Preparedness for dental practice in Australia: a qualitative study on the experiences of final-year students and new graduates | BMC Medical Education

Eighteen NGDPs dental practitioners and four FYSs (two dental and two dental prosthetist students) from across Australia participated in the qualitative interviews. NGDPs included seven dentists, six oral health therapists (OHT); two dental hygienists (DH); and three dental prosthetists (DP). Regarding geographical location, eight were from Queensland; seven from Victoria, two from Tasmania; and one from Western Australia. Nine participants indicated urban locations; eight reported working in regional/rural locations; and one NGDP reported both. Employment history information included practice types—twelve reported private practice only; five reported working in public practice only; and one NGDP reported both (Table 2).

Following an analysis of the interviews, it was considered that thematic saturation was reached, and recruitment ceased. Themes from the interviews were regrouped into six higher-order categories, corresponding to the dimensions of preparedness for practice as identified by Mahon and Ravindran [4].

Academic and technical competencies

Overall, the theme of feeling well prepared for practice in core dental competencies emerged strongly. Participants reported positive educational experiences and largely believed that they were prepared for initial practice. NGDPs believed that their training prepared them well to join the workforce and provided a sound foundation for safe practice:

“I think [the university] did actually a really good job in terms of cementing that into [their] grads.” (NGDP6)

There was also a sense amongst participants that their final-year placements, and the theoretical aspects of the course, prepared them well and provided confidence in commencing practice. Several graduates identified the transition from supervised practice to wholly independent practice as daunting; particularly at the beginning of their practice, due to a strong reliance on demonstrators and supervisors during training, or a perceived lack of sufficient exposure to specific clinical procedures.

“… just being independent and all that, that’s always a big jump, but I think, again, the university has prepared me pretty well for it.” (NGDP11)

NGs recognised that they had theoretical knowledge but were uncertain whether such preparation would be adequate. They demonstrated high levels of self-awareness by acknowledging that not everything could be taught in the program and resources could be accessed for self-learning.

“There always will be things that you have not been exposed to and things like that. Also, that dental school has sort of provided us sort of resources and places to go to when we do find those situations.” (NGDP1)

NGs identified some dental programs as being proactive in providing learning opportunities:

“… if you wanted something [dental procedures], you would generally be able to swap [dental procedures] and we had a system where students were able to put down on the list things that they hadn’t had an opportunity to do.“ (NG16)

Structural issues were mentioned as barriers to developing clinical competencies. These barriers went beyond exposure to information, resources, or the quality of demonstrators and academics:

“…There is a lot of students, big classes, not enough chairs and having that time cut.” (NGDP5)

A common theme from NGDPs, was a desire for more exposure to practical issues, more laboratory time, hands-on skills, including clinical restorative aspects such as endodontics, prosthodontics (both fixed and removable), as well as paediatric dentistry, and some surgical interventions (dental extractions and implants).

NGs also desired more exposure to aspects of patient care beyond specific oral health complaints. Some believed that more learning opportunities were required on how different aspects of a patients’ life influenced oral health care to encompass a more holistic view of the overall health of patients:

“…I think just in the curriculum in general, not focusing just on the physical, but also a greater emphasis on how socioeconomic things or disadvantaged culture, family types, that sort of thing, influences treatment.” (NGDP5)

NGs also suggested more specific teaching around recognising the signs of neglect and domestic abuse, as concern existed that not all areas where abuse or neglect may occur were covered (e.g., children or older adults). NGDPs and FYSs identified the need to have clearer protocols and guidelines on how to deal with these issues. Another area of concern for participants was the relatively low exposure to managing special needs patients.

Communication and interprofessional skills

Participants regarded communication and interprofessional skills as important competencies and overall felt that their communication skills of graduate dental professionals were acceptable for practice. Although they were aware that theory helped to improve their communication skills, they also highlighted that a practical approach to communication skills training would likely be more beneficial:

“A lot of people just do it in a very robotic way, not in a way that you will. I don’t think I’ll carry it into practice. They’re only doing it now because it’s on the form and they’re told they have to read it” (FYS3)

NGDPs were especially tested by communicating with patients perceived to be ‘challenging’ to communicate with (e.g., difficult, or abusive patients). Some NGDPs believed that they were unprepared to communicate with a parent or guardian, due to age differences, or where there were cultural and linguistic diversity, special needs and mental health concerns.

Moreover, NGDPs suggested extending communication skills training to cost-of-care and treatment plan discussions with the patient to obtain the best possible clinical outcome and referral communications. This same observation was made in relation to clinical entrepreneurship and financial solvency.

These observations show that NGDP’s were aware of both their own limits to knowledge and skills and also aware of the challenges to incorporate broader communication and skills training into the clinical training at dental schools.

Protective mechanisms and adaptative skills

Newly graduated dental practitioners articulated a range of coping strategies used in work situations, including managing time, everyday stressors, and balancing work and personal life. One NGDP identified the potential for increased student support during the course, particularly with respect to mental health and well-being and maladaptive strategies in their early years in practice:

“I think mental health-wise, it probably needs a bit of improvement, to be honest, because I find that a lot of students who I knew, who had a lot of potential, just resort to either dropping out of the course or choosing something completely different, or feeling like they have to harm themselves or they’re unable to talk to people…” (NGDP5)

Examples of maladaptive strategies that some NGDPs had adopted included self-blame, self-doubt and self-criticism:

“I used to always focus on what went wrong, but I never gave myself credit for what went right or what worked. And I was always making lists of things that I could change rather than things that worked…” (NGDP5)

For others it was more a matter of gaining confidence while applying what they had learned during their training.

“… I think a lot of it is just self-doubt. Self-doubt that probably is not warranted in the beginning because you have been trained in a good program and you have good experience. Enough to get into workplace and practice safely.” (NGDP6)

Professional attitude and ethical judgement

Participants identified self-reflection on their own practice and professional competence as the most significant issues in their preparedness for practice. Professional competence was considered both from the “what am I able to do based on my training” and “I’d like to try it to learn it” perspectives:

“And I feel like we were definitely told, “this is your scope of practice”. Like you only do what’s in your scope, what you’ve being trained in and are competent in”. (NGDP4)

FYSs’ self-reflections as future practitioners also recognised their limitations, while simultaneously, trying to extend themselves within their scope of practice:

“I think it’s going to be a pressure of trying to achieve a balance between being not adventurous, … and we keep growing and developing new skills, but also being somewhat sensible and practicing within the scope about limitations and putting our patients at risk.” (FYS2)

New graduates were also aware of their limitations as NGDPs and of the need to continuously upskill their knowledge base. They described the need for continuing professional development to keep up-to-date and improve their skills and knowledge.

NGDPs displayed awareness of the legal and ethical frameworks related to their dental professions and understood the value of this domain in delivering effective and safe oral health services. In the context of high levels of awareness, they also described being unprepared to deal with some legal aspects of dental practice:

“Basically, the teaching of law has been like all of you are going to get a complaint at some point, or all of you are going to get sued at some point. So just accept it and don’t worry about that, kind of thing, which hasn’t really put any of us at ease” (FYS3)

Nonetheless, NGDPs showed that they were able to self-evaluate their own abilities and training to provide safe dental care within their scope of practice.

“I think I’ll always give it a try and give it a shot, but sometimes I do take a step back and have a look and say,’look, that’s way beyond my capabilities’” (NGDP11)

NGs also described a lack of knowledge of their scope of practice by other members of the dental team. Significantly, new OHT, DH, and DP graduates reported that their scope of practice was not well known by the other dental professions, in particular the awareness of OHTs’ and DHs’ by dentists:

” I know what part of my scope was, but what the dentist thought of my scope was a completely different story at the beginning.” (NGDP14)

Oral health therapists and DP professionals often reported feeling less valued as a member of the dental care team:

“… some of the private practice will not treat us like, we are not treated like an equal member in the dental team.” (NGDP15)

Similarly, new OHT graduates reported that their scope of practice was misinterpreted by other dental professionals and highlighted the need for more dental team emphasis during training:

“I felt like the university, […] the dental school hasn’t prepared well enough to know like our place in the dental team” (NGDP15)

Clinical entrepreneurship and financial solvency

Participants identified some challenges in adapting to a business environment in private practice and managing financial responsibility. Both NGDPs and FYSs recognised the role that their training in the public healthcare system played in their impressions of managing the financial aspects of practice. During dental training, this was seen as an advantage, as well as a limitation:

“…we are at an advantage in the sense that we do not really need to navigate the tricky financial side of things, that we don’t need to really adapt our treatment plans accordingly.” (FYS2)

However, NGDPs acknowledged that the contrast between public and private contexts became more evident when NGDPs entered practice. New graduates perceived two different, contrasting ways, to be prepared for practice in oral healthcare. For NGDPs, the discussion of cost in private practice was somewhat daunting. Some graduates deliberately chose to become public dental practitioners to reduce the need for financial discussions with patients:

“…that’s like, honestly the main reason I went into public, because it stressed me out thinking about having to try and justify how much money I’m making at work and just all those types of things.” (NGDP4)

Both FYSs and NGDPs identified varying levels of training about the business aspects of practice, with an emphasis on their limited exposure to private dental practice in their training. For some NGDPs, financial training was non-existent, or did not meet expectations, and varied according to the NGDPs university and dental profession:

“…but if it’s for a private practice perspective, I don’t think any, well, from mine, from [dental school] perspective, I don’t think any graduates from [dental school], have received enough training and preparation to get into the private world.” (NGDP15)

Some NGDPs had some relevant experiences on placements and exposure to a mix of private and public patients during their final years of training. For example, a DP believed that the exposure and training was sufficient preparation for the financial and entrepreneurial aspect of practice:

“I think there was a dental practice management unit. It was a whole unit for the semester, which explained pretty much everything that could have been required to set up and run a practice there.” (NGDP10)

Graduates from universities where the training program had an established private clinic, described the value of this exposure for understanding the business elements of dental practice. However, the majority learn these business skills once they graduate and were exposed to daily practice.

Social and community orientation

The interviews investigated participants’ preparedness related to knowledge and skills in treating patients from a variety of culturally and linguistically diverse backgrounds, and Aboriginal and Torres Strait Islander People. Most participants believed that they received exposure to patients from culturally diverse backgrounds during their training; however, they believed that this exposure was ad-hoc:

“I guess we’ve got quite a diverse patient base, so I guess we got some passive exposure depending on your patients, of course.” (FYS2)

Participants believed that cultural training was not sufficiently comprehensive. In fact, some participants considered that most of their cultural and social perceptions evolved from their upbringing, high school and primary school education, and past personal experiences. Many participants believed that the current framing of the cultural competence curriculum was: “really a box ticking exercise for you.” (FYS3)

Issues around the provision of care according to the patient’s culture were also discussed. Both NGDPs and FYSs commented that, although they received training to treat people, there was less coverage or emphasis on cultural and psychological aspects of care during training. As a result, NGDPs perceived that they were unprepared to manage patients from culturally and linguistically diverse backgrounds and to provide culturally safe dental services:

“…things about safety and more about the psychology, understanding emotions and even cultural differences as well, that would be a good addition to the degree, not just looking at the medical aspect.“ (NGDP5)

Several NGDPs mentioned limited preparedness for practice in relation to social factors and health inequalities:

I think just in the curriculum in general, not focusing just on the physical, but also a greater emphasis on how socioeconomic things or disadvantaged culture, family types, that sort of thing, influences treatment…” (NGDP5)

Empathy was also stressed as a major issue by some NGDPs. One NGDP commented that a more wholistic approach to patient care should be addressed or emphasised during dental training:

“They say, my patient is such a big ****, and I’d say well, your patient has gone through a divorce; your patient is under financial strain; your patient has to pay for a taxi to get to the hospital, or she has to walk upstairs and she’s on crutches or using a walking stick.” (NGDP5)