The learning outcome of the dental undergraduate program in India, is to have graduates who are proficient in basic, pre and para clinical as well as clinical sciences and are capable of providing high quality dental treatment along with an understanding of social and psychological aspects of patient care. There is a strong emphasis on three domains of learning i.e, cognitive, psychomotor and attitude, throughout the undergraduate course, which helps students to gain theoretical knowledge and clinical acumen. As with any other field it has now been realized that in addition, soft skills are equally needed for a professional edge. These skills are critical in ensuring patients’ psychological, physical, social needs and well-being [1,2].

The technical abilities required to perform a job are referred to as hard skills and are objectively necessary for a given occupation while soft skills is a sociological term relating to a person’s Emotional Intelligence Quotient (EQ), the cluster of personality traits, social graces, communication, language, personal habits, friendliness and optimism that characterize relationships with the patients [3]. Perreault defined soft skills as personal qualities, attributes, interpersonal skills or the level of commitment of an individual that sets him apart from other individuals who may have similar skills and experience [4].  

As an integral part of general health, dental health care focuses on treating oral diseases and improving oral health. It must also be concerned with meeting the emotional needs and desires of the patients. This is largely determined by the personal characteristics of the caregivers. It is crucial for dental students to listen to patients intently, understand their concerns, and consider them as individuals who think and feel. This highlights the significance of possessing soft skills.  Soft skills will not be considered an alternative to hard skills, but rather as additional qualities. Students with good interpersonal skills can listen to and question their patients in an empathetic manner, allowing the patients to understand their oral health conditions and needs. Dalaya et al [5] reported that students are more likely to succeed in challenging circumstances if they are better trained in soft skills. Several studies have linked high levels of emotional intelligence and soft skills to not only strong academic performance but also better clinical outcomes, [6,7] good team management among students, colleagues, and staff members [8]. According to the literature, professionals with soft skills are more employable and collegial, and patients are happier with their clinical care [5,9]. Patients are less satisfied with the treatment provided by dentists who lack interpersonal skills [10].

Students who can learn and master such skills can gain a better understanding of their patients' needs, participate in tasks that meet their patients' expectations, and gain more control over their academic development and growth. Although soft skills are related to one’s personality trait, it can be acquired by training and learning [11]. In some countries, soft skills have been introduced in the dental teaching curriculum. At the General Assembly of the Association of Dental Education in Europe in 2009, it was agreed that all European Dental Schools must adhere to professional attitude and behaviour, ethics and jurisprudence (Domain I), interpersonal, communication and social skills (Domain II),knowledge base, information and information literacy (Domain III) [12]. Embedded within these domains were other soft skills categories including team work, critical thinking and problem solving, leadership and practice management. Similarly in 2011, the American Dental Education Association also identified these soft skills as competences for their ‘New General Dentist’. ^[8] In Malaysia, the soft skills module was introduced for dental students in 2006. Based on research data and expert opinion, the Ministry of Higher Education, Malaysia (MOHE) identified various soft skill areas introduced in the dental curriculum namely communication skills, leadership, critical thinking, professionalism, entrepreneurship, life-long learning and teamwork [13].

At present, to the best of our knowledge, dental colleges in India   are in the lag phase of teaching learning process of soft skills to their students as there is no formal guideline in the present dental undergraduate curriculum [14]. Recently, a revised Competency based curriculum for dental undergraduates has been proposed by the Dental Council of India which is still to be implemented with special emphasis on integration of Attitude, Ethics and Communication (AETCOM) module [15]. This kind of module has already been incorporated for medical graduates by Medical Council of India in 2018 [16,17].

This study was conducted to  evaluate  the  knowledge and understanding of Indian Dental Graduates about  soft skills , their awareness  and perception  about  these skills and to explore  the  need for  training to be incorporated in the curriculum for Indian dental undergraduates. 

This is a descriptive questionnaire-based study which used an online   questionnaire as a tool for obtaining information on knowledge, attitude and perceptions regarding soft skills from Indian Dental undergraduates. It was spread over a time frame of four months, from May to August 2022. Scientific approval was obtained from the Internal Research Review Committee and Ethical approval was obtained by the Institutional Ethic Committee before commencement of the study.

Aim

To evaluate   knowledge, attitude and perception of soft skills of Indian dental undergraduates.

Objective

Primary

To find out the gaps in soft skill competencies amongst dental undergraduates under the present curriculum. 

Secondary

To reflect upon and plan further interventions to bridge this gap.

Inclusion Criteria

BDS final year students and BDS Interns

Exclusion Criteria

BDS First, Second and Third-year Students were excluded from the study

Tool Used

A self-administered questionnaire was developed after literature search and review. It was incorporated in a Google form, as the tool for capturing information regarding demographic details, knowledge, awareness and perceptions of soft skills. The language used was English. The link of the same was disseminated through email and Whatsapp group to dental undergraduates of India. Participation was voluntary and anonymous with consent. Demographic data such as age, gender and year of study were also collected. The questionnaire had knowledge, awareness and perception components regarding soft skills. Responses  were noted in a five-point Likert scale, in which responders had specified their level of agreement to a statement in five points,  Strongly disagree (0) Disagree (1) Neutral (2) Agree (3) Strongly agree (4). The content validity of questionnaires was done by a group of experts by calculating the content validity index (CVI). The questionnaire was subjected to a pilot study wherein 30 respondents from the final year and intern batch filled the questionnaire to ensure that the respondents were interpreting the questions as intended, before carrying out the study on a larger sample.

Sample Size Calculation

The sample size was estimated using nMaster software (version 2, CMC, Vellore). The sample size estimation was done for Estimating Single Proportion. Anticipating a 50% prevalence of soft skills among Indian dental undergraduates, absolute precision of 5%, and a 95% confidence interval, a design effect of 2 (as the sample was selected in the form of clusters and not from random sampling method, so, to compensate for the clustering effect, the sample size was multiplied by a design effect of 2), a sample size of 768 was found to be sufficient.

Sample size calculation formula

Where

p: Expected prevalence = 0.5

d: Absolute precision required on either side of the prevalence = 0.05 or 5%

Z: 1.96

Statistical Analysis

Data was analyzed using SPSS (Version 16.0. Chicago, SPSS Inc.). The data was entered into Microsoft excel spreadsheet and then imported to SPSS for analysis. Demographic variables and responses to different items of the questionnaire were summarized and presented as frequencies. As the responses to the items of the

survey instrument were recorded on a Likert scale, the individual items scores and domain scores were summarized as Means & Standard deviation. The responses to various items were compared across gender & year, using Chi square test. The level of statistical significance was set at 0.05.

A total of 789 dental undergraduates responded and filled up the questionnaire. The participants were studying in institutions located in different parts of India. Age of the participants was 21 yrs and above with 65% of the participants being in the age ranges of 23-25 years. Among them, 72% were females and 28% were males. 50 % respondents were final year students and 50% were Interns. Frequency and percentage of demographics details of the respondents is depicted in Fig (1).

Fig 1: Demographic Details of Respondents I.E. Age, Gender and Year of Study.

On analysis of responses about knowledge of soft skill, 80 % of the respondents   had knowledge of soft skills (with p value = 0.282 showing non-significant result) but many of the respondents were not aware of the different categories of soft skills (with significant p value=0.044) and that it could be acquired by learning and training (Fig 2).

Fig 2: Knowledge about Soft Skills.

Regarding perception of having the different categories of soft skill, most of the respondents perceived to not “strongly agree” but just “agree” to having these soft skills in them. (Fig 3) The mean of Likert scale for each category is shown in Table 1. This shows that participants agree to have these competencies in them but they do not strongly believe to possess them.

Fig 3: Self Perceived Level of Soft Skills.

Of all the skills, the mean score for financial and entrepreneur skills was  2.34 and 2.49   which was  lower than some skills  and also there was a significant difference between males and females  with a p value of 0.001 for managing the workforce and finances of a private dental set up. And 0.024 for recognizing economic, environmental, and social implications in professional practice (Table 1).

Table 1: Table Showing Mean Scores of Perceived Level of Soft Skills and P Value Across Gender and Year of Study.

The communication skills between final year students and intern batch, showed a significant difference, with p value 0.033 and 0.017 where interns perceived themselves to be better than final years. Genderwise there were significant differences in majority of the soft skills with males more strongly agreeing to possess the soft skills than their female counterparts. In teamwork and leadership, however, genderwise there was no significant difference with p values of 0.247 and 0.053. However, males were more capable of appreciating and respecting the attitude, behavior, and beliefs of team members than their female counterparts with a significant p value of 0.022.

Communication, leadership, time management, problem solving, adaptability, and openness to new information and experiences are some of the soft skills that an individual should possess.  When information and understanding is processed between two individuals by any effective means by verbally, non-verbally or through writing effective communication occurs. Body language,tone of voice and  words have  impact levels at 55%,38% and 7% respectively.  Active listening and history taking are important requisites for effective communication to take place. Non-verbal communication through facial expression, contact, gestures, proximity and eye contact also contribute to effectiveness albeit within cultural context. Possession of these abilities aids in rapid career advancement and even though non-inherent, can be acquired through experiential deep learning processes [18].

In our study, 789 students from all over India responded to the online questionnaire of whom 80% had remembrance of soft skills as per Bloom’s revised taxonomy [19]. This however needs to grow into understanding and application into patient care and interpersonal interactions. This will not only enhance the faith of the patient in the treating dentist but also increase patient compliance. This has been observed by Holt and McHugh [20] who noted that a dentist’s interpersonal qualities was the primary reason for switching dentists. Effective communication creates a stronger group, which aids the team leader in organizing activities and, in turn, reduces stressful situations [21].

Six different categories of soft skills are relevant to the profession of dentistry namely communication skills, teamwork and leadership skills, professional and moral ethics, critical thinking and problem solving skills, continuous learning skills and entrepreneur skills. These skills have already been incorporated in the curriculum of dental undergraduates by other countries. It was noteworthy that in our study, 39% of the respondents were not aware of these stratifications.

It is crucial for a doctor to have excellent communication skills. In the present study, the comparison of communication skills between final year students and intern batch, showed a significant difference, with P value 0.033 and 0.017 where interns perceive themselves to be better than final years. This may be attributed to more hours of patient exposure of interns than final year students as they are a year ahead in their clinical training. Cowpe et al [12] have highlighted a number of soft skill competencies for graduating European dentists, such as communication, problem solving, team building, and leadership, professionalism and social interaction. Use of appropriate communication skills, such as showing empathy and reassuring patients, can help reduce their anxiety, as shown in a study published in BMJ Open [22,23]. Undergraduate education shouldinclude the development of strong communication, professional, and behavioural competencies, as emphasised by Manoque et al [24]. The doctor patient relationship is built and maintained through open lines of communication, which focus on more than just relaying facts. These lines of communications are essential for reaching a diagnosis, formulating a plan of care, reaching agreement on course of treatment, and most importantly ensuring that the patient follows the plan. Participating in treatment planning for one’s oral health problem shares responsibility with the patient and improves the likelihood of compliance. Non-verbal communication practices, such as the doctor’s distance from the patient, forward lean, and body alignment, have been linked to increased patient satisfaction and compliance. The mean score of nonverbal aspects of communication skill was 2.41 in our study which shows poorer skill in this aspect. Teaching and training dental students in both verbal and nonverbal forms of successful communication ought to be a standard part of the curriculum at all accredited dental schools. Dentists in training should pay close attention to their patient’s feedback, address their problems, and view each person as unique when caring for them. [25].

However, there are several hurdles to effective communication, such as time constraints, [26] a lack of experience/practice, and skills in cultural competency among practitioners, and an unwillingness to create relationships with patients from different backgrounds.

Of all the skills, the mean score for financial and entrepreneur skills was 2.34 and 2.49 .Individually or in partnership with hospitals or educational institutions, financial management is an extremely significant component [27]. Upon completion of their training and residencies, some dentists seek employment at hospitals and other healthcare facilities, but others prefer to open their own practices. Dentists who establish a private practice must possess solid business acumen in order to successfully operate their enterprise. Therefore, they should be competent to outline business structures and autonomously work. They are responsible for hiring and training staff, ensuring compliance with all laws, marketing the practice, and overseeing its daily operations. The establishment of a successful dental practice will benefit from financial and entrepreneur skills.

The dental field requires constant consultation and teamwork amongst specialists. In our study it was found that both males and females had an equal leaning towards teamwork and leadership. However, males were more capable of appreciating and respecting the attitude, behaviour, and beliefs of team members than their female counterparts. Students should begin cultivating relationship and teamwork skills early on in their education because these are essential for working with patients. While some dentists are fortunate enough to appreciate their coworkers, Jupp found that many others had to deal with staff related concerns that contributed to a negative work environment [28]. She hypothesized that the lack of focus on the cultivation of soft skills like teamwork and leadership was to blame. Leadership and management are not provided nearly enough time in medical schools, according to research by Abbas et al [29]. Students, however, are aware of the need of learning management and leadership skills. Positive findings for team competency were found in a research of dentistry students in Canada [30]. The results of the ADEA’ survey on professional competences was likewise consistent with this finding. [31]. The students at the University of Manchester demonstrated teamwork skills, but the underlying relationship conflicts were unavoidable, as Qualtrough [32] explains. She argued that effective teamwork is an acquired skill and an integral part of dental education. To build collaborative abilities, formal training is emphasized by Brodsky et al. [33] as well. Those involved in the study concluded that formal teamwork training and team based practices in neonatal intensive care significantly improved teamwork, communication skills, support and respect for one another, sharing of information, and greater situation awareness . Planning and treatment of shared patients should be a part of the education program as the shared responsibility would encourage positive interactions between team members and enhance team performance [34].

Ethical dilemma arise when moral decisions must be made given alternative options.  In our study it was noted that there was a significant difference between male and females in the possession of professional and ethical skills such as capability of resolving professional and ethical conflicts in the event of mishandling of a case due to negligence. They were also able to protect their patient’s respect and privacy as well as respect and keep professional boundaries with patients, cowrkers and the public. Referring cases to a more skilled dentist is an ethical option that should be made when circumstances warrant. Students must understand that the purpose of clinical training is not merely to increase their clinical knowledge and skills, but also to instill the professionalism and ethical standards necessary to provide high quality patient care. The development of a professional attitude and reliance on ethical and moral principles within the dental profession and in society is an important objective of dental education. Maintaining patient confidentiality demonstrates respect for their right to privacy. Establishing rapport and trust with a patient requires respect for his or her individuality and privacy [35,36]. Students must be taught ethical decision making and critical thinking in order for them to manage competing interests. In reality, allowing students to think critically is a core objective of education [37]. Reasoning, creativity, responsible problem solving, making judgments and conclusions, as well as acquiring, assessing, and utilizing information, are all components of critical thinking and decision making skills [38]. Dentists have an ethical and legal obligation to stay updated in their field so that they can offer their patients the most advanced treatment alternatives [39,40]. The establishment of a self-directed continuing professional development program is intended to encourage individual dentists to continually improve their knowledge and abilities.

The foundation for lifelong learning should be developed in dental schools, and its significance should be instilled in students so that they are equipped for the dentistry of the future. Different pedagogical approaches, such as lectures, seminars, case-based studies, problem-based learning (PBL), project oriented PBL (POPBL), and simulation laboratory activities, have been used to teach soft skills [41,42]. Development of a soft skills competency model should be done scientifically using a model such as Kern’s six step approach [43]. Adequate time  should be given to   explore general and specific  needs assessment, outline goals, specific learning objectives, teaching learning methods, assessment tools, organization, implementation and  finally  evaluation by internal or external bodies, such as,  Internal Quality Assurance Committee of the respective Institute  and National Accreditation Board, the statutory external evaluating agency in India. Soft skills can be inculcated through various teaching-learning methods, one of which is the didactic method. However, to make it student centered and to instill experiential learning, participatory methods such as role plays, like in the Indian context “nukkad natak” can be effective. Nukkad natak [44] or “path natya” as known in Marathi, is a drama performed on streets to create awareness of social and behavioral issues.

The majority of respondents were aware of the concept of soft skills; however, many lacked an understanding of the various subcategories of soft skills, and a significant number of them did not strongly agree that they possessed the aforementioned skills, particularly nonverbal communication and financial and enterpreunial skills. It will be beneficial to include soft skills courses or training modules in the curriculum for dental undergraduates in India.

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