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J Dent Educ. 69(2): 281-284 2005
© 2005 American Dental Education Association
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Educational Methodologies

Improvement in the Interpersonal Communication Skills of Dental Students

Timothy L. Hottel, D.D.S., M.S., M.B.A.; Patrick C. Hardigan, Ph.D.

Key words: interpersonal communication skills, behavior management, patient relations

Submitted for publication 07/29/04; accepted 10/29/04


   Abstract
Top
 Abstract
Methods
 Results
 Discussion
 References
 
This study compared the interpersonal communication skills of seventy-eight third-year dental students when interacting with their patients before and after they participated in a thirty-five-hour course that addressed recognition of anxiety, interviewing techniques, patient records, behavior management, and patient relations. Students were evaluated before and after attending the course by psychology graduate students who used a behavioral observation form that measured expressive and receptive communication skills, nonverbal communication skills, professional presentation, and sensitivity to cultural, ethnic, and gender diversity. At the conclusion of this course, students’ interpersonal skills were rated significantly higher than prior to the course at the p<.0001 level. The outcomes of this study indicate that effective communication between dental students and their patients may be acquired and refined through a course that addresses basic interviewing skills.

F or almost four decades, professional psychology has been closely linked with the health sciences and has experienced an expanded role in that arena. This study illustrates how a course in behavioral science can be used to facilitate and augment the training of dental students. In this case, training in communication techniques can be beneficial in improving the scope of dental education by providing the future practitioner with the increased capacity to understand and respond to the needs of patients.

Incorporation of psychology into the training of dental students is especially advantageous to allow future dentists to identify and respond to psychological reactions by the patient. Dental work is filled with psychological phenomenon. Discomfort and pain are often perceived and, in many cases, are even associated with routine dental procedures, causing anxiety and avoidance.1 Beyond the obvious anxiety associated with dental pain, the intrusiveness of a dental procedure often creates numerous psychological reactions for both the dentist and the patient.

This study was designed to observe and document the effect of a course in patient management conducted for third-year dental students at Nova Southeastern University College of Dental Medicine. The topics of this course are recognition of anxiety, interviewing techniques, patient records, behavior management, and patient relations.

The purpose of this study, expanding on a previous pilot study,2 was to evaluate the outcomes achieved through a didactic training program in patient management. One should be able to assess the relevance of this type of course by comparing the differences observed between pre- and post-course observations. Specifically, the intent of this project was to document any improvement in students’ interpersonal skills.


   Methods
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 Abstract
 Methods
Results
 Discussion
 References
 
A five-point behavioral observation rating scale3 consisting of ten items was used to assess dental students’ interviewing skills. Skills were rated along a continuum with 1 representing strongly disagree, 2 disagree, 3 unsure, 4 agree, and 5 strongly agree.

The rating scale was designed to evaluate a wide range of interviewing skills. The following five items assessed expressive and receptive communication skills:

  1. presented questions that were clear and to the point,
  2. presented information regarding dental techniques in a clear and organized manner,
  3. appeared to focus and "listen" to the patient,
  4. responded appropriately to the patient’s content, and
  5. conducted a well-organized and concise interview.

The following three items assessed nonverbal communication skills:

  1. noticed and appropriately addressed the patient’s nonverbal behavior,
  2. maintained appropriate eye contact during the interview, and
  3. facilitated patient in feeling less anxious and more comfortable.

Lastly, the following two items globally assessed presentation and interviewing skills:

  1. presented self in a professional manner, and
  2. appeared sensitive to issues of cultural, racial, ethnic, and gender diversity.

The observation rating scale used in this study to assess the interviewing skills of dental students was used for this purpose in two previous studies where it was found to be a reliable measure.2,3

To ensure the internal reliability of this rating scale, Cronbach’s Alpha was calculated for the results of the current study. Adequate content validity may be ensured by carefully evaluating the full range of behaviors to be observed.4,5 Therefore, the inclusion of items designed to rate nonverbal communication skills and professional demeanor, in addition to the items designed to evaluate expressive and receptive communication skills, helped to ensure the rating scale’s content validity for a global assessment of interviewing skills.

A thirty-five-hour training course was provided to third-year dental students. A licensed psycholo gist taught the lecture portion of the course. This segment of the training course focused on helping the dental students to gain a conceptual understanding of interpersonal communications, as well as an increased awareness of verbal and nonverbal manifestations of anxiety. Doctoral-level psychology students who had already obtained their master’s degrees taught the second portion of the class, which consisted of laboratory activities. The labs were designed to facilitate the translation of theoretical knowledge into the application of improved clinical skills. First, the lab instructors modeled appropriate communication techniques; after that, the dental students roleplayed various interactions between dentists and patients to practice their interviewing skills. Corrective feedback was provided by the lab instructors, as well as by the other dental students. During the labs, students learned how to conduct anxiety reduction techniques, such as diaphragmatic breathing and progressive muscle relaxation.1

Using the ten-item rating scale, behavioral observations were made of the dental students’ interactions with their patients both before and after the training course was provided. While the students were informed that an observation was to take place, they were unaware of when they would be observed. Therefore, they were unable to anticipate the day or the patient that they would be treating when they were being observed. In this regard, the timing of the observation was viewed to be random with no special attention paid to a "selected" patient.

The lab instructors used in this study were trained psychology doctoral students. Their training program included measures to minimize potential error and bias since their observations were subjective in nature. Ten lab instructors conducted the observations. Each of the observers performed the following tasks: observed the interviewing skills of ten dental students before they completed the training course, led a weekly lab addressing communication skills to ten different dental students, and observed the interviewing skills of ten different dental students after the training course was completed. The pre- and post-course mean and standard deviation for the observations are presented in Table 1Go. The observers were randomly assigned to a different group of ten dental students for each of the three tasks in order to decrease any bias by the observers. Inter-rater reliability was established by providing each of the observers with identical and detailed training on the specific criteria to be used in determining the rating for each item on the behavioral scale. To ensure inter-rater reliability, a two-way random effects model was calculated for the results of this study.


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  		Table 1. Pre- and post-course mean and standard deviations
 
Third-year dental students at Nova Southeastern University College of Dental Medicine completed the training course on interpersonal communication as part of their core curriculum. Of the 100 third-year dental students, seventy-eight were included in the study. The twenty-two students not included fell into at least one of the following categories: a pretraining evaluation was not completed, the training course was not completed, and/or a post-training evaluation was not completed. The academic performance (GPA, class rank, and board scores) and demographic characteristics of the excluded students were not different from those students included in the study. Therefore, it was concluded that these students were excluded due to random events and the remaining sample was representative of the third-year dental students at Nova Southeastern University College of Dental Medicine.


   Results
Top
 Abstract
 Methods
 Results
Discussion
 References
 
The internal reliability of the behavioral observation rating scale was assessed by calculating Cronbach’s Alpha. The value for Cronbach’s Alpha was .74, which indicates that the behavioral observation rating scale used was internally reliable and that all ten items appeared to adequately assess the interviewing skills of the dental students.

To ensure reliability among the ten observers’ independent ratings of the interviewing skills of the dental students, a two-way random effect model was used to measure inter-rater reliability. This formula was chosen since it accounts for the random effects of both the measures and the observers when there are more then two tests (one test, one retest) to be correlated.6 The average intraclass correlation for measuring inter-rater reliability was .7410. This result indicates that there was fairly strong agreement between observers and measures.

Paired sample t-tests were calculated for each of the ten items on the behavioral rating scale to determine if the training course was successful in improving the students’ interviewing skills. These calculations showed that all ten items on the behavioral rating scale were significant at p<.0001. The results of these paired sample t-tests, including effect sizes and degrees of freedom, are shown in Table 2Go. For this study, effect size estimates are the standardized differences between pre- and post-scores on the questionnaire.


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  		Table 2. Paired sample t-tests for each item of the behavioral rating scale
 
Based on comparisons between the observers’ ratings before and after the training course was provided, the results in Table 2Go indicate that the course was effective in improving all the interviewing skills of the students (p<.0001). Due to their large effect sizes, the interviewing skills that displayed the greatest improvements after completion of the training course were the following: attending to the patient’s nonverbal behavior (ES = 1.15), decreasing the patient’s anxiety and increasing his or her level of comfort (ES = .98), and focusing and listening to the patient (ES = .90). These data show that the training course was most effective in helping the students to develop these particular interviewing skills. Maintaining appropriate eye contact was the skill that showed the least amount of improvement, as evidenced by its smaller effect size (ES = .54).

Prior to receiving the training course, the dental students showed a relative strength in presenting themselves in a professional manner (M = 4.59) and displayed relative weakness for attending to patients’ nonverbal behaviors (M = 3.73) and appearing sensitive to issues of cultural, racial, ethnic, and gender diversity (M = 3.91). Participation in the course most effectively facilitated the improvement of the students’ attentiveness to patients’ nonverbal behaviors (ES = 1.15). Even after completing the course, the students continued to maintain their relative weakness for appearing sensitive to diversity issues (ES = .63), as well as their relative strength for possessing a professional demeanor (ES = .64).


   Discussion
Top
 Abstract
 Methods
 Results
 Discussion
References
 
Dental education is in a constant state of change. The evolution of the curriculum has grown to the point that many programs include coursework in the area of psychology. Over 70 percent of U.S. and Canadian dental schools have courses specifically addressing the subject matter of interpersonal communication, a current requirement addressed in accreditation standard 2–7.7 Surveys conducted at this institution indicate that dental students expect to gain a working knowledge in patient management. This project was designed to study, evaluate, and assess the outcomes of a course designed to help students develop their interpersonal communications skills. These skills were taught to increase students’ ability to relate to their patients. "As in medicine, cross-sectional studies have reported that effective interpersonal communication in dentistry increases patient satisfaction and patient compliance, at the same time it reduces patient anxiety and the risk of malpractice claims."7 This in turn may lead to increased patient referrals, which will have a direct correlation with the growth of a practice.

This study differed from recent studies7,8 since it not only involved typical classroom lectures and roleplaying, but also involved direct interaction with patients. The training provided for the dental students used many psychological techniques to help the student acquire the skills necessary to conduct a thorough interview and adequately respond to the patient’s psychological reactions. The improvements gained in the students’ interviewing skills after receiving this training exemplifies how psychologists may be extremely useful in providing consultation and education for dentistry as well as other professions.

The results of this current study, while useful to the Nova Southeastern University College of Dental Medicine, also have implications for other dental schools. One of the goals of dental schools is to train their students to have excellent technical skills and production. Increasingly, these schools also seek to ensure that their graduates are able to understand the overall health care needs of their patients, not just to treat the oral cavity. This means that these professional schools are striving to graduate dentists who are able to relate, understand, and effectively communicate with their patients.9

The outcomes of this study demonstrated that the course was effective in improving the interviewing skills of the dental students. An improvement in interviewing skills has been previously shown to directly correlate to increased productivity.2 Therefore, this type of course may show multiple benefits in the overall training of dental students.


   Acknowledgments
 
The author wants to thank Christine L. Hiler, M.S., Ph.D., for her comments in the development of this project. Dr. Hiler was a doctoral candidate, Nova Southeastern University, Department of Psychological Studies, during this study.


   Footnotes
 
Dr. Hottel is Professor, Department of Prosthodontics and Executive Associate Dean and Associate Dean for Academic and Financial Affairs, Nova Southeastern University College of Dental Medicine; Dr. Hardigan is Executive Director of Assessment, Evaluation, and Faculty Development, Nova Southeastern University Health Professions Division. Direct correspondence and requests for reprints to Dr. Timothy L. Hottel, Nova Southeastern University, College of Dental Medicine, 3200 S. University Drive, Ft. Lauderdale, FL 33328; 954-262-7349 phone; 954-262-1782 fax; thottel{at}nova.edu.


   REFERENCES
Top
 Abstract
 Methods
 Results
 Discussion
 References
 

  1. Andrews G, Crino R, Hunt C, Lompe L, Page A. The treatment of anxiety disorders: clinicians’ guide and patient manuals. New York: Cambridge University Press, 1994.
  2. Hottel TL, Hiler CL. The effects of patient management training on the interpersonal communication and clinical skills of third-year dental students. Psychol Indep Prac 2001;2(4):73–9.
  3. Hiler CL. Interpersonal skills training of the dental student. Psychol Indep Prac 2001;2(3):91–103.
  4. Hops H, Davis B, Longoria N. Methodological issues indirect observation: illustrations with the living in family environments (LIFE) coding system. J Clin Child Psychol 1995;24:193–203.
  5. Piacentini J. Checklists and rating scales. In: Ollendick TH, Hersen M, eds. Handbook of child and adolescent assessment. Needham Heights, MA: Simon & Schuster, 1993:82–97.
  6. Shrout PE, Fleiss JL. Intraclass correlations: uses in assessing rater reliability. Psychol Bull 1979;86:420–8.
  7. Yoshida T, Milgrom P, Coldwell S. How do U.S. and Canadian dental schools teach interpersonal communication skills? J Dent Educ 2002;66(11):1281–8.[Abstract]
  8. Hannah A, Millichamp C, Ayers M. A communication skills course for undergraduate dental students. J Dent Educ 2004;68(9):970–7.[Abstract/Free Full Text]
  9. Hiler CL. Psychological consultation in dental training. MS thesis, Nova Southeastern University, Ft. Lauderdale, FL, 2002.



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