Dental students’ perception and performance in final year undergraduate clinical examination during COVID-19

Objective: To assess the perception and the performance of dental students on clinical component of the final year examination held during COVID-19 pandemic. Methods: Final year dental undergraduates (n=86) in year 2014 participated in the study. A pre tested, self-administered questionnaire (online Google form) was used to assess their preparedness and perception regarding changed clinical set up. Percentage marks obtained for each component was used to assess their performance during pre COVID and COVID times. Results: The mean scores for knowledge, attitude and fear were 82%, 94% and 77% respectively. There was no significance in the perception regarding the clinical set up for prosthetic dentistry (p= 0.317) and restorative dentistry (p=0.384) when pre and during COVID-19 groups were compared. However, a statistically significant difference was observed for oral surgery component (p=0.005) for the same. There was no significant correlation between the perception scores and the students’ performance for all three clinical components. (Spearman r ≈ 0.000, p-value = 0.998). Similarly, no significant correlation was found between actual performance and the statements ‘they could have performed better’; ‘needed more time’ (Spearman r ≈ 0.057, p-value = 0.742) (spearman r ≈ -0.023, p-value = 0.778) were considered. Conclusion: These results suggest students’ knowledge and attitude regarding preparedness for clinical examination during COVID-19 is satisfactory. Students’ performance is not significantly affected by their perception or subjective opinion in all three clinical components. 
  
 
Keywords 
Assessments, COVID-19, Dental education, Perception, Student performance


INTRODUCTION
The Corona Virus Disease 2019 (COVID-19) is an ongoing 2 global pandemic of corona virus with more than 100 million 3 confirmed cases and more than two million reported deaths 4 worldwide. (1) The virus has surged in many regions with 5 multiple waves in countries that had apparent success in 6 suppressing initial outbreaks and Sri Lanka is no exception.

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The COVID-19 pandemic has forced the world into a health 8 and economic crisis interrupting numerous regular routine 9 activities and has affected work, free movement, trade, and 10 education. (2) 11 During the current pandemic, the Occupational Safety 12 and Health Administration (OSHA, gov) classified dentists 13 in the very-high risk category due to due to potential 14 exposure to corona virus through close contact with the oral 15 and nasal cavities which are portals of exit of viral particle 16 and the routine use of aerosol-generating procedures. (3,4) 17 Recent studies suggesting COVID-19 may become airborne 18 through aerosols formed during medical procedures or 19 be transmitted indirectly through saliva has also been 20 published. (5-9) 21 is a challenge due to many reasons. Dental education 23 can be considered to have four major domains. The first 24 is imparting knowledge which can easily be delivered  The lockdown resulted in postponement of examina-44 tions in many dental schools whereas some had their 45 examinations entirely online. (11) Some educational institutes 46 have proposed that their assessments will be conducted in alternative formats to allow students to complete them 48 remotely. The faculties had to work to different schedules 49 and requirements and some variations relating to assessment 50 periods had to be introduced in order to mitigate the skilling of students due to the lack of clinical practice for 76 four months it was decided to conduct the operative dental 77 procedure in restorative dentistry clinical examination on a 78 mannequin. In order to make the examination uniform and 79 standardized the examination component of the students 80 who had completed the clinical prior to the stoppage due to 81 COVID-19 had to be annulled requiring those students to re-82 sit the practical. It was decided to continue the same clinical 83 examination format for oral surgery and prosthetic dentistry 84 due to them being minimal or non-aerosol generating.

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Although there are a number of studies pertaining to 86 influence of novel Corona virus disease in dental hospital 87 practice and dental education, authors hardly could retrieve 88 any research carried out considering students' and staff 89 perception in adjusting to the new clinical assessment set 90 up with specific infection control practices. Therefore, the 91 aim of this study was to assess the perception of the dental 92 students and the staff on clinical component of the final 93 year examination held during COVID-19 pandemic. Further 94 it was also to assess whether the change has affected the 95 students' performance at the examination. This study will 96 be helpful in identifying the perception of students and 97 staff in the only dental school in the country who were 98 involved in the examination conducted in the new set up to 99 comply with COVID-19 guidelines. Furthermore, the results 100 would influence necessary improvements in the clinical 101 setup, teaching and conducting examinations in the future. 102

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The study was approved by the Ethics Review Committee 104 of the Faculty of Dental Sciences, University of Peradeniya, 105 Sri Lanka. (ERC/FDS/UOP/1/2020/27). All the final year 106 dental undergraduates (n=86) in year 2014 and all the 107 staff involved in the clinical components of oral surgery, 108 prosthetic dentistry and restorative dentistry of the Final 109 BDS examination were invited to participate in the study 110 with their informed written consent.

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A pre tested, self-administered questionnaire (online Google 113 form) was used as the study instrument for the students. 114 The web link of the survey was disseminated among dental 115 students and the examiners by electronic mail and social 116 media. Identification details were not collected through the 117 questionnaire and the anonymity of all participants was 118 ensured.   Students were given twenty minutes to complete history 155 taking and examination to arrive at a tentative diagnosis and 156 ten minutes for the presentation and discussion.

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Restorative dentistry component 158 Operative procedure was carried out in phantom heads.

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Only ten students were taken inside the simulator lab, and . The scores 177 were compared for significance difference between genders. 178 Statistical significance was considered as p value <0.05.

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Section B was used to assess the perception of students 180 regarding challenges faced at the new clinical set up. A 181 score for perception about clinical set up was obtained 182 by summing up positive statements (1-6 and 13) and 183 perception regarding Personal Protective Equipment (PPE) 184 by (statements 7-10 and 12). Students' subjective perception 185 regarding their performance was also obtained (statements 186 11 and 14) and these were compared between the examina-187 tions held during pre COVID and COVID times.

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A separate analysis was undertaken to compare the 189 students' performance in three disciplines during pre 190 COVID and COVID times by using marks they obtained. 191 Further, correlation was calculated between the students' 192 perception during COVID and the performance in the three 193 clinical components separately. Mann-Whitney U test was 194 used to compare the means and Pearson correlation test was 195 used to assess the correlations. The statements in common, 196 of the two questionnaires given to the examiners and non-197 examiners were used to generate two separate scores for 198 positive and negative statements.

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Response to students' Questionnaire 201 Response rate for the students' questionnaire was 82%. 202 Seventy-one students out of the eighty-six students of the 203 2014 batch had submitted their response via Google form. 204 Out of the participants, 28% were males and 72% were 205 females.

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Students' preparedness as shown by knowledge, Attitude, 207 and fear scores 208 The average scores for knowledge, attitude and fear were 209 82%, 94% and 77% respectively in the group of students 210 indicating that they were knowledgeable and had a positive 211 attitude to participate in the clinical session despite having 212 fear. However, there was no significant difference in the 213 means of knowledge, attitude, and fear scores with respect 214 to the gender (Table 1). When the students' perception was considered, more than 218 70% of the students were positive with regard to the changed 219 clinical environment. Twenty four percent to 100% of the 220 students were in agreement with the negative impact of PPE 221 on clinical set up. Majority (88%) agreed that they were able 222 to complete the examination within the allocated time but  There was no significant correlation between the perception 258 scores and the students' performance for all three clinical 259 components (Spearman r ≈ 0.000, p-value = 0.998). There 260 was no significant correlation between the perception on 261 PPE and the students' performance either for prosthetic 262 dentistry and oral surgery (Spearman r ≈ -0.053, p-value = 263 0.615) (Figure 2).     S1 Adequate information on the procedure was given before commencement of the examination S2 Exam set up was well organized S3 Exam environment was friendly S4 Infection control procedures practiced during the examination were adequate S5 Adequate PPE was provided during the examination S6 Adequate chair side assistance was provided to me during the examination S7 Wearing PPE affected the communication S8 I was Uncomfortable wearing the PPE S9 I felt that the professionalism was affected while wearing PPE S10 Wearing PPE needed extra time to carry out the procedure S11 I was able to finish the examination within the given time S12 After completing the procedure, I felt that my hands eyes or face might have got contaminated S13 The measures that were taken was adequate for my safety S14 I think I could have performed better if these new changes were not there to be knowledgeable regarding the precautionary guidelines 294 and clinicians need to be responsible both within the 295 clinical environment and outside to minimize the spread of 296 infection. Our findings are supportive of the fact that the 297 dental students' preparedness in terms of knowledge and 298 attitudes is satisfactory to participate in sessions involving 299 same. (18)(19)(20) In a study done in Iran (19) it has been shown that 302 mean knowledge score regarding COVID-19 was 59.7% and 303 the mean attitude score was 66% compared to a knowledge 304 score of 63% and attitude score of 79.8% among medical 305 and dental students in Nepal. (20) Our score for knowledge 306 on COVID-19 is higher than reported in previous studies

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More than half of the students (56%) felt they could have 347 performed better if the changes had not been there. This 348 is in agreement with a previous study where 53% stated 349 their clinical performance was negatively affected by the 350 COVID pandemic. (21) Moreover, case presentation used 351 which required communication both with the patient and 352 the examiner could have been affected to a certain degree due 353 to wearing of PPE and might have led to a lower mean in the 354 marks in oral surgery. Further, conducting the examination 355 in mannequins could be the reason for poor performance 356 in restorative dentistry compared to pre COVID-19 time 357 since students did not have an opportunity to practice such 358 procedures after their pre-clinical time which was about 359 18 months before. Possible de-skilling which might have 360 occurred due to the lock down could have been another 361 contributory factor for lower performance in the restorative 362 dentistry component. However, no significant correlation 363 was observed with the students' subjective opinion regarding 364 their performance and the students' actual performance. 365 This was a very encouraging finding to endorse both 366 the clinical training and the assessments involving direct 367 patient contact can be undertaken in 'new normal' situation 368 provided the whole dental team adapts to the recommended 369 precautionary guidelines. Unfortunately, authors could not 370 track down any studies carried out in similar settings for 371 discussion.

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There had been many practical changes in different 373 institutions such as clinical reasoning exercises, case pre-374 sentation narratives and self-reflection activities based on 375 portfolios/log diaries. (11) Even though some of these had 376 already been incorporated in the formative assessments 377 in our institution they had not been used for summative 378 assessments. Thus, it was not possible to make use of those 379 modalities in the examination. However, portfolios/log 380 diaries could be used to assess the much required hand skill 381 of a student which is a fact to be remembered should the 382 pandemic continues.

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A high-stake online exam had been implemented during 384 COVID-19 time for final year dental students for their exit 385 exam in the form of Modified Essay Questions (MEQs), 386 Multiple Choice Questions (MCQs), OSCEs and an oral 387 exam to assess didactic knowledge, clinical acumen, and 388 communication skills. (22) While it is possible to assess the 389 analytical and decision making skills of a student by these 390 methods it would hardly be of any importance to assess the 391 actual hand skills of the operator. Even though technology 392 can supplement education in many ways it can never replace 393 programmes such as dentistry as there are many variables 395 that cannot be simulated to a great degree in mannequins.

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On the other hand if clinical training involving direct contact 397 with the patients can be undertaken there seems to be no 398 reason why the same cannot be applied in assessments.