Attitude of Dental Prostheses Residents of Faculty of Dentistry of Tabriz University of Medical Sciences to Objective Structured Clinical Examination ( OSCE )

*Corresponding author: Elnaz Moslehifard, Email:elnaz_moslehi@yahoo.com © 2015 The Authors. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, as long as the original authors and source are cited. No permission is required from the authors or the publishers. Article History: Received: 26 March 2015 Accepted: 7 Jan 2016 ePublished: 1 Feb 2016


Introduction
In medical sciences, education is a regular, continuous, and planned process resulting in changes in the learner's knowledge, attitude, and skills. 1 Students learn psychomotor subjects better than cognitive ones.Since practical and clinical training is the main part of medical education, its evaluation plays a significant role in improving the quality of training and is a reliable tool for assessing students' learning rates. 2 Considering the extraordinary importance of clinical training, clinical evaluation is of high importance in evaluating the success rate. 3,4In traditional education, students' learning rate is evaluated using oral and written examinations.One of the most important disadvantages of this method is that students merely rely on their memorized materials and their capability in using theoretical and practical knowledge is not evaluated.Objectives and techniques to evaluate knowledge have been improved using modern techniques of education, i.e., student-based education and more participation of students in the learning process. 5,6uasi-real examinations evaluate cognitive as well as emotional and psychomotor areas. 7he Association for Medical Education in Europe recommended several methods and techniques for practical and clinical evaluation corresponding with educational objectives including Objective Structured Clinical Examination (OSCE). 8OSCE was initially introduced by Harden et al. in 1975.It was then quickly used by other faculties and several studies were conducted to evaluate it. 9SCE is one of the most reliable and authentic methods for evaluating clinical skills of medical students.It is mainly held to objectively and comprehensively evaluate clinical knowledge and skills of the students when they face patients.OSCE deals with three important categories: diagnosis, treatment plan, and patient management. 5his method evaluates the realization rate of educational objectives considering the cognitive, emotional, and psychomotor skills of medical students.Although details of the examination vary in different conditions, its general structure consists of 15-20 questions in separate stations and the examination is held for a specific time period. 9xperienced human forces, detailed planning, facilities, and reliable assessment tools are required to hold the examination. 10valuating the attitudes of participants in several studies is a way to evaluate the efficiency of this examination and recognize its weak and strong points in order to improve the current conditions.According to results of the studies conducted on paramedical students in Iran and abroad, most students were more satisfied with OSCE than with other methods. 11,12According to Zare 13 and Tazakori 14 , most nursing students were satisfied with OSCE in comparison with traditional evaluations and their grade average was higher using OSCE.According to some studies, students were dissatisfied with the OSCE method mainly due to high levels of stress arising from being observed by the evaluators and time limitations. 11,15Several studies reported positive attitudes. 16,17Saboury et al. 5 studied attitudes of specialized dentistry students of Shahid Beheshti University of Medical Sciences about OSCE.The attitude was generally positive, but most students referred to it as a stressful method.At present, OSCE is part of all medical and dental board exam evaluations in Iran.Considering the importance and wide application of this method, further research is required to study its different aspects.The present study aimed at evaluating attitudes of specialized dental prostheses students of Tabriz dental faculty toward OSCE examinations.

Methodology
In this cross sectional-descriptive study, two questionnaires were designed.One questionnaire dealt with nature of OSCE and the other with the OSCE examination (Table 1).The OSCE examination was carried out in three successive years, 2012-14, to increase the sample size and the year of examination did not induce any effect on the OSCE examination.Following the OSCE examination in July 2012, 2013, and 2014, the questionnaires were delivered to all dental prostheses residents.In total, 40 questionnaires were filled within three years.The questionnaire included ten five-choice items evaluating the general attitude of the residents toward OSCE and twelve five-choice items toward OSCE nature.

Data acquisition
All questions included a statement which could be ranked by the students on a Likert scale.The questions were designed based on conventional questions of previous and similar studies and were adjusted by two authorized professors of specialized dentistry education.According to authentic resources and authorities, the validity of the questionnaire was of content type and its reliability (0.74) was determined through calculating Cronbach's alpha coefficient.Also, the students' scores were recorded.In each exam These scores included the opinions of prostheses residents about their general attitude toward OSCE, levels of stress during OSCE, and the relationship between the grade obtained by the residents in the examination and their attitude toward OSCE.

Statistical analysis
Statistical analysis of the Likert items was conducted by calculating frequencies in percent.Pearson correlations were used to evaluate the effect of the acquired score on the grade of participants' general attitude toward the examination and their evaluation from the mentioned examination (α=5%).Statistical assessment was performed by SPSS version 17.

Ethical consideration
Consent forms were available for individual examinees.They agreed and signed the consent forms on the basis that the examinees' names were kept confidential.

Results
Opinions of prostheses residents about general attitude toward OSCE (questions 1-10) and the OSCE itself (questions 11-22) are shown in Tables 2 and 3, respectively.Most residents (90%) suffered from high levels of stress during OSCE.In addition, most residents (62.5%) referred to the large number of questions as a positive factor.There was a close relation between the grade obtained by the residents in the examination and their attitude to OSCE (p=0.015,r=0.38), as well as their evaluation about the examination (P=0.002,r=0.48).Students with better grades had a more positive attitude toward OSCE.

Discussion
Acquiring required knowledge, skill, and attitude is the main and final objective in medical education.Evaluation aims at comparing predetermined educational objectives and the results obtained from the desired plan.Evaluation should be transparent, unbiased, and standard.It should assess students' performance based on the determined educational objectives and it should be continuous and provide the students with the required feedback. 5To have a successful evaluation, it is better to collect and evaluate the students' feedback.In this regard, the attitudes of specialized prostheses students of dental faculty of Tabriz University of Medical Sciences toward the use of Objective Structured Clinical Examination were evaluated.Results of The examination differentiates skilled and unskilled students -32.5 10 37.5 20

Table 2. Answers of prostheses residents to attitude questions in OSCE examination (in percent)
pre-test questions indicated the positive attitude of residents to the OSCE method, as 62.5% of the subjects were aware of objectives of this evaluation method and its efficiency in evaluating practical skills.The findings corresponded with studies by Imani 18 , Awaisu 19 , and Saboury 5 conducted on medical, pharmaceutical, and dentistry students, respectively.Abraham et al. 20 confirmed the OSCE examination for a physiology course where the students were more satisfied in comparison with the traditional methods.Additionally, the satisfaction of psychiatry residents with OSCE taking two different board exams, one by OSCE technique and two by traditional method, was confirmed in a study conducted by Zarghamiet al.. 21 Faryabi et al. 15 studied the attitudes of dentistry students of Kerman University of Medical Sciences and reported that only 34.8% of the students referred to the usefulness of OSCE and most of them preferred the written method.
In the present study, there was not any difference between students' attitude before and after OSCE, which is contrary to the findings of a study conducted by Sabouryet al.. 5 Several studies have been conducted about the effect of the OSCE examination on an increase of students' stress.
In the present study, most students (90%) suffered from high levels of stress during the examination, which was similar to the findings of Furlong et al.22.The students' stress reported in studies of Sabouryet al. 5 , Jaliliet al. 23 , and our study were 64.1%, 63.3%, and 62.5%, respectively.Both Brand et al. 24 andZartman et al. 25 referred to stress among students during the examination.Unfamiliarity of the students with this kind of examination, presence of invigilators and instructors in the examination, nonstandard and ambiguous questions, time limitations, and fatigue resulting from the exam have been introduced as causes of stress in different studies.However, every subject may be stressful under any condition. 26milar to the study of Saboury 5 and Faryabi 15 , most students (62.5%) in the present study referred to the usefulness of more stations in improving the quality of examinations.Most students believed that there was a logical process considering time duration, order, and number of the stations, indicating the appropriate structure of the examination.Additionally, pre-test and post-test opinions were the same.
There was a meaningful relation between the acquired grade, students' attitude toward the examination, and their evaluation about the examinations.Students with better grades had more positive attitudes toward the examination.This was similar to a study conducted by Malik et al.. 27 It may indicate that objectivity and uniformity of the examination along with its justness resulted in better attitudes and satisfaction and most students were interested in including OSCE as part of residency courses.This result was similar to those in a study by Furlong et al.. 22 A majority of students emphasized that OSCE was able to evaluate a wide range of skills and practical methods in dentistry.In addition, a study by Sood reveals the advantages and disadvantages of the procedure during treatment.Clinical skills can be evaluated well by OSCE, and feedback from the exam improves theory and practice of dentistry science. 28articular clinical skills can be measured by using OSCE to observe the performance of a task and improve the validity of interpretation.It is possible to provide immediate feedback enhancing learning capabilities which can be the case for teachers as well to help them correct their teachinglearning errors.On the other hand, there exist some disadvantages to the exam, including labour-intensiveness and its costs, limitation of resources and faculty time, and challenges with real patients.In addition, in cases of complicated skills that normally require a comprehensive peer review, it is difficult to make a conclusion in the short examination time period, which decays the validity at the expense of reliability.][31] In the current study, only postgraduate students of prosthodontics were evaluated.Further studies are required to evaluate the possible effect of student's grade and specialized field on the attitude of students upon usefulness of OSCEs in learning.Since accurate, complete, and exact evaluation of clinical skills and capabilities is not possible through traditional methods only, it is necessary to hold appropriate examinations, e.g., OSCEs, in order to evaluate cognitive (knowledge), attitude, and psychomotor (skill) areas as well.This examination may serve as a starting point to evaluate the students more objectively, effectively, and satisfactorily.

Conclusion
OSCE is a technique by which the professional skills and capabilities of practitioners in clinical situations are determined.It also deals with three important categories of diagnosis, treatment plan, and practical management.This method evaluates the realization rate of educational objectives considering cognitive, emotional, and psychomotor skills of medical students.Considering the satisfaction level of the students in this study, OSCE was efficient in improving the quality of the examination, providing effective feedback to the students, and improving the course and may be regarded as part of residents' training courses.Although there are some barriers and restrictions in holding the examination, its use is recommended for dental prostheses residents in order to confidently evaluate their practical skills.

Table 1 .
The more the number of the stations, the more the evaluation opportunity of the studentsThe less the number of the stations, the more the allocated time and the more effective the answers of the students Questionnaire evaluating OSCE examination of residents

Table 3 .
Answers of prostheses residents to questions about OSCE examination (in percent)