A Systematic Review: Study on Challenges Faced by Dental Interns in the Workforce: Suggestions for Pacific Nations

Results

Discussion

This systematic review demonstrated the challenges faced by dental interns in the workforce. It was also found that the challenges experienced by dental interns were highlighted across the studies and could be attributed to five factors which are WPB, handling medical emergencies, community placement, lack of interdisciplinary approach and poor record keeping.

Bullying can be described as a complex violent, antisocial conduct marked by repetitive harassment of a weaker victim without any provocation (Ramachandran, 2012). ‘Workplace bullying’ (WPB) means offending, harassing, socially excluding someone or negatively affecting daily duties of victims (Ullah et al., 2018). Some examples of WPB include direct attacks, such as cursing, mocking, hitting or indirect ones such as spreading rumours of the victim (Law et al., 2011). WPB is becoming a common occurrence, and the health care sector is no exception to this (Annagür, 2010). In the case of doctors in training, some bullying behaviours may be done with the intention to improve trainee’s performance, however, the impact on the trainee may be the opposite (Paice & Smith, 2009). A junior who feels undermined and shamed by a senior will hesitate to ask questions or seek support from him or her. Furthermore, unhelpful criticism, sarcastic comments and embarrassment in front of colleagues will cause even the strongest trainee to lose confidence in him or herself (Paice & Smith, 2009). Another major reason for WPB in the hospital has been attributed to senior doctors venting out their disaffection of workload and pressure, onto junior colleagues, leading to a climate of anger and disappointment (Paice & Smith, 2009; Paice et al., 2002). Some forms of bullying in the medical field are more insidious, such as threats over references and support letters, because progress in the medical sector still works on a system of patronage and word of mouth (Lone et al., 2009). Having said that, doctors in training, similar to other employees have the right to be treated with respect, dignity and consideration. They should not be subjected to behaviours that undermine their self-confidence and professional self-esteem (Lahari et al., 2012). This is because, WPB on an individual level has been linked with health care workers having: lower levels of job satisfaction, high levels of anxiety and depression, increase in sickness/absenteeism or desire to leave work (Kivimaki et al., 2000; Quine, 1999, 2001). Organisational consequences of WPB can manifest in a hostile or toxic work environment, which is closely linked to compromised quality of patient safety and care. It also inhibits teamwork, disrupts behaviour and obstructs communication and has the potential to increase medical errors by affecting the quality of healthcare organisation (Bentley et al., 2009; Martin, 2008). Overall, WPB of any sort must be condemned, interns, as well as other staff, must be given respect and a positive environment to work in. This is because, victims of bullying may themselves go on to harass others when they become seniors, thus continuing the vicious cycle of abuse (Lahari et al., 2012). It is believed that medical students not only learn medicine but also learn behaviour patterns of their seniors and mentors, widely regarded as the ‘hidden curriculum of medical education’ (Hsu & Marshall, 1987). Thus, it could be said that WPB is a major challenge that dental interns face upon joining an institution, and policies and initiatives must be created that condemn WPB.

Handling medical emergencies is another major challenge faced by dental interns that requires attention. This is because many situations in the dental office can incite medical emergencies (Albelaihi et al., 2017). The most common medical emergencies encountered in the dental chair include: postural hypotension, bronchospasm, swallowed foreign bodies, anaphylaxis, syncope, hypoglycemia, seizures, cardiac arrest and angina pectoris (Ahamed & Kumar, 2016). In general, these emergencies can be life-threatening, and there have been instances of patients dying due to medical emergencies in the dental setting (Little et al., 2002). Effective management of medical emergencies in the dental office is ultimately the dentists’ responsibility, via emergency management procedures aimed at reducing mortality and morbidity when the need arises (Ahamed & Kumar, 2016; Albelaihi et al., 2017). Lack of training and inability to manage medical emergencies can lead to serious consequences and legal action (Wood, 2014). According to Shenoy et al. (2016) dental students suggested that emergency postings should be introduced early in their curriculum to build their confidence in handling any mishaps or emergency situation. Furthermore, Shenoy et al. (2016), Sharma and Attar (2012), Ahamed and Kumar (2016), Elanchezhiyan et al. (2013), Mukherji et al. (2019) and Albelaihi et al. (2017) express deficiencies in the current way the dentists are trained to deal with medical emergencies, and that there is a need for incorporating structured training of BLS into the school dental curriculum, together with additional periodical assessment and enhancement training for dental professionals regarding medical emergencies. Mukherji et al. (2019) further elaborate that theoretical knowledge with demonstrations but without practice is insufficient to ensure competence in handling medical emergencies. Frequent training with the use of simulated scenarios in the environment where the emergency response will be delivered is recommended to achieve better results. Overall, it could be said that managing medical emergencies is a huge challenge for dental interns, and strategies must be in place to make dental interns competent in the management of medical emergencies to improve patient care.

Another major challenge dental intern’s face is during their community placement. Introduction of compulsory rural attachment in the internship programme of dental interns has been done, since most dentists usually practice in the cities and treat the affluent parts of the urban population, thus, it is often difficult for the rural population to get access to emergency and basic oral health care (Shinde et al., 2018). This geographical unequal distribution of the dentist–population ratio significantly influences the accessibility to oral health care services and presents a challenging problem in the planning and delivery of quality dental care in these areas (Sharma et al., 2014). Rural attachments are referred to as ‘outreach’ or ‘outplacement’ programmes, where mobile dental clinics as well as portable dental equipment are used to provide dental services in the absence of traditional set-ups (Shinde et al., 2018). According to Yoder (2006), community service has the capability to provide dental students with knowledge and motivation to engage into and promote public health by understanding and appreciating the concepts, characteristics and objectives of community service and its impact on the public. However, other important job attributes, such as better income, good living conditions, utilisation of skills, education opportunities for children, safe working and living environment, tilt the balance in favour of urban location (India Health Beat, 2009). Overall, it could be said that rural settings pose significant challenges, and dental interns could feel intimated and demotivated when faced with such challenges. Thus, it is important to mitigate these challenges, so that dental interns feel at ease and possibly take up rural postings in the future. For instance, K. M. Shah Dental College is implementing strategies at its peripheral centres in order to increase the efficiency of outreach programmers. One such strategy is the expansion of peripheral centres in terms of infrastructure and providing dental students with the most recent technology for patient management (Thanveer et al., 2013).

Utilising an interdisciplinary approach is another significant challenge encountered by dental interns. Interdisciplinary dentistry is manifested by the application of methods, concepts and perspectives that go beyond the boundaries of individual specialty (Slavicek et al., 2013) to deliver the highest level of dental care to every patient (Spear & Kokich, 2007). In countries such as India, Bachelor of Dental Surgery graduates are posted in several departments for short periods of time to obtain clinical abilities relating to the particular department. As a result, they are poorly prepared to carry out comprehensive treatment planning or interdisciplinary approach Elangovan et al., 2010; Vasanthakumar & D′Cruz, 2014). Shigli et al. (2015) elaborated that the current scenario involves dental interns providing treatment is based on the knowledge that is compartmentalised, and there is a need to develop an internship programme, based on the concept of an interdisciplinary approach.

Lastly, poor record keeping is another issue displayed by dental interns, which needs attention. This is because, clinical records play a vital role in the process dental care delivery, as they are essential for the diagnosis, planning and correction sequencing of treatment (Faisal et al., 2017). Dental records comprise of clinical notes, plaster models, radiographs and treatment done including serial numbers of prosthesis (Kutesa & Frantz, 2016). These records also serve other purposes, such as administrative, research, quality assurance, education and even used as evidence in legal proceedings. Therefore, producing detailed accurate patient records, maintaining, storing and retrieving them should be an integral part of practice, and this habit should be ingrained during the professional training of dental students (Behura et al., 2020). Faisal et al. (2017) further elaborate that organising training sessions on a regular basis that informs students about the benefits of accurate and detailed records, as well as problems that might arise when records are substandard would greatly help in inculcating the trend of efficient and qualitative record keeping in the times to come.

Conclusion

Challenges faced by dental interns in the workplace include WPB, handling medical emergencies, community placement, lack of interdisciplinary approach and poor record keeping. The aim of this literature review was to highlight this grey area, of new graduates leaving the profession or moving over to the private sector, which is very prevalent in PIC. There is a need for PIC to conduct research and surveys, to identify the challenges its dental interns are facing. This will create an ideal foundation from which strategies and initiatives can be implemented and enforced in the dental internship programme. The ultimate goal is to ensure dental graduates are retained in the profession and public sector. Further ensuring that oral health services are delivered efficiently and oral status of the Pacific is not compromised.