Assessing Critical Thinking Outcomes of Dental Hygiene ... · PDF file1082 Journal of Dental...

1082 Journal of Dental Education ■ Volume 79, Number 9

Assessing Critical Thinking Outcomes of Dental Hygiene Students Utilizing Virtual Patient Simulation: A Mixed Methods StudyJoanna L. Allaire, RDH, MDHAbstract: Dental hygiene educators must determine which educational practices best promote critical thinking, a quality neces-sary to translate knowledge into sound clinical decision making. The aim of this small pilot study was to determine whether virtual patient simulation had an effect on the critical thinking of dental hygiene students. A pretest-posttest design using the Health Science Reasoning Test was used to evaluate the critical thinking skills of senior dental hygiene students at The University of Texas School of Dentistry at Houston Dental Hygiene Program before and after their experience with computer-based patient simulation cases. Additional survey questions sought to identify the students’ perceptions of whether the experience had helped develop their critical thinking skills and improved their ability to provide competent patient care. A convenience sample of 31 senior dental hygiene students completed both the pretest and posttest (81.5% of total students in that class); 30 senior dental hygiene students completed the survey on perceptions of the simulation (78.9% response rate). Although the results did not show a significant increase in mean scores, the students reported feeling that the use of virtual patients was an effective teaching method to promote critical thinking, problem-solving, and confidence in the clinical realm. The results of this pilot study may have implications to support the use of virtual patient simulations in dental hygiene education. Future research could include a larger controlled study to validate findings from this study.

Prof. Allaire is Associate Professor, Periodontics and Dental Hygiene, The University of Texas School of Dentistry at Houston. Direct correspondence to Prof. Joanna L. Allaire, 54 Thundercreek Place, The Woodlands, TX 77381; 936-788-4294; [email protected].

Keywords: allied dental education, dental hygiene, critical thinking, teaching method, patient simulation, virtual patients

Submitted for publication 11/12/14; accepted 2/3/15

While treating patients, dentists and dental hygienists are required to analyze clini-cal situations in order to solve complex

clinical problems, and there is general agreement among health professions educators that critical thinking is a desirable attribute for students to de-velop.1 The American Dental Education Association Commission on Change and Innovation in Dental Education (ADEA CCI) defined critical thinking as “the reflective process in which individuals assess a situation or evaluate data by using mental capacities characterized by adjectives such as compare, analyze, distinguish, reflect, and judge.”2 An individual with strong critical thinking skills will be adept at ask-ing pertinent questions, linking new knowledge to prior knowledge, finding solutions to problems, and making and defending decisions based on evidence.3

The importance of critical thinking for the dental hygienist has been emphasized by numerous organizations. The National Dental Hygiene Re-search Agenda of the American Dental Hygienists’ Association (ADHA) documented the need for stud-ies on educational methods that can validate and test measures that evaluate students’ critical thinking and

decision-making skills.4 The Commission on Dental Accreditation (CODA) states in its Accreditation Standards for Dental Hygiene Education Programs (Standard 2-22) that graduates “must be competent in problem-solving strategies related to comprehensive patient care and management of patients.”5 CODA explains the intent of this standard by affirming that “critical thinking and decision-making skills are necessary to provide effective and efficient dental hygiene services.” The ADEA CCI lists critical thinking as one of the eight core principles essential to dental education.2

Critical thinking has been recognized as an essential attribute for health care professionals.6 Clinical reasoning can be described as the integra-tion of critical thinking and data collection directed toward patient care.7 While treating patients, dentists and dental hygienists are required to analyze clinical situations in order to solve complex clinical prob-lems. Critical thinking skills equip students to con-nect the dots between what they have learned in the classroom and their ability to provide comprehensive patient care.8 To this end, dental hygiene educators seek teaching methods that enhance critical thinking

September 2015 ■ Journal of Dental Education 1083

based simulations to animated virtual patients that are able to interact with the user and respond to the student’s questions. These computer-based simula-tions are constructed with techniques borrowed from the gaming industry. Another format for virtual patients utilizes a combination of media (e.g., audio, video, interactive computer exercises). The most sophisticated format employs manikins that can be programmed to interact with the clinician and are able to display physiological responses to assessments and treatment modalities.19

Little research has been conducted to evaluate the impact of virtual patients on the critical thinking skills of health care providers. A review of the litera-ture seeking to clarify the role of virtual patients in medical education suggested that the use of virtual patients can facilitate learning and potentially im-prove clinical reasoning, a skill that is dependent on critical thinking.22 A quantitative study investigating the effect of simulation as an instructional strategy on critical thinking abilities of nursing students found an increase in critical thinking scores as measured by the Health Science Reasoning Test.23 Qualitative studies in medical and nursing education have sought to discover student perceptions of the value of vir-tual patients. For example, a study that used focus groups found that medical students identified virtual patients as an important educational tool that fostered clinical reasoning skills,15 and a study of graduate nurses found that the use of simulation resulted in increased confidence in their critical thinking skills.24 A recurrent theme is the need for well-designed vir-tual patient cases that reflect the reality of clinical practice. The difficulty level of the cases must be appropriate for the learner, and each session should include debriefing by a facilitator to assist with the reflective process.15,17,21

Simulation in dentistry and dental hygiene has traditionally focused on the teaching of psycho-motor skills emphasizing structured practice with feedback.1,25 To take research in this area beyond procedural knowledge, the aim of this small pilot study was to determine whether the use of virtual patient simulation had an effect on the critical think-ing skills of dental hygiene students. Specifically, the objectives of the study were to 1) measure the critical thinking ability of senior dental hygiene students before their virtual patient experience and after two semesters of utilizing virtual patient simulation and 2) assess the students’ perceptions of those experiences.

skills to prepare future dental hygienists to keep pace with diverse and ever-changing developments in the delivery of oral health care.3 Dental hygienists use clinical reasoning while working through the dental hygiene process of care as they analyze relevant in-formation, use inductive and deductive reasoning to determine a dental hygiene diagnosis, create a care plan, and evaluate patient outcomes.7,9 Studies have found that health professions students’ critical think-ing skills may be a predictor of success in clinical performance and judgment.9-11

Dental hygiene educators use strategies to fos-ter critical thinking in students to help them attain the capacity to function as an entry-level hygienist and to possess the skills necessary to become self-directed learners.12 However, Williams’s study was rare in its evaluation of whether these strategies are effective in developing dental hygienists who are good critical thinkers.7 Effective clinical practice requires students to be able to convert information they have collected from lectures or textbooks into applied knowledge.13 Dental and dental hygiene education has tradition-ally used two models of teaching: the dissemination of knowledge and the development of psychomotor skills. Educators aspire to include instructional ap-proaches that go beyond these two pedagogies to ensure that students can integrate and apply their knowledge and skills in successful clinical practice.1

Simulation is a learner-centered teaching method that uses innovative techniques to promote a deeper understanding of didactic content. Simulation has been defined as “an attempt to replicate some or nearly all essential aspects of a clinical situation so that the situation may be more readily understood and managed when it occurs for real in clinical practice.”14 Simulation has been used in medical and nursing education for decades and includes techniques that are varied in complexity such as case-based discussions, standardized patients, virtual patients, and high-fidelity manikins with the goal of developing students’ higher level cognition and improved psychomotor skills in a non-threatening environment.15-18 Simulation builds on the scientific knowledge of the learner and puts additional empha-sis on clinical decision making, reasoning, ethics, empathy, and compassion.19-22

Virtual patient simulation is an active learning strategy that uses computer-based virtual patients to create a simulated patient experience that replicates as closely as possible an authentic clinical sce-nario.15,16,19-22 Formats range from simple computer-


MethodsApproval (with exempt status) for the study

was obtained from the Institutional Review Board at The University of Texas School of Dentistry at Houston. The same exempt status was granted by the Institutional Review Board at the University of Tennessee Health Science Center, where the investi-gator was enrolled in the Master of Dental Hygiene program.

The University of Texas School of Dentistry at Houston introduced computer-based patient simula-tion into its dental hygiene curriculum in 2011 to fulfill one of the goals of the school’s strategic plan.26 The purpose of virtual patients at this dental school is to provide a virtual learning environment as close to reality as possible with facilitation by faculty. The experience challenges students’ critical thinking skills as they “treat” virtual patients. The program’s specific objectives for virtual patients are to 1) pro-vide students with a common and consistent clinical education experience supplementing the variety of experiences in direct patient care; 2) integrate bio-medical and clinical sciences in a standardized, case-based clinical setting; 3) provide a more frequent and consistent experience for students in performing and refining psychomotor skills; and 4) teach medical management, ethics, patient management, public health, and other relevant topics to all students in a patient care setting.27

To introduce this methodology, a core working group of dental hygiene faculty members began by developing two computer-based cases that would be utilized by fourth-year Bachelor of Science in Dental Hygiene degree-seeking students over several sessions (Table 1). Specific learning objectives were created for each module. The goal of the cases was to allow the students to work through the dental hygiene process of care with the virtual patient. While doing so, students had to make choices and decisions that impacted the outcome. The virtual patients presented realistic problems that the learners had to identify by interpreting pertinent patient data and were designed to replicate as authentically as possible real-life clinical scenarios. The faculty members sought to develop cases that integrated students’ basic science knowledge with their clinical knowledge as a way to help them bridge the gap between what they learned in the classroom and the provision of patient care. The two cases offered scenarios that the students may not have experienced in clinic and included situations that incorporated all aspects of clinical practice. Tabl

e 1.

Vir

tual

pat

ient

ses

sion

s us

ed in

stu

dy

Sess

ion,

Se

mes

ter

Topi

c/s

Lear

ning

Obj

ectiv

esSu

bjec

t Mat

ter

Mod

es o

f Del

iver

yEv

alua

tion

Met

hod

Patie

nt “

EJ”

Sess

ion

1Fa

ll

•C

ompl

exm

edic

al

hist

ory

1. A

naly

ze m

edic

al h

isto

ry fi

ndin

gs.

2. D

eter

min

e th

e ne

ed fo

r a

med

ical

co

nsul

tatio

n an

d cr

eate

a c

onsu

ltatio

n le

tter.

•P

harm

acol

ogy

•A

nato

my

and

phys

iolo

gy•

Pre

clin

ical

tech

-ni

que

•V

ideo

ofp

atie

ntin

terv

iew

•W

ritte

nna

rrat

ive

•Y

ouTu

bev

ideo

sab

outp

atho

-ph

ysio

logy

of h

yper

tens

ion

•J

AD

Aa

rtic

lea

bout

hyp

erte

n-si

on

•G

uide

dqu

estio

nsfr

om

facu

lty fo

r gr

oup

disc

ussi

on•

Deb

riefi

ngw

ithfa

culty

fa

cilit

ator

•S

elf-

asse

ssm

entr

ubri

c

Patie

nt “

EJ”

Sess

ion

2Fa

ll

•

Dia

bete

s•

Ext

raor

alfi

ndin

gs•

Xer

osto

mia

•D

emin

eral

izat

ion

1. A

pply

info

rmat

ion

obta

ined

from

the

med

ical

con

sulta

tion

repo

rt to

the

patie

nt’s

case

.2.

Ide

ntify

sys

tem

ic c

ondi

tions

or

med

i-ca

tions

that

may

impa

ct th

e pa

tient

’s or

al h

ealth

.3.

Com

pare

Typ

eIa

ndT

ype

IIdi

abet

es.

4. S

umm

ariz

e th

e go

als

of d

iabe

tic

cont

rol.

5.E

xpla

inth

ere

latio

nshi

pbe

twee

ndi

abet

es a

nd th

e pe

riod

ontiu

m.

6.D

iscu

ssa

nex

trao

ralfi

ndin

gth

atm

ay

be r

elat

ed to

the

syst

emic

con

ditio

n.7.

Des

crib

e th

e pr

oces

s to

det

erm

ine

a pa

tient

’sxe

rost

omia

leve

ls.

•P

harm

acol

ogy

•P

recl

inic

alte

ch-

niqu

e•

Int

roto

den

tal

hygi

ene

•P

erio

dont

olog

y•

Ana

tom

yan

dph

ysio

logy

•W

ritte

nco

nsul

tatio

nre

port

fr

om p

atie

nt’s

phys

icia

n•

Onl

ine

cont

inui

nge

duca

-tio

n co

urse

on

peri

odon

tal

man

agem

ento

fap

atie

ntw

ith

diab

etes

•Y

ouTu

bev

ideo

on

how

glu

cose

is

use

d in

the

body

•V

ideo

from

Dr.

Oz

TVs

how

ab

out d

iabe

tes

•W

ebsi

tee

xpla

inin

gH

bA1C

•V

ideo

dis

cuss

ing

insu

linr

esis

-ta

nce

and

Aca

ntho

sis

Neg

ri-

cans

•G

uide

dqu

estio

nsfr

om

facu

lty fo

r gr

oup

disc

ussi

on•

Sof

tCha

lke

xerc

ise

ond

ia-

bete

s•

Deb

riefi

ngw

ithfa

culty

•S

elf-

asse

ssm

entr

ubri

c

Patie

nt “

EJ”

Sess

ion

3Fa

ll

•R

isk

asse

ssm

ent

•N

utri

tion

•P

laqu

ein

dex

1.C

alcu

late

pat

ient

’sbo

dym

ass

inde

xan

d ev

alua

te r

esul

ts.

2. D

iscu

ss d

ieta

ry r

ecal

l and

cal

oric

in

take

.3.

Dis

cuss

die

tary

mod

ifica

tions

for

patie

nt.

4.I

dent

ifya

ndd

iscu

ssn

ewo

rall

esio

n.5.

Det

erm

ine

wha

tmic

roor

gani

sms

are

pres

ent i

n a

mic

rosc

opic

pla

que

sam

ple.

•I

ntro

duct

ion

to

dent

al h

ygie

ne•

Nut

ritio

n•

Mic

robi

olog

y•

Ora

lpat

holo

gy

•S

hort

Pow

erPo

into

utlin

ing

Ms.

Jim

enez

’s di

et•

“B

ouqu

otto

Go”

CD

ofc

om-

mon

ora

l les

ions

•M

icro

scop

esl

ide

ofa

pla

que

sam

ple

•C

ompl

ete

adi

etar

yre

call

form

for

Ms.

Jim

enez

•W

ritte

npa

thol

ogy

cons

ult

form

•G

uide

dqu

estio

nsfr

om

facu

lty fo

r gr

oup

disc

ussi

on•

Sel

f-as

sess

men

trub

ric

Patie

nt “

EJ”

Sess

ion

4Fa

ll

•M

edic

ale

mer

genc

y1.

Ide

ntify

and

dis

cuss

pat

ient

man

age-

men

t tec

hniq

ues

for

vari

ous

med

ical

em

erge

ncie

s.

•D

enta

lem

erge

n-ci

es•

Vid

eos

•G

uide

dqu

estio

nsfr

om

facu

lty fo

r gr

oup

disc

ussi

on•

Sel

f-as

sess

men

trub

ric

Patie

nt “

EJ”

Sess

ion

5Sp

ring

•O

ralp

hysi

othe

rapy

ai

ds•

Eth

ical

dile

mm

a

1. I

dent

ify a

nd d

iscu

ss th

e us

e of

app

ro-

pria

te O

PT a

ids.

2.D

iscu

ssa

per

sona

lized

OH

Ireg

imen

.3.

Dis

cuss

eth

ical

issu

es o

f dom

estic

vio

-le

nce

and

its p

rofe

ssio

nal o

blig

atio

ns.

•I

ntro

duct

ion

to

dent

al h

ygie

ne•

Pre

clin

ical

tech

-ni

que

•E

thic

s

•C

linic

alp

hoto

grap

hs•

Dem

onst

ratio

nby

facu

ltyo

nEl

mo

•W

ritte

nna

rrat

ive

•W

ebsi

tefo

rdo

mes

ticv

iole

nce

law

sin

Tex

as

•S

tude

ntd

emon

stra

tion

on

patie

nt m

anne

quin

•G

uide

dqu

estio

nsfr

om

facu

lty fo

r gr

oup

disc

ussi

on•

Sel

f-as

sess

men

trub

ric

Patie

nt “

PF”

Sess

ion

1Sp

ring

•D

Hd

iagn

osis

•D

Hc

are

plan

•P

erio

dont

itis

patie

nt•

Eth

ical

dile

mm

a•

Tob

acco

dep

ende

nce

coun

selli

ng

1.F

orm

ulat

ea

DH

dia

gnos

is.

2.C

reat

ea

DH

car

epl

anb

ased

on

DH

di

agno

sis.

3.E

xam

ine

ane

thic

ald

ilem

ma

and

dete

rmin

e su

itabl

e re

spon

ses.

4. A

pply

pri

ncip

les

of to

bacc

o ce

ssat

ion

coun

selin

g.

•I

ntro

duct

ion

to

dent

al h

ygie

ne•

Pre

clin

ical

tech

-ni

que

•C

linic

als

emin

ar•

Eth

ics

•P

erio

dont

olog

y

•R

adio

grap

hs

•C

linic

alp

hoto

grap

hs•

Per

iodo

ntal

cha

rt•

Wri

tten

narr

ativ

e•

Pow

erPo

intp

rese

ntat

ion

•A

sk,A

dvis

e,R

efer

web

site

•P

erio

dont

ald

iagn

osis

wor

k-sh

eet

•F

ager

stro

mte

stfo

rto

bacc

ode

pend

ence

•G

uide

dqu

estio

nsfr

om

facu

lty fo

r gr

oup

disc

ussi

on•

Sel

f-as

sess

men

trub

ric

Patie

nt “

PF”

Sess

ion

2Sp

ring

•C

ultu

rals

ensi

tivity

•I

nstr

umen

tatio

n1.

Ide

ntify

and

pra

ctic

e cu

ltura

lly s

ensi

-tiv

e pa

tient

car

e.2.

Rec

ogni

zeim

prop

erin

stru

men

tatio

nte

chni

ques

.3.

Des

crib

eho

wto

cor

rect

inst

rum

enta

-tio

n te

chni

que

erro

rs.

•I

ntro

duct

ion

to

dent

al h

ygie

ne•

Clin

ical

sem

inar

•V

ideo

sof

cul

tura

llyin

sens

itive

an

d cu

ltura

lly s

ensi

tive

patie

nt

inte

ract

ions

•V

ideo

ofp

oor

inst

rum

enta

tion

tech

niqu

e

•G

uide

dqu

estio

nsfr

om

facu

lty fo

r gr

oup

disc

ussi

on•

Sel

f-as

sess

men

trub

ric


Tabl

e 1.

Vir

tual

pat

ient

ses

sion

s us

ed in

stu

dy

Sess

ion,

Se

mes

ter

Topi

c/s

Lear

ning

Obj

ectiv

esSu

bjec

t Mat

ter

Mod

es o

f Del

iver

yEv

alua

tion

Met

hod

Patie

nt “

EJ”

Sess

ion

1Fa

ll

•C

ompl

exm

edic

al

hist

ory

1. A

naly

ze m

edic

al h

isto

ry fi

ndin

gs.

2. D

eter

min

e th

e ne

ed fo

r a

med

ical

co

nsul

tatio

n an

d cr

eate

a c

onsu

ltatio

n le

tter.

•P

harm

acol

ogy

•A

nato

my

and

phys

iolo

gy•

Pre

clin

ical

tech

-ni

que

•V

ideo

ofp

atie

ntin

terv

iew

•W

ritte

nna

rrat

ive

•Y

ouTu

bev

ideo

sab

outp

atho

-ph

ysio

logy

of h

yper

tens

ion

•J

AD

Aa

rtic

lea

bout

hyp

erte

n-si

on

•G

uide

dqu

estio

nsfr

om

facu

lty fo

r gr

oup

disc

ussi

on•

Deb

riefi

ngw

ithfa

culty

fa

cilit

ator

•S

elf-

asse

ssm

entr

ubri

c

Patie

nt “

EJ”

Sess

ion

2Fa

ll

•

Dia

bete

s•

Ext

raor

alfi

ndin

gs•

Xer

osto

mia

•D

emin

eral

izat

ion

1. A

pply

info

rmat

ion

obta

ined

from

the

med

ical

con

sulta

tion

repo

rt to

the

patie

nt’s

case

.2.

Ide

ntify

sys

tem

ic c

ondi

tions

or

med

i-ca

tions

that

may

impa

ct th

e pa

tient

’s or

al h

ealth

.3.

Com

pare

Typ

eIa

ndT

ype

IIdi

abet

es.

4. S

umm

ariz

e th

e go

als

of d

iabe

tic

cont

rol.

5.E

xpla

inth

ere

latio

nshi

pbe

twee

ndi

abet

es a

nd th

e pe

riod

ontiu

m.

6.D

iscu

ssa

nex

trao

ralfi

ndin

gth

atm

ay

be r

elat

ed to

the

syst

emic

con

ditio

n.7.

Des

crib

e th

e pr

oces

s to

det

erm

ine

a pa

tient

’sxe

rost

omia

leve

ls.

•P

harm

acol

ogy

•P

recl

inic

alte

ch-

niqu

e•

Int

roto

den

tal

hygi

ene

•P

erio

dont

olog

y•

Ana

tom

yan

dph

ysio

logy

•W

ritte

nco

nsul

tatio

nre

port

fr

om p

atie

nt’s

phys

icia

n•

Onl

ine

cont

inui

nge

duca

-tio

n co

urse

on

peri

odon

tal

man

agem

ento

fap

atie

ntw

ith

diab

etes

•Y

ouTu

bev

ideo

on

how

glu

cose

is

use

d in

the

body

•V

ideo

from

Dr.

Oz

TVs

how

ab

out d

iabe

tes

•W

ebsi

tee

xpla

inin

gH

bA1C

•V

ideo

dis

cuss

ing

insu

linr

esis

-ta

nce

and

Aca

ntho

sis

Neg

ri-

cans

•G

uide

dqu

estio

nsfr

om

facu

lty fo

r gr

oup

disc

ussi

on•

Sof

tCha

lke

xerc

ise

ond

ia-

bete

s•

Deb

riefi

ngw

ithfa

culty

•S

elf-

asse

ssm

entr

ubri

c

Patie

nt “

EJ”

Sess

ion

3Fa

ll

•R

isk

asse

ssm

ent

•N

utri

tion

•P

laqu

ein

dex

1.C

alcu

late

pat

ient

’sbo

dym

ass

inde

xan

d ev

alua

te r

esul

ts.

2. D

iscu

ss d

ieta

ry r

ecal

l and

cal

oric

in

take

.3.

Dis

cuss

die

tary

mod

ifica

tions

for

patie

nt.

4.I

dent

ifya

ndd

iscu

ssn

ewo

rall

esio

n.5.

Det

erm

ine

wha

tmic

roor

gani

sms

are

pres

ent i

n a

mic

rosc

opic

pla

que

sam

ple.

•I

ntro

duct

ion

to

dent

al h

ygie

ne•

Nut

ritio

n•

Mic

robi

olog

y•

Ora

lpat

holo

gy

•S

hort

Pow

erPo

into

utlin

ing

Ms.

Jim

enez

’s di

et•

“B

ouqu

otto

Go”

CD

ofc

om-

mon

ora

l les

ions

•M

icro

scop

esl

ide

ofa

pla

que

sam

ple

•C

ompl

ete

adi

etar

yre

call

form

for

Ms.

Jim

enez

•W

ritte

npa

thol

ogy

cons

ult

form

•G

uide

dqu

estio

nsfr

om

facu

lty fo

r gr

oup

disc

ussi

on•

Sel

f-as

sess

men

trub

ric

Patie

nt “

EJ”

Sess

ion

4Fa

ll

•M

edic

ale

mer

genc

y1.

Ide

ntify

and

dis

cuss

pat

ient

man

age-

men

t tec

hniq

ues

for

vari

ous

med

ical

em

erge

ncie

s.

•D

enta

lem

erge

n-ci

es•

Vid

eos

•G

uide

dqu

estio

nsfr

om

facu

lty fo

r gr

oup

disc

ussi

on•

Sel

f-as

sess

men

trub

ric

Patie

nt “

EJ”

Sess

ion

5Sp

ring

•O

ralp

hysi

othe

rapy

ai

ds•

Eth

ical

dile

mm

a

1. I

dent

ify a

nd d

iscu

ss th

e us

e of

app

ro-

pria

te O

PT a

ids.

2.D

iscu

ssa

per

sona

lized

OH

Ireg

imen

.3.

Dis

cuss

eth

ical

issu

es o

f dom

estic

vio

-le

nce

and

its p

rofe

ssio

nal o

blig

atio

ns.

•I

ntro

duct

ion

to

dent

al h

ygie

ne•

Pre

clin

ical

tech

-ni

que

•E

thic

s

•C

linic

alp

hoto

grap

hs•

Dem

onst

ratio

nby

facu

ltyo

nEl

mo

•W

ritte

nna

rrat

ive

•W

ebsi

tefo

rdo

mes

ticv

iole

nce

law

sin

Tex

as

•S

tude

ntd

emon

stra

tion

on

patie

nt m

anne

quin

•G

uide

dqu

estio

nsfr

om

facu

lty fo

r gr

oup

disc

ussi

on•

Sel

f-as

sess

men

trub

ric

Patie

nt “

PF”

Sess

ion

1Sp

ring

•D

Hd

iagn

osis

•D

Hc

are

plan

•P

erio

dont

itis

patie

nt•

Eth

ical

dile

mm

a•

Tob

acco

dep

ende

nce

coun

selli

ng

1.F

orm

ulat

ea

DH

dia

gnos

is.

2.C

reat

ea

DH

car

epl

anb

ased

on

DH

di

agno

sis.

3.E

xam

ine

ane

thic

ald

ilem

ma

and

dete

rmin

e su

itabl

e re

spon

ses.

4. A

pply

pri

ncip

les

of to

bacc

o ce

ssat

ion

coun

selin

g.

•I

ntro

duct

ion

to

dent

al h

ygie

ne•

Pre

clin

ical

tech

-ni

que

•C

linic

als

emin

ar•

Eth

ics

•P

erio

dont

olog

y

•R

adio

grap

hs

•C

linic

alp

hoto

grap

hs•

Per

iodo

ntal

cha

rt•

Wri

tten

narr

ativ

e•

Pow

erPo

intp

rese

ntat

ion

•A

sk,A

dvis

e,R

efer

web

site

•P

erio

dont

ald

iagn

osis

wor

k-sh

eet

•F

ager

stro

mte

stfo

rto

bacc

ode

pend

ence

•G

uide

dqu

estio

nsfr

om

facu

lty fo

r gr

oup

disc

ussi

on•

Sel

f-as

sess

men

trub

ric

Patie

nt “

PF”

Sess

ion

2Sp

ring

•C

ultu

rals

ensi

tivity

•I

nstr

umen

tatio

n1.

Ide

ntify

and

pra

ctic

e cu

ltura

lly s

ensi

-tiv

e pa

tient

car

e.2.

Rec

ogni

zeim

prop

erin

stru

men

tatio

nte

chni

ques

.3.

Des

crib

eho

wto

cor

rect

inst

rum

enta

-tio

n te

chni

que

erro

rs.

•I

ntro

duct

ion

to

dent

al h

ygie

ne•

Clin

ical

sem

inar

•V

ideo

sof

cul

tura

llyin

sens

itive

an

d cu

ltura

lly s

ensi

tive

patie

nt

inte

ract

ions

•V

ideo

ofp

oor

inst

rum

enta

tion

tech

niqu

e

•G

uide

dqu

estio

nsfr

om

facu

lty fo

r gr

oup

disc

ussi

on•

Sel

f-as

sess

men

trub

ric


demands of problem-based learning. Scores of 14 or lower suggest fundamental weaknesses in core critical thinking skills and are classified as “not manifested.” A score of 10 or lower is extremely weak and not consistent with minimal entry-level college performance.

The HSRT is part of the California Critical Thinking Test family of instruments that assesses critical thinking skills with questions in contexts suited to health care professionals although no health science knowledge is presumed. The HSRT provides five measures of critical thinking domains in addition to a total score that is an overall measure of critical thinking skill level. The five scale scores are analysis and interpretation, inference, evaluation and explanation, deductive reasoning, and inductive reasoning. The HSRT is based on the consensus statement of the American Philosophical Association (APA) and has undergone extensive testing and vali-dation.28,29,31 Validation studies with the HSRT have shown internal consistency (Kuder Richardson-20) ranging from 0.77 to 0.84 with an overall internal consistency of 0.81.29,31 A KR-20 above 0.70 indicates an acceptable level of internal consistency. The 0.81 overall reliability coefficient of the HSRT is more than sufficient for researchers to have confidence in the internal consistency of its items to measure the desired construct of critical thinking.

Content and construct validity of the HSRT have also been established by correlating test items with the cognitive skills identified by the Delphi Report from the APA.28,29,31 Construct validity of the HSRT refers to the degree to which it measures the Delphi conceptualization of critical thinking. Content validity on the HSRT refers to its ability to represent the various aspects of the specific construct in ques-tion, specifically the domain of critical thinking.29,31 Further, evidence for the construct validity of the HSRT is apparent by the improvement in students’ scores after they had taken a course in critical think-ing. The same validation studies have also established that there is no evidence of threats to validity due to prior experience with the instrument (test effects).

In this study, the HSRT pretest was admin-istered at the beginning of the fall semester before the students had any exposure to virtual patient simulation. Instructions were given by the principal investigator using a standardized script provided by Insight Assessment, the company that developed the HSRT.29,31 After the investigator left the room, an independent administrator proctored the test and collected the score sheets. The HSRT was again

Since treating a patient is more than scaling and root planing or preparing a tooth for a crown, virtual patient cases also simulated nonclinical com-ponents of patient care including communication, cultural sensitivity, ethics, and professionalism. The students were exposed to such situations as a patient with a hypoglycemic episode, which required them to assess the patient’s condition and quickly come up with a plan of action. Content was delivered in various modes including written narratives, patient interviews, photographs, and radiographs. Addi-tional information came from sources such as journal articles and videos. Each section of the case was accompanied by guided questions to be answered either independently or in pairs and then discussed in a small group with a faculty facilitator. The role of the faculty facilitator was simply to guide the discussion and encourage the students to explore all aspects relevant to the case. Facilitators were encouraged to create a safe and positive environment conducive to learning, exploration, discussion, and feedback. The students participated in virtual patient sessions one afternoon a month during the fall and spring semesters.

The faculty members participated in calibra-tion sessions before each virtual patient session. A debriefing session was held at the end of each session to help the students assimilate the material and to encourage reflective thinking. Debriefing was guided by faculty members with the goal of reinforcing the learning objectives and evaluating the outcomes of the simulation session.

The quantitative portion of this study utilized a pretest-posttest design using the Health Science Reasoning Test (HSRT). In the first month of their senior year, students were invited to participate in the 45-minute pretest to measure their critical thinking skills. Students were given a written invitation to participate, and consent was implied by completion of the instrument. Participants were randomly as-signed a nine-digit identifying number to protect their anonymity. Students were informed that participation would have no bearing on their grades and that test scores would remain anonymous.

The HSRT is a 33-item multiple-choice test designed to measure critical thinking skills with a total possible score of 33.28-31 A score of 25 or above indicates strong core critical thinking skills, typi-cal of an individual capable of complex problem-solving. Scores between 15 and 24 are associated with demonstrated competence in critical thinking. These individuals should be capable of meeting the


match individuals to their scores. Data collected included composite scores as well as five subscale scores for analysis, inference, evaluation, inductive reasoning, and deductive reasoning for each of the test groups (pretest and posttest). The paired t-test of comparisons of the mean overall scores did not demonstrate a statistically significant gain from pre-test (M=19.219, SD=5.116) to posttest (M=20.188, SD=3.685; t[30]=1.84, p=-0.075) (Table 2, Table 3).

Examining mean score differences in small samples can result in an incomplete analysis of pre-test-posttest data when the tests are for the same test-takers.30 A more informative way to examine scores, particularly in small samples, would be to examine the difference in scores for each individual from pre-test to posttest.30 The analysis in this study included the difference in scores from each individual from pretest to posttest. While the mean difference score was only 0.77, some students improved their scores as much as six points. However, a few students’ scores dropped from pretest to posttest. Figure 1 shows the scores of the 31 students who submitted both a pretest and a posttest.

When compared to national norms of under-graduate health sciences students, the average of the national percentile rankings for the pretest group was in the 48th percentile. The average of the post-test sample rankings was the 53rd percentile. The comparison of the individual and group scores to

administered as a posttest toward the end of the spring semester. Score sheets for both pretest and posttest were sent to Insight Assessment for scoring and analysis.

In an effort to further evaluate the use of virtual patients in this dental hygiene curriculum, a survey was administered to explore the students’ perceptions of whether virtual patient simulation helped develop their critical thinking skills and improved their ability to provide competent patient care. This survey instru-ment was designed by the author. Survey items (on a five-point Likert scale) sought to define the effect virtual patients had on students’ critical thinking, clinical decision making, and confidence.

ResultsA convenience sample of 34 senior dental hy-

giene students initially agreed to participate in the study, but only 31 completed both the HSRT pretest and posttest. That was 81.5% of the total students in that class. In the second part of the study, a conve-nience sample of 30 senior dental hygiene students completed the survey on their perceptions of the simulation (78.9% response rate).

Demographic data on the participants were not obtained as information regarding gender, age, or ethnicity could have enabled the investigator to

Table 2. Pretest descriptive statistics

Variable N Mean SEMean StDev Min Q1 Median Q3 Max

Total score 34 19.47 0.87 5.1 8 16 19 24 28Inductive 34 7.27 0.31 1.8 2 6 8 8 10Deductive 34 6.15 0.38 2.2 1 5 6 8 10Analysis 34 4.12 0.22 1.3 1 3 4 5 6Inference 34 3.15 0.22 1.2 0 2 3 4 6Evaluation 34 4.56 0.23 1.3 1 4 5 5 6

Note:Totalhighestpossiblescorewas33.

Table 3. Posttest descriptive statistics

Variable N Mean SEMean StDev Min Q1 Median Q3 Max

Total score 31 20.30 0.64 3.7 12 17 20 23 28Inductive 31 7.46 0.30 1.7 3 7 8 9 10Deductive 31 6.33 0.33 1.8 2 5 6 8 9Analysis 31 4.15 0.21 1.2 1 3 4 5 6Inference 31 3.24 0.15 0.9 1 3 3 4 5Evaluation 31 4.67 0.23 1.3 1 4 5 6 6

Note:Totalhighestpossiblescorewas33.


fidence in their ability to provide patient care. This survey found that the students perceived virtual pa-tient simulation to be a favorable learning experience that helped them utilize critical thinking in making clinical decisions regarding their virtual patients. The responding students’ perceptions were largely favorable: 86.7% agreed or strongly agreed that the use of virtual patients improved their critical thinking skills, and 93.3% agreed or strongly agreed that the use of virtual patients improved their ability to make good clinical decisions. Likewise, 73.4% agreed or strongly agreed that they felt more confident treating patients because of their experience with virtual pa-tient simulation. A forced completion question asked the students to make additional comments regarding their perceptions of virtual patients. One student reported that the virtual patient session was “helpful in reinforcing information that we learn but may not have the chance to practice in the clinical setting.” Another commented that “virtual patient simulation was great by helping us with clinical decision mak-ing.” Other comments pointed to students’ feeling that the sessions should have been more challenging and that they wished they had had the opportunity to experience the sessions earlier in the curriculum.

a similar national sample of test-takers provides a way to judge the relative strength of the test-takers.

In addition to the total score, five HSRT sub-scale scores were compared from pretest to posttest (Figure 2 and Figure 3). The subscale scores represent the major core skills identified in the APA’s Delphi Report.28 Analysis and interpretation skills are used to closely examine ideas, to recognize assumptions, reasons, and claims, and to be able to assimilate de-tailed information from paragraphs, charts, diagrams, and graphs. The inference scale measures the ability to draw conclusions based on reasons and evidence. Evaluation and explanation skills are used to identify the credibility of claims as well as the strength and weakness of arguments. The deductive reasoning scale measures the ability to move from the assumed truth of a premise to a logical conclusion. Induc-tive reasoning involves the ability to draw probable conclusions based on evidence, data, testimony, or relevant cases. Evaluation of these subscales is help-ful in identifying any individual area weaknesses.29,31

As well as measuring changes in the students’ critical thinking, this study sought to determine how they would characterize the effect of virtual patient simulation on their critical thinking ability and con-

Figure 1. Students’ difference scores on Health Science Reasoning Test (HSRT) from pretest to posttest

Note:Bluebarsindicateeducationallymeaningfulgains.Orangebarsareunexplainedlosses.


Figure 3. Students’ Health Science Reasoning Test scale area scores at posttest

Note: Bluebarsarestrongscores;whitebarsaremoderatescores;andorangebarsare“notmanifested.”

Figure 2. Students’ Health Science Reasoning Test scale area scores at pretest

Note: Bluebarsarestrongscores;whitebarsaremoderatescores;andorangebarsare“notmanifested.”


the mean of some of the highest pretest scores could account for the relatively low overall change in mean scores. This phenomenon can occur when relatively high (or relatively low) scores are followed by less extreme ones nearer the subject’s true mean, as an individual’s score is determined in part by skill and in part by chance.

The results of the survey following the HSRT posttest suggested that students found the virtual patient sessions to be a positive educational experi-ence. Responses indicated that the students perceived virtual patient simulation to be an effective teaching method to promote critical thinking, problem-solv-ing, and confidence in the clinical realm.

There were several limitations to this pilot study, beginning with the fact that it featured a very small convenience sample, which limits the gener-alizability of the findings. Demographic data were not obtained, but specific demographic information might have explained some of the lower scores, par-ticularly if English was not the primary language of the test-taker. Although my research found little in the medical or dental education literature addressing the design of virtual patient cases to maximize the use of critical thinking, the virtual patient cases may not have been designed with adequate complexity to require the students to adequately exercise critical thinking skills. Additionally, utilizing more sophis-ticated simulations, such as high-fidelity manikins used in medical education that can interact with the student clinician, may further foster critical thinking. Study design would have been strengthened with the addition of a control group, which was not a practical option as all students were required to participate in the virtual patient sessions. Finally, there is no way to definitively conclude that improvements in students’ critical thinking scores were attributed to the use of the virtual patient simulations. Improved overall scores could have resulted from the effects of history and maturation; also, students in this study were likely to have been exposed to other educational strategies throughout the curriculum that were de-signed to promote critical thinking.

ConclusionThe results of this pilot study indicated that the

virtual patient simulations did not have a direct effect on the critical thinking scores of these senior dental hygiene students, measured with the HSRT. The students did, however, report that the use of virtual

Discussion Although there was not a significant gain in the

mean score, more than one-third of the participating students scored at least two points higher on the post-test HSRT than the pretest. Test-retest reliability for the HSRT meets or exceeds 0.88 in samples in which administration conditions are adequately controlled at pretest and posttest.31 Correlation levels of 0.80 are generally considered acceptable. With no inter-vention aimed at improving critical thinking skills, test-takers will likely score within one point of their pretest score.31 As each question on the HSRT con-tains distractor choices that invite common human reasoning errors, an overall improvement suggests that, on average, the participants made fewer reason-ing errors and used their critical thinking skills to accurately identify the one correct answer at posttest.

Although most students improved their scores, a few had scores that dropped from pretest to post-test. One such participant completed less than 60% of the items at posttest after completing the entire test at pretest (scoring 18 at pretest and 15 at posttest). A difference of -1 or -2 is possible as test-takers are challenged by the items and choose the wrong re-sponse, while a large decrease would indicate a false test, as critical thinking skills do not deteriorate over short periods of time unless there is an intervening cognitive injury.30 Reasons for the decrease in scores at posttest could be attributed to diminished effort. Some individuals lack sufficient intrinsic motivation to put forth the effort necessary for a cognitively challenging test when they do not see any personal benefit. Instead of refusing to take the test, they may rush through it or leave a number of questions unanswered.31 The posttest was given near the end of the senior year, so it is also possible that motivation was reduced, a phenomenon reported in a previous study.32 It is possible that motivation to complete the test and deliver necessary effort was diminished due to “senioritis” or burnout. Student burnout with resulting lack of motivation toward the end of the senior year has been identified by researchers.33

One interesting result was the consistent gains in total scores overall, except in the group that scored the highest at pretest. The number of scores in the 25-30 range (indicating strong core critical thinking skills) was less at posttest, with six participants scor-ing in this range at pretest vs. only two at posttest. This phenomenon may be due to regression to the mean in this non-random sample. The regression to


8. Facione PA, Facione NC, Giancarlo CAF. Professional judgment and the disposition toward critical thinking. Millbrae, CA: California Academic Press, 1997.

9. Williams KB, Schmidt C, Tillis TSI, et al. Predictive validity of critical thinking skills and disposition for the national board dental hygiene examination: a preliminary invesitgation. J Dent Educ 2006;70(5):536-44.

10. Brooks KL, Shepard JM. The relationship between clini-cal decision-making skills in nursing and general critical thinking abilities of senior nursing students in four types of nursing programs. J Nurs Educ 1990;29(9):391-9.

11. Morrison S, Walsh-Free K. Writing multiple-choice items that promote and measure critical thinking. J Nurs Educ 2001;1(40):17-23.

12. Hendricson WD. Educational strategies associated with development of problem-solving, critical thinking, and self-directed learning. J Dent Educ 2006;70(9):925-36.

13. Allen KL, More FG. Clinical simulation and foundation skills: an integrated multidisciplinary approach to teach-ing. J Dent Educ 2004;68(4):468-74.

14. Morton PG. Creating a laboratory that simulates the criti-cal care environment. Crit Care Nurs 1995;16(6):76-81.

15. Botezatu M, Hult H, Fors UG. Virtual patient simulation: what do students make of it? A focus group study. BMC Med Educ 2010;10(91):1-8.

16. Saleh N. The value of virtual patients in medical education. Ann Behav Sci Med Educ 2010;16(2):29-31.

17. Kardong-Edgren SE, Starkweather AR, Ward LD. The integration of simulation into a clinical foundations of nursing course: student and faculty perspectives. Int J Nurs Educ Scholarsh 2008;5(1):1-16.

18. Khan K, Pattison T, Sherwood M. Simulation in medical education. Med Teach 2011;33:1-3.

19. Hendricson W. Changes in educational methodologies in predoctoral dental education: finding the perfect intersec-tion. J Dent Educ 2012;76(1):118-34.

20. Boynton JR, Green TG, Johnson LA, et al. The virtual child: evaluation of an internet-based pediatric behavior management simulation. J Dent Educ 2007;71(9):1187-93.

21. Weis PA, Guyton-Simmons J. A computer simulation for teaching critical thinking skills. Nurse Educ 1998;23(2): 30-3.

22. Cook DA, Triola MM. Virtual patients: a critical literature review and proposed next steps. Med Educ 2009;43: 303-11.

23. Sullivan-Mann J, Perron CA, Fellner AN. The effects of simulation on nursing students’ critical thinking scores: a quantitative study. Newborn Infant Nurs Rev 2009;9(2):111-6.

24. Kaddoura M. New graduate nurses’ perceptions of the effects of clinical simulation on their critical think-ing, learning, and confidence. J Contin Educ Nurs 2010;41(11):506-16.

25. Phillips J, Berge ZL. Second life for dental eduation. J Dent Educ 2009;73(11):1260-4.

26. The University of Texas School of Dentistry at Houston strategic plan 2011-16. Houston: The University of Texas School of Dentistry at Houston, 2011.

27. Henson H. Dental branch change initiative: simulation in DDS and DH preclinical and clinical education. Houston: The University of Texas School of Dentistry at Houston, 2010.

patients contributed to building their critical thinking skills and confidence in making good clinical deci-sions. Quantitative evaluation of computer-simulated patients in dental and dental hygiene education is lim-ited particularly for outcome measures of simulation in the area of critical thinking. This study contributes to the literature supporting educational strategies that promote critical thinking in dental hygiene students. There is a need for additional randomized controlled studies with larger sample sizes. It is also important to evaluate the instructional design of virtual patient cases to ensure that cases challenge the students to use their critical thinking skills. Further research is necessary to evaluate the effectiveness of strategies such as virtual patient simulation that are intended to increase students’ critical thinking skills and the application and transfer of knowledge to clinical care.

AcknowledgmentsI would like to extend thanks to the following

who made the completion of this project possible: Dee August, PhD, Research and Assessment, Insight Assessment, for statistical analysis; Harold A. Hen-son, RDH, Med, my onsite faculty mentor; Nancy J. Williams, RDH, EdD, graduate faculty advisor; The University of Texas School of Dentistry at Houston dental hygiene class of 2012 for participating in the study; and the Dean’s Academy of Teaching Schol-ars at The University of Texas School of Dentistry at Houston for awarding me a grant to complete the study.

REFERENCES 1. Chambers D. Lessons from students in a critical think-

ing course: a case for the third pedagogy. J Dent Educ 2009;73(1):65-80.

2. American Dental Education Association. Commission on Change and Innovation in Dental Education, 2008. At: www.adea.org/adeacci/About/Pages/default.aspx. Accessed 11 June 2011.

3. Moore T. Implementation of problem-based learning in a baccalaureate dental hygiene program. J Dent Educ 2001;71(8):1058-69.

4. American Dental Hygienists’ Association. National dental hygiene research agenda, 2007. At: https://www.adha.org/resourcesdocs/7111_National_Dental_Hygiene_Re-search_Agenda.pdf. Accessed 21 May 2011.

5. Commission on Dental Accreditation. Accreditation stan-dards for dental hygiene education programs. Chicago: American Dental Association, 1998:1-41.

6. Khatami S, MacEntee MI. Evolution of clinical reasoning in dental education. J Dent Educ 2011;75(3):321-8.

7. Williams KB. Predictive validity of critical thinking skills for initial clinical dental hygiene performance. J Dent Educ 2003;67(11):1180-92.


31. Health science reasoning test user manual. Millbrae, CA: Insight Assessment, California Academic Press, 2014.

32. Rogal SM, Young J. Exploring critical thinking in critical care nursing education: a pilot study. J Contin Educ Nurs 2008;39(1):28-33.

33. Schaufeli WB, Martinez IM, Pinto AM, et al. Burnout and engagement in university students: a cross-national study. J Cross Cult Psychol 2002;33(5):464-81.

28. Facione P. Critical thinking: a statement of expert consensus for purposes of educational assessment and instruction—the Delphi report. Millbrae, CA: American Philosophical Association, 1990.

29. Facione NC, Facione PA. The health science reasoning test: a test of critical thinking skills for health care profes-sionals test manual. Millbrae, CA: Insight Assessment, California Academic Press, 2010.

30. Insight assessment: premium report for Joanna Allaire. San Jose: Insight Assessment, 2012.

Assessing Critical Thinking Outcomes of Dental Hygiene ... · PDF file1082 Journal of Dental...

Documents

Transcript of Assessing Critical Thinking Outcomes of Dental Hygiene ... · PDF file1082 Journal of Dental...