Perceptions of dental students on introduction of simulation-based BLS teaching in their course

arrest requiring cardiopulmonary is one such medical emergency which can occur in dental oﬃce. Every dental practitioner therefore should at least be able to perform the basics of CPR. The purpose of the study was to demonstrate self-perceived perceptions of change in knowledge, skills and conﬁdence level of 3 rd year dental students after introduction of simulation based basic life support (BLS) teaching. It was assumed that after simulation based BLS teaching, dental students would feel more conﬁdent in providing immediate management to a patient of cardiac arrest during dental practice. and of were taken on a questionnaire, based on Likert scale. Change in self-perceived perceptions of knowledge, skills and conﬁdence of students was analyzed. Analysis showed that simulation based teaching signiﬁcantly increases the level of knowledge, skills and self-perceived conﬁdence of students regarding BLS skills. The study demonstrates change in 3 rd year dental students’ perceptions of knowledge, skills and conﬁdence level after simulation based BLS teaching. The results show that simulation-based training improves the self-perceived knowledge, skills and conﬁdence level of students about BLS (p = 0.001) when compared with no hands on training (pre-test). Surcouf et al, (2013) reported, that simulation based training of residents on neonatal resuscitation show similar results. Their study provided strong evidence that simulation based training helps in increasing self-perceived conﬁdence of residents (Wilcoxon signed rank test, total score p = 0.000). Similarly, Sopka et al, (2012), observed students attitude and self-assessment towards emergency medical care after practical training. The results revealed that the comparison of pre and post-evaluation showed a great increase in self-conﬁdence (p < 0.0001). The study by Hendrickse et al, 2001cited by Hamilton 2004, also suggested that simulation training in resuscitation helps the participants to improve their knowledge in a relatively realistic arena and allows them to familiarize themselves with the equipment and procedures. patient comparison with non-simulation intervention, learner satisfaction 0.79(0.27–1.31) process skill 0.35 (0.12–0.59) outcomes favored


Introduction
One of the most important single determinants for quality healthcare provision is the competence of medical/dental practitioner, particularly, when an unexpected emergency arises (Ibnerasa, Hashmi, & Chaudrhy, 2011). Cardiac arrest is a medical emergency requiring immediate Cardio-pulmonary resuscitation (CPR) for survival (Li et al., 2013). Dentist sometimes have to face similar medical emergency requiring CPR during dental procedures. Such emergencies most likely occur during and after local anesthesia, primarily during tooth extraction and endodontics (Carvalho, Costa, & Marcelo, 2008). According to Carvalho et al 2008, the frequency of medical emergencies during dental practice are increasing as dentists are seeing an increasing number of elderly and medically compromised patients and are performing more sedation procedures. This justifies the need for every dental practitioner to be able to perform the basics of cardiopulmonary resuscitation (CPR): chest compression and rescue breaths (Laurent et al., 2009), especially when chances of survival of the patient of cardiac arrest are reduced by 7 to 10 percent every minute if CPR is not done on time (Carvalho et al., 2008).
Cardiopulmonary resuscitation training is not mandatory in dental schools in Pakistan and certification in BLS is not a requirement for dental graduation. BLS skills are taught during general medicine rotation and only theoretical part of the subject is covered in the form of lecturing. The students therefore do not feel confident to manage a medical emergency requiring CPR.
Medical education increasingly relies on simulation technology to provide a tool to increase learner knowledge (Wayne et al., 2006). Simulation training in resuscitation helps in improving the knowledge of the participants in a relatively realistic arena and allows them to familiarize themselves with the equipment and procedures (Hamilton, 2005). Wadas (1999), reported that both confidence and performance improved following the initiation of a cardiac arrest simulation programme, and that the documentation of actual cardiac arrest situations improved as a result 7 .
Little information has been published about the self-perceived competence and confidence of dental undergraduates in regard to managing a medical emergency with BLS or CPR in the dental practice (Carvalho et al., 2008).
The purpose of this study is to demonstrate the effect of simulation-based BLS teaching on the self-perceived confidence level of 3 rd year dental students regarding management of a patient of cardiac arrest. The goal is to highlight the gap that exists in clinical knowledge and skill of the students in this regard. It is assumed that after simulation based teaching, dental students will feel more confident in performing BLS on a patient of cardiac arrest. The study also reports perceptions of students regarding simulation based BLS learning experience.

Setting
The study was carried out in Lahore Medical and Dental College, Lahore, Pakistan in 2014.

Participants
The study participants were 3 rd year dental students. The study group comprised of 45 students (N = 45) doing General medicine clinical attachment at the affiliated Hospital.
Ethical approval was obtained through the Institutional Review Board of Lahore Medical and Dental College, Lahore. Participants were briefed about the details of the study and verbal consent was taken. To ensure students participation, they were told that attending this session will be counted towards their one day of medicine ward rotation.

Instruments for data collection
Data was collected on a 10-item test-questionnaire with items relating to knowledge, skills and perception of ability to perform CPR. Reliability of the questionnaire was checked, Cronbach's α .732. The students were asked to mark their responses on a 5-point Likert scale with options ranging from 1-Strongly disagree to 5-Strongly agree.
Perceptions of students regarding Simulation based learning experience were also taken on separate Likert scale based proforma.

Intervention
All the students were asked to mark their responses prior to the Simulation based skill session (Pre-test). The students were shown a 15-minute video of a real life event of emergency BLS procedure, followed by demonstration of all the steps of BLS procedure by the tutor on non-automated Basic buddy TM mannequin manufactured by Nasco life/form. Product # SB27354U ("Nasco Lifeform,"). The students were then asked to practice the steps of BLS skills on the manikin. Every participant was given same time to practice with necessary feedback by the tutor during the session. After the session was over, the students were asked to self-evaluate their knowledge, skills and confidence level regarding basic life support skills by marking their responses on the test-questionnaire (Posttest-S).
A post session evaluation of the skill session was done to see the perceptions of students about BLS training with the help of simulator. The students were asked to rate their experience using 5-point Likert scale. Students' perceptions are tabulated in Table 2. SPSS version 20 was used for data entry and analysis. Descriptive statistics were applied, and means and standard deviations were calculated for pre and post-tests. Student's T test was applied to compare pre and post-test means. pvalue of <0.05 was taken as significant.

Results
Out of 45 students attending General Medicine rotation, 1 student was absent on the day of intervention (N = 44). Mean scores for the pre and post-test are shown with marked increase in all the post test scores. (table 1).
The analysis between pre-test and post-test scores reveals highly significant result (p = .000).
Regarding perceptions of students about simulation based learning experience, most of the students thought that simulation based learning session was extremely helpful in increasing the knowledge (100 %) and confidence (95.4 %) about BLS skills. They were of the opinion that video session (95.5%) and teachers' feedback (84.1%) were very useful during the learning of BLS skills. 95.55% students regarded BLS skills as essential for the practice of dentistry (table 2).

Discussion
The study demonstrates change in 3 rd year dental students' perceptions of knowledge, skills and confidence level after simulation based BLS teaching. The results show that simulation-based training improves the self-perceived knowledge, skills and confidence level of students about BLS (p = 0.001) when compared with no hands on training (pre-test). Surcouf et al, (2013) reported, that simulation based training of residents on neonatal resuscitation show similar results. Their study provided strong evidence that simulation based training helps in increasing self-perceived confidence of residents (Wilcoxon signed rank test, total score p = 0.000). Similarly, Sopka et al, (2012), observed students attitude and self-assessment towards emergency medical care after practical training. The results revealed that the comparison of pre and post-evaluation showed a great increase in self-confidence (p < 0.0001).
The study by Hendrickse et al, 2001cited by Hamilton 2004, also suggested that simulation training in resuscitation helps the participants to improve their knowledge in a relatively realistic arena and allows them to familiarize themselves with the equipment and procedures.
The above findings validate the research hypothesis that simulation based teaching in BLS will help dentists develop deeper knowledge about medical emergencies. Patient care tasks require team work and traditional curricular formats do not prepare students for such collaborative practice (Sperling, Clark, & Kang, 2013). Classroom teaching especially lectures, provide little chance for interaction between students and between students and instructor. The students therefore are unable to integrate such knowledge during clinical practice especially in an emergency situation (Patel, Arocha, Branch, & Karlin, 2004).
Looking at the results of the above study it can be concluded that theoretical information is not enough to ensure CPR competence (Kavari & Chohedri, 2007). Hands on training sessions in emergency medical care will enhance dental students' awareness of importance of BLS skills as well as increase their self-confidence in performing these procedures.

Limitations and future research
This study design has lots of limitations. First, this study has been carried out on one class of one dental school. This limits the generalization of the findings. Future studies involving more classes from different dental schools should be carried out to improve the reliability of findings. Second, the study measures self-assessed perceptions of students regarding their knowledge, skills and confidence after intervention, and lacks objective assessment of the acquired skill. Objective assessment of the skill with perceptions about increase in confidence will be more valid in documenting procedural competence. Third, this study only measures immediate improvement of knowledge of BLS skills after one instructional intervention and does not account for the decay of knowledge over-time and how much  (Laurent et al, 2008). Longitudinal studies in this regard should be carried out in dental graduates.

Conclusions
In spite of number of limitations pointed out in this study, the study sheds some light on the deficient training of dental students regarding medical emergencies like cardiac arrest especially in our part of the world. Similar studies cited in the literature are carried out on practicing dentists or on dental graduates (Carvalho et al., 2008) (Laurent et al., 2009). The results of this study shows that one teaching session in basic life support skills is able to enhance dental students' awareness of importance of BLS skills and to increase their self-confidence in performing the procedure (Sopka et al., 2013). The results of the study will useful in developing countries where dental students either receive no teaching of emergency medical skills or where only lecture based teaching of emergency medical skills are done.