has been effective as both a framework for curriculum reform and the clinical model resulting in improved student performance. Those that do not value the learning process may be frustrated, mystified, or openly resistant to the switch to an educational program based on competency.
The same study discussed within the student perspectives by Tucker et al (2018) also investigated faculty's perception of a change to CBE. This survey revealed that all faculty agreed that by the end of the program the majority of students are prepared for private practice. The faculty also noted that they were able to evaluate the student's clinical skills more effectively within the competency based program compared to that of the traditional grading and that the majority of students were better clinicians at the end of the competency based program. The SEE was used as a tool by faculty to better modify and adapt the programs curriculum to improve student outcomes each year, the different disciplines marked can be seen in table 1.
Conclusion
Competency based education is not a new teaching concept in healthcare, but a relatively unresearched concept in dental and dental hygiene curriculums. While there is a multitude of information regarding CBE in other health professions, particularly medical and nursing education, there is not a significant amount within dentistry and even less within dental hygiene. While there is literature surrounding the benefit of implementing CBE within the dental curriculum, there is little information surrounding the impacts of its implementation, both the positives, and the negatives. This is surprising, as much of the resources and information found was from the late 1990s and early 2000s. If implemented within curriculums, many institutions would be reviewing its efficacy.
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