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ASSESSMENT DENTISTRY STUDENTS' PERFORMANCE IN EMERGENCY CARE
Kemelova G.
MD, PhD, Associated Professor, is a Director of Simulation Centre at the Karaganda State Medical University (Kazakhstan). ORCID ID https://orcid.org/0000-0002-1326-2363
Tuleutaeva S.
MD, PhD, Associated Professor, is a Head of the Children and Surgical Dentistry Department at the Karaganda State Medical University (Kazakhstan). Scopus ID 56801779400.
Aimbetova D.
Simulation Centre Deputy at the Karaganda State Medical University (Kazakhstan).
Issatayeva Zh.
MD, is a Manager of Educational Recourse of the Simulation Centre at the Karaganda State Medical University (Kazakhstan).
GarifuUina R.
5year student of Dentistry at the Karaganda State Medical University (Kazakhstan).
Abstract
Background: In the dental curriculum the topic of emergency care and insufficient knowledge and skills in dental practice were not widely available, especially for general dentists. A new simulation course based on managing a common to life-threatening emergency in the dental curriculum was implemented. The aim of the project to develop a simulation course for dental students in emergency care, and study of the course effectiveness and students' performance in a group clinical exam.
Methods: In the study 49 students' classroom academic performance, intermediate control results, questionnaires as well as the examiners' reviews and the feedback on behalf of standardized patients were used. The results were evaluated using the methods of the classical test theory (a Cronbach, the discrimination index and the correlation coefficient).
Results: The research evaluated a new format of the clinical exam in crisis management, the effectiveness of the electronic checklist, the attitudes of students, examiners and standardized patients to this exam format. The advantages and disadvantages of group clinical examination and the electronic method of assessment using tablets were highlighted, and the correlations of the current assessment approach with the results of final test were analyzed.
Conclusion: The simulation course, the group clinical examination, and e-checklist can be regarded as good methods of teaching and assessment of students' clinical competencies.
Keywords: group clinical exam, dentistry, emergency, clinical skills, assessment.
Practice points
• The simulation course of emergency care management for dental undergraduates is a mandatory subject.
• A combination of teaching clinical skills and clinical scenarios increases the students' performance.
• A group clinical exam promotes increase individual performance and responsibility.
• Assessment with e-checklist allowed giving a feedback timely
Introduction
Training a future dentist is difficult and diversified and depends on the development of knowledge and skills that will be furthermore applied in clinical practice (Perry et al. 2017). The foundation course in dentistry and skills development take the first three years of training, and are aimed at understanding the mechanism of the factors affecting dental health, the genesis of pathological conditions, as well as determining the main symptoms and conditions in dental diseases and
mastering methods of treatment and prevention of major dental diseases (Field et al. 2017). In the fourth and fifth years of education, students consolidate fundamental knowledge and develop practical clinical skills (Tiwana et al. 2007; Tan et al. 2011). However, although the curriculum mostly includes a course in clinical emergency care for future dentists, it mostly supposes theoretical study and does not sufficiently focus on the development of clinical skills in emergency situations which cannot be excluded in dental practice.
Clinical practice shows that, dentists may not be able to provide adequate help in emergency situations (Girdler et al. 1999; Pietila et al. 2009). The analysis of more than 100 sources provided by the Internet and the University library (articles, abstracts, textbooks and etc.) in the PubMed, Cochrane Library and other database showed that information on crisis management in a curriculum of dentistry and/or dental office is very scarce. During the routine dental care, dentists can encounter medical emergencies and they must be ready to manage crisis (Rubin et al. 2017). Medical emergency
in dental practice may take place, so dentists should be familiar with the crisis management and should be prepared to respond and effectively manage emergency conditions (Bichun et al. 2016). Some of the medicines used in dental practice, such as drugs for the local anesthesia, may be the cause of the anaphylaxis or heart attack (Roy et al. 2017; Cukovi et al. 2017). In order to address this issue, the new curriculum of 2017 included Simulation course in emergency for the 5th year dentistry students, and they were required to take simulation course in obligatory; the course gives 2 credits. The simulation course covers medical scenarios in the dental office.
The curriculum includes the most frequently - occurring urgent conditions in clinical practice in dentistry (Cardiopulmonary resuscitation (CPR), anaphy-laxis, acute coronary syndrome, trauma, and shock). Dentistry Students were trained in a simulation center equipped with the most necessary simulators and mannequins for mastering clinical skills in emergency. The training was carried out in accordance with the national protocols for the emergency medical care. One of the important criteria for the successful development of clinical skills in Dentistry is the assessment and analysis of the results. All the assessment tools used have benefits and limitations, but no method exists that can fully assess all clinical skills, so different assessment methods should be used. To monitor learning outcomes classroom performance and intermediate control were conducted in simulation laboratory. According to Miller's pyramid 'Model of abilities', both the analysis of clinical competences at the stages of 'Shows how' and 'Does', and student's clinical performance were assessed. Student competence achievement was conducted throughout the entire cycle of classes and included comments and feedback from the trainer. To assess the effectiveness of the training course, to evaluate the achievement of professional skills and the final results it was decided to conduct a comprehensive assessment in the form of a group clinical examination that covered the various competences of students (clinical skills, communication skills, counseling skills, teamwork skills and professional skills). The purpose of this work is develop a simulation course for dental students in emergency care, and study of the course effectiveness and students' performance in a group clinical exam.
Methods
This study was descriptive study and used quantitative and analytical methods. The objects of the study were the undergraduates in Dentistry in Karaganda State Medical University. The materials for the study were the results of ongoing monitoring, intermediate control and group clinical examination results, online questionnaire of students, feedback on behalf of examiners and standardized patients. Dentistry students (n=49), who participated in the clinical examination and online survey, standardized patients (n=2) and examiners (n=6) were involved in this study. The results of study and the feedback provided by the participants
were analyzed. The primary target point was the score at the group clinical session with a standardized scoring grid, observation, and video recording). In the study used data with median and 25%-75% percentiles.
Results
Training undergraduates in emergency care is a rather complicated process because it should involve not only learning how to tackle the problem a patient has, but also include critical thinking aspects, such as decision-making and problem-solving skills. According to the curriculum in Dentistry for the 5 year students ' Simulation course in emergency' was provided in the autumn semester and supposed 2 credits of 90 hours. 49 students learned this course at different time in small groups within the general schedule of the semester. The module included the main crisis situations students need to know about as well as Medical Emergency Prevention course, action plan, emergency drugs and equipment, and clinical decision making in emergency situations. This module of simulation course used different methods (simulation, team-based learning -TBL, case-based learning -CBL, and near-peer-assisted learning -NPAL) for training crisis management and different tools to assess the outcomes at the stages of learning: pre-test in basic knowledge in emergency issues, daily assessment with debriefing, and group clinical exam (GCE).
The most effective method to evaluate students' performance is daily assessment with giving constructive feedback. Students learned common crisis conditions for two weeks and they were assessed by simulation instructors every day. In the middle of the course there was intermediate test using checklist of mastered skills. Final test of students' achievements was as a group clinical examination and included 9 cycles at two parallel stations. The task for the station was chosen to be anaphylaxis and it was one of the list of the nine skills in emergency which had been mastered by students in the simulation course. In the group clinical exam the team consisted of three students - one leader and 2 assistants. The teams were formed randomly through a computer program, so in one team there were students from different groups, and some of them even did not know each other. The team list was published three days before the exam and the students could find other team members to revise the skills, to identify alleged responsibilities of the team members and discuss possible issues of the teamwork. The criteria for the checklist were developed, reviewed and evaluated by the faculty.
Previous experience, when paper checklist showed both advantages and disadvantages, and was used to develop a new e-checklist which had not been used in assessment earlier. The format of the e-check-list is 9 criteria points for assessing clinical skills, communication skills, teamwork skills, and decision-making skills. The results were calculated in percentage. Each point of the e-checklist was assigned a skill significance coefficient in this clinical case.
Figure 1 - Percentage of clinical skills and communication skills in check-list items
Figure 1 shows the ratio of clinical and communicative skills in e-checklist items. 7 points of the e-checklist for assessing clinical skills show how student mastered the emergency medical care algorithm and 2 points for assessing communicative competence is one-third of the total list of skills. According to the results of the GCE it was revealed that the highest average score of 11.3 was shown for Diagnostic search and the
lowest average score of 5.4. 'Effective compliance with patient feedback'. This is due to the fact that most students tend to learn only skills' algorithms and pay the least attention to effective communication with the patient. In our case, according to the clinical task, the standardized patient was a standardized relative as a distractor.
Figure 2 - Average score in the e-checklist for group clinical exam
According to the diagram in Figure 2, it should be noted that the diagnostic search for the patient's problem, emergency care according to the algorithm and the preliminary diagnosis were performed by the students at a fairly good level, which allows to conclude that the students' performance is good and they are well aware of and perform the algorithms in medical care. Patient monitoring in crisis and actions after crisis were carried out at a middle level. Teamwork and work with a standardized patient were performed at a low level. Probably, it is due to the fact that students and instructor paid more attention to the mastering of practical skills and
least to the communication skills. So, to improve effective communication skills among students and develop effective compliance with patients it is necessary to increase the number of class hours in clinical scenarios with standardized patients.
Studies of the exam participants' satisfaction were one of the study tasks. The students' satisfaction after the new format of the clinical exam was rated through an online questionnaire, in which 100% of respondents participated. 79.6% of respondents rated the level of exam quality as 'the highest', 16.3% - 'high' and 4.1% - 'medium'. Equipment of the exam included computer-enhanced mannequin and adjunct equipment
such as drugs, IV fluids, for trachea intubation and etc. 69.4% of respondents answered that the level of equipment at the exam was 'the highest', 22.4% - 'high' and 8.2% - 'medium'. 81.6% of the students answered that the quality of the task at the exam was 'the highest', 12.2% - 'high', and 6.1% - 'satisfactory'. To the question 'Is the time enough to complete the clinical case?' 87.8% answered 'yes' and 12.2% answered 'no. Overall, students were satisfied by the format, equipment and tasks at group clinical exam, which they were taking for the first time.
Respondents were asked to identify three positive and three negative aspects of this group clinical exam. As a positive side of the GCE they noted team working, because decision-making in a team allowed each team member to be friendlier, try understand strengths and weaknesses in short time, to be almost in the clinical situation, use the ability to combine teamwork and demonstrate communication skills. According to some respondents 'At the exam the real stress situation which may happen in reality was simulated. The situation was
close to the real one. Teamwork helped us to realize all our abilities and identify our shortcomings'.
As to the negative aspects of the group clinical exam the following was mentioned: 'not enough time to complete the clinical case', 'absence of the right drug', 'the mistake of one team member affects the evaluation of the results of the whole team', 'the leader cannot always control the situation, in this case it's hard to decide who should take the responsibility instead', 'some students were really surprised because before the exam they did not know their positions', 'in some teams students were much more knowledgeable while in some others all the participants were of low level'. Based on the results of the group clinical examination, students identified their strengths and weaknesses in emergency care. To assess the effectiveness of the simulation course in emergency and to reveal strengths and weaknesses, a comparative analysis of the outcomes was made based skill mastering on daily scale, intermediate border control and final exam.
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To assess the internal reliability in general, Cronbach on a scale of 0 to 1 was measured. In case if a=0, it is considered that the exam is completely unreliable because of the lack of agreement between all the marks. At a=1, the exam is considered absolutely reliable. The most acceptable indicator, when a from 0.7 to 0.9, and, if a is less than 0.5, it is considered unacceptable. In this study, a = 0.591, which characterizes the permissible value. It is also important to measure the standard error of measurement. In our case, the standard deviation of the final score of the discipline is 2.13 SEm%, the standard deviation of the average score (SD) is 3.33, the average score is 85.89%, which indicates a good preparedness of students. This parameter allows to find if students have achieved the required competence with the highest probability. The required level of competence is determined by experts before the exam, and it is officially accepted at University as a passing grade (or passing standard) of 75%, which is
same with the Angoff procedure. The results of the exam show that 12 (24.5%) of students are considered incompetent, who should pay attention to the learning outcomes in the future. The discrimination index ranges from -1 to +1. In this study from 0.01 to 0.18, which means that all students have the competences required by the training and educational standard (curriculum). The absence of the negative index of discrimination suggests that the students showed not bad competence; however, high final scores might be the result of overrating on daily basis and during intermediate tests on behalf of the instructor. Correlation with the final score as well as the discrimination index are calculated and represent the correlation coefficient with the final score. The correlation coefficient is measured from -1 to +1. In the study, the highest correlation coefficient of the group clinical examination is 0.99, and the smallest correlation coefficient is -0.01, which indicates a
low correlation of the daily control with the final control. To measure the reliability of the exam, it is necessary to measure a Cronbach after removing the point of measured values (control form). In normal reliability measurements, a should decrease, which indicates the reliability of individual values. In this study, a Cronbach of the group clinical exam was decreasing, which confirms the reliability of this exam, both daily and intermediate control tended to decrease, which reduces the reliability of control forms, which should be revised later. According to the feedback received from standardized patients (relatives) and examiners, the advantages and disadvantages of this examination were identified.
The advantages of the group clinical exam:
1. Economy. The length of the exam significantly reduced the time of assessment. Simultaneously it was possible to observe the actions of three students, which shortened the time of the exam. At the end of the exam, both students and departments of basic disciplines could receive the results of the exam, which were processed automatically, on the same day. Also, the exact calculation of the exam time, the number of student cycles allow to correctly distribute the load at the simulation center.
2. Objectivity. The tasks and e-checklist items assessed not only the knowledge and skills of students, but also the teamwork and communication skills.
3. Psychological aspect. Teamwork reduced stress for students. Three students in the room worked together making decision within the clinical case (leader and two assistant), supporting each other, but at the same time they tried to demonstrate their own knowledge and skills. Assessment of team reduced the emotional load for the standardized patients and examiners.
4. Communication skills. This format of the exam evaluates interpersonal interactions while working in team, which is very important for future healthcare professionals. Students demonstrated communication skills: quickly responded to the clinical situation, applied non-verbal means of communication, such as touching, used such techniques as inviting to discuss issues in private (asking to go out to the corridor), spoke loudly and precisely. When students worked with a standardized relative of the patient he/she collected additional information about the patient's problem (allergy, disease and life anamnesis etc.).
5. Solving problem. Students could demonstrate skills in decision-making in crisis, giving recommendations to relatives as to patient management and taking responsibility for the patient problem.
6. E-checklist. E-checklist was first developed and used to assess the knowledge and skills of the 5th year students of Dentistry, the device used was tablet. One of the important points of the examination is fast processing the data obtained and timely delivery of the results. Electronic assessment format is effective and easy to use; it makes collection of data, calculation and identification of students and result processing much less time consuming. Moreover, it allows expense reduction and convenience for the examiners when
choosing checklist items, facilitates the work for those responsible for collecting checklists and uploading the results to common database.
Disadvantages of the group clinical exam:
1. Not all students could demonstrate effective communication skills. Some students used time during the contact with the patient's relative ineffectively, showed insufficient knowledge of communication skills.
2. Some examiners didn't know how to use the new checklist effectively as they weren't gadget experienced.
Another limitation to the electronic method of evaluation is related to the efficiency of Wi-Fi connection, which is still a problem at the University and some examiners' lack of computer skills.
Conclusion
Introduction of the simulation course in medical emergency for students of Dentistry is practical taking in consideration the fact the requirements for health professionals have increased. The training process in medical emergency covers the most common urgent conditions and crisis that every undergraduate in Dentistry needs to master. To assess the effectiveness of training and the reliability of assessment tools various assessment methods should be used; this will improve the quality of the course and learning outcomes. The present study allows to make the following conclusions:
1. The simulation course in emergency care in Dentistry curriculum is need.
2. To develop clinical and communication skills in medical emergency it is necessary to increase the duration of training communicative skills including those of communication with patients.
3. Group clinical examination using electronic checklist facilitates data processing, saves time and other resources.
4. To ensure an effective educational process at the undergraduate level in Dentistry and improve the reliability of the daily assessment and intermediate control the tasks and criteria of e-checklist should be clearly defined at the stage of training.
Acknowledgement
The authors are grateful to all dentistry undergraduates, medical teachers and staff of the Simulation Centre who helped finding resources and gave great ideas for writing the article.
Conflict of interest
We decline any conflict of interest for this study. The study was organized on the authors' own behalf, without any sponsorship. There is no private or legal persons' commercial interest in the results of the study.
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ABSORPTION ACTIVITY OF BLOOD NEUTROPHILS UNDER CONDITIONS OF LIPID
PEROXIDATION ACTIVATION
Milyutin M.
Candidate of medical Sciences, Associate Professor, Department of Human Anatomy Russia, National research nuclear University MEPhI, Institute of atomic energy of the MEPhI, Obninsk
Myalin A.
Candidate of medical Sciences, Associate Professor, Department of Human Anatomy Russia, National research nuclear University MEPhI, Institute of atomic energy of the MEPhI, Obninsk
ПОГЛОТИТЕЛЬНАЯ АКТИВНОСТЬ НЕЙТРОФИЛОВ КРОВИ В УСЛОВИЯХ АКТИВАЦИИ ПЕРЕКИСНОГО ОКИСЛЕНИЯ ЛИПИДОВ
Милютин М.В.
Кандидат медицинских наук, доцент, кафедра Анатомии человека Россия, Национальный исследовательский ядерный университет МИФИ, Институт атомной энергетики НИЯУ МИФИ, г. Обнинск
Мялин А.Н.
Доцент, кандидат медицинских наук, кафедра Анатомии человека Россия, Национальный исследовательский ядерный университет МИФИ, Институт атомной энергетики НИЯУ МИФИ, г. Обнинск
Abstract
It is established that feeding of experimental animals (in this case - pigs) with food waste of a multi-day collection is essentially an experimental model of phagocytosis insufficiency. The most likely cause of these disorders is the activation of lipid peroxidation, which is typical for long-day food waste collection. The delay of neutrophil involvement in the phagocytic process was established with the help of different exposure in the thermostat. The most appropriate way to correct the detected violations is the introduction of antioxidants.
Аннотация
Установлено, что скармливание подопытным животным (в данном случае - свиньям) пищеотходов многодневного сбора по своей сути является экспериментальной моделью недостаточности фагоцитоза. Наиболее вероятной причиной этих нарушений является активация перекисного окисления липидов, характерная для пищеотходов многодневного сбора. С помощью различной экспозиции в термостате установлено замедление вовлечения нейтрофилов в фагоцитарный процесс. Наиболее подходящим способом коррекции выявленных нарушений представляется введение антиоксидантов.
Keywords: lipid peroxidation, experimental model of phagocytosis deficiency, indicators of phagocytic activity of neutrophils.
Ключевые слова: перекисное окисление липидов, экспериментальная модель недостаточности фагоцитоза, показатели фагоцитарной активности нейтрофилов.
