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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 10  |  Issue : 2  |  Page : 181-186

Using qualitative research for curricular redesign of communication skills training in a dental school: From gap identification to leveraging stakeholder voices for facilitating change


1 Urja-Catalysts for Transformation, Bengaluru; MHPE Student, School of Health Professions Education, Maastricht University, The Netherlands; Department of Public Health Dentistry, D A Pandu Memorial RV Dental College, Bengaluru, Karnataka, India
2 Department of Community Medicine & Dean Medical Education, Believers Church Medical College, Thiruvalla, Kerala, India

Date of Submission19-Oct-2022
Date of Acceptance10-Nov-2022
Date of Web Publication23-Dec-2022

Correspondence Address:
Dr. Jyotsna Sriranga
63, Sri Shankara Krupa, Hare Krishna Road, 3rd Cross, 7th Main, Akshayanagara West, Bengaluru - 560 068, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/amhs.amhs_240_22

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  Abstract 


Background and Aim: Poor patient-health care provider (HCP) communication skills are a major contributor for noncompliance, lack of trust and sometimes even violence against the HCPs. The students are expected to pick up communication competency through observation and self-learning. In this context, there is a need to bring in the implicit curriculum to the ambit of the explicit curriculum. Here, the focus was on “listening” to the stakeholder's voice to establish the need for explicit communication skills training and justify its importance to professional practice. Materials and Methods: A socioconstructivist world-view and qualitative research methodology was adopted. The method of data collection was interviews and focus group discussions. The dean, teaching faculty, students, and patients were interviewed until data saturation. The data were transcribed and a team of 3 coders coded the data manually using inductive methods. Results: This study identified the gaps in the existing curricular framework for teaching communication skills. Six major themes emerged from the research. The research process served as a tool to leverage on the gaps identified and build a customized communication skills training program for students. Conclusion: The process of qualitative research involves the extensive interviews and discussions with stakeholders to better understand the underlying issues. It initiates dialogs and helps to co-construct solutions to the educational problems. Such self-discovered solutions for change in curriculum that emerges from key stakeholders from within the institution, they are more likely to be accepted, adopted and “institutionalised”.

Keywords: Communication skills, curriculum, qualitative research, stakeholder's voice


How to cite this article:
Sriranga J, Chacko TV. Using qualitative research for curricular redesign of communication skills training in a dental school: From gap identification to leveraging stakeholder voices for facilitating change. Arch Med Health Sci 2022;10:181-6

How to cite this URL:
Sriranga J, Chacko TV. Using qualitative research for curricular redesign of communication skills training in a dental school: From gap identification to leveraging stakeholder voices for facilitating change. Arch Med Health Sci [serial online] 2022 [cited 2023 Jan 31];10:181-6. Available from: https://www.amhsjournal.org/text.asp?2022/10/2/181/364965




  Introduction Top


Poor patient-healthcare provider (HCP) communication skills have been identified to be major contributor for noncompliance, lack of trust and sometimes even violence against the HCP.[1],[2],[3] This understanding has led to “communication skills” being universally identified as one of the “core competencies” required for any health care professional.[4],[5],[6],[7],[8],[9],[10],[11],[12],[13]

For dental undergraduates, communication skills involve verbal and nonverbal interaction with the patients, faculty, peers, and the oral health care team. It involves the identification of relevant information being provided by the patient, which in turn requires active listening skills and empathy. It requires professional judgment regarding the appropriateness and medical accuracy of the information being provided to the patient. The HCP also needs to be sensitive to the patient's needs and maintain confidentiality of the information received.[1]

In India, Dental Council of India (DCI) regulates the dental education system. The DCI, in its DCI BDS Course Regulations, 2007[13] has listed out that the graduate dentist should be able to (1) Assess patients' goals, values, and concerns to establish rapport and guide patient care (2) Communicate freely, orally and in writing with all concerned. Although this requirement is laudable, the nuances of how communication skills are to be taught or assessed is not spelt out by the apex regulatory body. In our dental school too as in several other dental schools in India as well, the students are expected to pick up communication competency through observation and self-learning. As such, there are no organized formal communication skills training sessions.

The curriculum experienced by a learner includes the caught and the taught curriculum. While the taught curriculum is explicitly detailed in terms of clarity regarding learning objectives and measured outcomes, the implicit curriculum is often expected to be picked up by the learner. Implicit curriculum involves sporadic and unscripted learning.[14] Hence, the learning quality is neither measured nor assured. In this context, there is a need to bring in the implicit curriculum to the ambit of the explicit curriculum.

The problem often faced by curriculum designers when tasked with review of existing curriculum, is to justify the inclusion of a new topic, particularly in the backdrop of an overloaded curriculum with competing resource requirements.[15] The curriculum designers as a first step have to establish the need for an explicit curriculum for the new topic/subject under consideration by justifying its importance to professional practice. The question often raised is how to develop a “research evidence” in education to bring about the change. While policy documents can help set the direction, it is often the stakeholder's voice which has the strength to justify the need for change in status quo. Researching the stakeholder's voice requires the researcher to adopt a socio-constructivist/critical theory world-view compared to the positivist or postpositivist world-views.[16] This stakeholder's voice is best explored using a qualitative research approach which looks in-depth towards the what's, why's and how's of the educational problem.

Hence, in this article, we describe in detail how we approached the review of an existing communication skills training using a qualitative research design to identify the gap in the implicit part of the curriculum in a dental school; the description of how the educational stakeholders' voice was brought to be heard and documented. It also includes identification of the problems which arose because of the gap, the potential solutions to address the gap and how we leveraged this for initiating advocacy with institution's academic decision makers to bring in the communication skills training into the explicit curriculum domain is shared. This detailed description of the socio-constructivist approach and the processes used is done with the hope that this will facilitate its adoption or replication by the journal's audience outside the local context where the study was done.


  Materials and Methoids Top


Methodology and reporting of qualitative research

A socio constructivist world-view influenced our interview process. As a research team we sought to co-construct the “truth” with respect to the research question under consideration i.e., “What is the gap with respect to communication skills training in the implicit curriculum of the dental school?” This warranted the need to adopt a qualitative research methodology to explore and find the answers to our research question. The method of data collection was interviews and focus group discussions (FGDs).

While there are several guidelines available to aid reporting of qualitative research, the authors chose the Consolidated Criteria for Reporting Qualitative guidelines[17] owing to its popularity and thus its ease in adoption by the intended audience of this paper.

Consolidated Criteria for Reporting Qualitative Domain 1: Research team and reflexivity

The principal investigator is a qualified Public Health Dentist, trained in qualitative research and has prior research experience with qualitative methods of data collection. She has a background in public health dentistry and health professional education and is a faculty in a dental school. She believes that communication skills are crucial for a successful doctor-patient interaction and a vast majority of the conflicts can be avoided by practicing good communication skills. She also believes that communication skills can be taught to students and should be given due attention in the curriculum. Others in the research team also have experience in doing qualitative research and educational leadership to recognize its utility in perspective transformation of stakeholders and thereby facilitate their participation in the changes dictated by the data-driven themes that emerged from the qualitative exploration.

Consolidated Criteria for Reporting Qualitative Domain 2: Study design

The researchers wanted to understand the stakeholder's voice toward “communication skills of dental HCPs.” The stakeholders chosen were those on whom the communication skills of dental HCPs had a direct impact. The students were our first choice as they had to pick up communication skills through an informal curriculum and had to figure out effective communication strategies on their own. Our second set of stakeholders was the patients who visited the dental school for treatment. Since these patients were the beneficiaries of the communication skills, it was crucial to understand their expectations from our trainee dentists. The teaching faculty who supervised the students were the next stakeholders under consideration. The teaching faculty spent considerable time observing and giving feedback to the students in their chair-side discussions, and thus had a good vantage point to observe the communication skills. The Dean, being the curriculum leader, was strategically included to understand the vision, felt needs, and road map for enhancing the communication skills of students. A total of 37 individuals were interviewed.

The Dean and faculty were selected based on the purposive sampling. The students and patients were invited to participate in the study. Data were collected at the workplace for the dean, faculty, and students while the patients were interviewed in an informal setting. Only the principal investigator and the participants were present at the time of data collection. The participants were assured that confidentiality will be maintained and their individual identities will not be revealed. Informed written consent was obtained from all the participants. Ethical clearance was obtained from the Institutional Review Board (IRB no: 120/Vol-1/2015).

Data collection

The principal investigator J prepared the Key Informant Interview (KII) guides and FGD guides based on literature review and the research objectives. The interview guides were developed after initial review of literature and brainstorming with the research team. All the relevant domains were identified and pilot tested for cognition and comprehensiveness. The interview guide evolved as the research progressed. A total of six FGD's (Two with the faculty group, three with the student group and one with the patient group) and four KII with the faculty in key academic and administrative positions were conducted till data saturation was reached. The interviews lasted between 25 and 45 min. All the interviews were audio-recorded and transcribed. The data collection and analysis progressed together.

Consolidated Criteria for Reporting Qualitative Domain 3: Data analysis and findings

A team of 3 coders coded the data manually using inductive methods. The data was coded individually and then discussed for consensus. A thematic analysis of the emergent data was done. Following the thematic analysis, six major themes were identified. Theme 1: Relevance of communication skills for dental HCPs; Theme 2: Current communication skills and its impact on patient management; Theme 3: Language as a significant factor in effective communication skills; Theme 4: Body language as a communication tool; Theme 5: Curricular support for teaching communication skills; and Theme 6: Teaching and Assessing communication skills. The thematic analysis was shared with the participants for member-checking. Based on the information obtained, the dean and one of the faculty who was heading the department were re-interviewed.

Description of the themes

Theme 1: Relevance of communication skills for dental health care providers

The respondents unanimously agreed that communication skills are essential skills, sometimes more important than technical skills. It influences the patient (by establishing rapport, improved confidence and trust, improved compliance), benefits the student (improves student confidence and provides positive energy). The stakeholders said if dental students are not trained in communication skills, then they will miss out on this important skill in patient care.

Patient 1: “If the student doesn't know the language and be able to communicate, then I won't get the treatment done as needed.”

Student 3: “So when I am talking to them (patients) in a nice way, they will be much happier and will reveal more things like what is happening to them…that is very much important for us to diagnose.”

Faculty 3: “Communication is emphasised in all higher education (courses). If our students don't learn (this essential skill), they will be at a loss compared to other students.”

Researcher reflexivity: With this, the felt need for training students in communication skills was co-constructed with our stakeholders. This was our first step in creating research-backed evidence base.

Theme 2: Current communication skills and its impact on patient management

The stakeholders could clearly identify the influence of communication skills on patient management. Some reported a positive influence with the patient benefitting by the communication skills. Others reported patient–dentist conflicts, poor compliance and drop outs due to poor communication skills.

Student: “I was unhappy that I couldn't manage that patient by myself. It was really difficult for me to convince. I really lost my temper. The patient did not come back.”

Patient: Some students have spoken very nicely to me and I am very happy with their service. Some of them don't know how to speak properly at all.

Dean: “We have got postgraduate students who have done complete dentures, there are a few flaws in it but the patient is very happy. We have got students who have done everything properly but because of lack of communication skill, the acceptance by the patient is not proper.”

Faculty: “When patients complain that students don't do a good job, we know it is because of poor communication. Then we have to solve it.”

Researcher reflexivity: Identifying the impact of communication skills on patient management was significant, since good patient-management is crucial for the institution, faculty, students and the community. This discussion built the foundation for the narrative on the need to train students in communication skills.

Theme 3: Language as a significant factor in effective communication skills

Patients visiting our dental school feel comfortable to converse in the local language, Kannada. On the other hand, our students come from across India and are not necessarily conversant in Kannada. This creates an additional barrier in communication, which was brought forth by the patient's voice.

Patient: “They should know to speak in Kannada. I could not understand what one of the students was saying. She was talking in Hindi.”

Student: “I was not fluent in kannada. That patient had no confidence in me.”

Dean: “When it comes to patients they have to talk in their understandable local language.”

Researcher reflexivity: The language as a barrier to communication was strongly expressed by all the stakeholders. We agree that language is a significant factor in effective communication skills. Identification of this gap paved the way for training students to be conversant in the local language.

Theme 4: Body language as a communication tool

Patients and students alike identified the significance of body language as a communication tool. Poor body language was perceived as lack of confidence. This in turn influenced the dentist-patient relationship.

Patient: “I also felt they were scared or not so very confident as to what they were communicating. I feel they should be bolder when they are explaining.”

Student: “Comforting the patient, the way you talk, the body language you have, the way you treat, the way you smile, the way he responds back, that is important.”

Researcher reflexivity: Body language is a powerful communicator, irrespective of the language being used for verbal communication. The stakeholders' voice highlighted the need for training students in nonverbal communication skills. This was taken into consideration while designing the communication skills workshop.

Theme 5: Curricular support for teaching communication skills

This emerged as core theme in our exploration. The dean, faculty and students identified a significant curricular gap in prioritising development of communication skills. Students and faculty said that while communication skills were part of the implicit curriculum, it was grossly inadequate and completely unstructured. Students expressed that they learnt communication skills by themselves through experience.

Student: “In department we learn it by ourselves.”

Faculty: “If you really go through their (DCI) regulation, they do mention communication in their vision mission but when it comes to their specific learning objectives, there is no curriculum specially made for communication.”

Faculty: “If they (student) come with some average (communication) competency, they remain with that and it improves very little.”

Efforts were being made by individual teachers to teach communication skills as part of the implicit curriculum. Unfortunately, these were not very effective as the faculty were not trained specifically to teach the needed communication skills.

Faculty: “There is no concerted or planned component of curriculum which actually addresses that part (Communication skills training)”

Faculty: “You should have special faculty who are trained for imparting this knowledge. Not all of us are effective communicators, even among the staff.”

While the gap in the curriculum was identified, there were apprehensions regarding overloading the curriculum, especially when the curriculum is time bound and students have prescribed coursework to complete as an eligibility requirement particularly with respect to the minimum number of patients (quota) the student has to treat to be eligible for the summative exams.

Dean: “Everybody is loading the students with all kinds of things. Basic things are neglected. Where is the time to train them?”

Faculty: “Yes, student is put under the pressure of quota. So, he or she is not bothered about improving the communication skill or professionalism”

Student: “I don't spend so much of time (interacting with the patient) because the duration of practical hours is very less, we have to finish our quota”

Researcher reflexivity: The gap in defining communication skills as part of the explicit curriculum was highlighted in our advocacy efforts. Since we directly could not modify the curriculum, (since the prescribed DCI curriculum has to be followed), we shifted our focus towards providing additional training on communication skills. A balance had to be made between loading the curriculum with extensive communication skills training versus the resources available in terms of skilled trainers, time and money available for the training.

Theme 6: Teaching and assessing communication skills.

The stakeholders said communication skills should be taught – primarily by incorporating it into the curriculum. They suggested having workshops, periodic training programs etc., to enhance their soft skills. Early clinical exposure will also help the 1st and 2nd year undergraduates to hone their communication skills before actually treating patients in their clinical years (third, fourth and final years):

Faculty: “As soon as they enter this institution, in 1st year the language training should be given. In 2nd year or 3rd year, before they enter the clinics, the students should be specifically taught how to interact with the patient.”

Student: “Language sections should be focused at some point and empathy-all this should be taught to us. There should be workshops.”

Role of faculty in training

While a few teachers were opposed to the idea of them teaching communication skills, others welcomed it. This showed us the potential areas of resistance to include communication skills as part of the curriculum. Anticipation of resistance helped in designing the educational solution to the problem. The students were trained by communication experts.

Faculty: “We cannot teach them language. We have other things to teach.”

Faculty: “We can modify the curriculum. We can take up the initiative. Sometime has to be devoted to improving their communication skills.”

Assessment of communication skills

Communication skills assessment was not given additional weightage in case-based discussions. This lack of assessment was a significant gap in learning which was voiced by the stakeholders. The stakeholders said that specific marks should be allocated for assessing communication skills as “assessment drives learning”. The assessor should use a standardized evaluation format and should be well trained to provide formative assessment and feedback to the student:

Student: “A part of marks can be allotted in case management to include observing us on how we interact with patients.”

Faculty: “So obviously they will do well, if you are giving marks; 99% of them will do well.”

Dean: “Students' mentality is to pass. Nothing more than that.”

Researcher reflexivity: The solutions offered for the educational problem were to conduct workshops, periodic training and language training sessions by communication experts. This input helped us in designing the educational training program. While the training could be incorporated, systematically assessing communication skills, required change in the assessment pattern. The magnitude of change required was higher since this called for revamping of the assessment system to bring in work place based assessment and 360 degree evaluation of communication skills. The faculty and students had to be trained in this assessment system. Since the magnitude of change was higher, the resistance to change was also expected to be high. Hence, this “felt need” was delegated to be taken up at a later stage in the design process.


  Discussion Top


The researchers were keen on understanding the stakeholder's voice regarding the communication skills of the students, existing gaps in curriculum training and potential solutions to improve the communication skills of students. Qualitative research and documentation was carried out to build an evidence-base for establishing the need for change in the existing education system of the institution.

The thematic analysis helped in logically co-constructing the narrative. The first theme focused on the need for communication skills training. This helped firmly establish the felt need for the change. The second theme focused on the current communication skills and its impact on patient management. Documenting critical incidents where poor communication led to dentist-patient conflict created a sense of urgency and highlighted the impact of poor communication skills. With theme three and four, the spotlight was on language and nonverbal communication. This strengthened the narrative to focus on the crux of the communication skills to micro dissect the issue under consideration. With theme five, the narrative discussed the role of the curriculum and existing gaps which have contributed to the problems outlined in the previous themes. Theme six brought the focus towards potential solutions to the curricular problem and co-constructed actionable solutions.

Advocacy efforts to address the educational problem

With the research evidence, the educational problem was escalated to the dean and curriculum implementation committee. The stakeholders had also been purposively invited to participate in the research. This included the dean and few curriculum committee members. Hence it was easier to get their “buy in” to address the problem. The potential solutions to the problem were enlisted and a definitive educational program was proposed by J to address the gap in communication skills. The Dean and the curriculum committee members extended their support to the educational program and suggested an expanded program to include other significant skills, currently not prioritised in the curriculum. Based on the shared understanding, a training program was tailor-made to train students in communication skills, ethics, professionalism and infection control practices. This program is currently in its 7th year since inception and has transitioned from a 2-day workshop to a 5-day workshop. Students, are now additionally being trained in empathy, humanities, prescription-writing before beginning their clinical training.

Lessons learnt and implications for educational designers, researchers and leaders

Identifying a significant educational problem and creating a shared understanding was the first step towards finding potential workable solutions. In-depth interviews and FGDs created a buzz around the problem and got the stakeholders to talk about it. The research process gave some critical insights in designing solutions to educational problem on hand. Since the participants were purposively involved, it was easier to get a buy-in and transition towards “our (institutional) project”. Involving the dean, who is the key influential educational leader substantially strengthened the forces for the change. The resistance to change had to be counteracted with dialogues, open communication and at times working around the resistance. The entire exercise calls for commitment, passion, and people management skills from the educators.


  Conclusion Top


Educational designers are often confronted with challenges of solving educational problems. This requires carrying out research to establish the evidence for the problem, chalk out potential solutions. Since qualitative research methods use the socio constructivist approach, they are often suitable to establish the research evidence as they bring forth the stakeholder's voice on the issue under consideration. The process of qualitative research involves extensive interviews and discussions with stakeholders to better understand the underlying issues thus initiating dialogues and helps to co-construct solutions to the educational problems from within the institution. Since such self-discovered solutions for change in curriculum emerge from key stakeholders within the institution, they are more likely to be accepted, adopted and “institutionalised.”

Acknowledgement

The authors would like to acknowledge the following contributions:

  1. Dr. Pushpanjali K, for her contribution to the research conceptualisation and design
  2. Dr. Deepti Vadavi – for data analysis
  3. Dr. Dinesh -Former Dean, D A P M R V Dental College for administrative support.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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