| Abstract|| |
Purpose: Faculty development programs (FDP) are essential to equip teachers with the knowledge and skills required to fulfil their multiple roles. In India, dental educators undergo minimal training in teaching and related responsibilities. Long-term outcomes of such programs are not reported in any literature. This questionnaire survey was conducted to analyze the long-term outcome of a FDP, conducted for dental educators, at four levels of Kirkpatrick's model of evaluation.
Methods: Beginning in 2013, dental educators in a health-professions university underwent FDP in two phases. The topics covered were toward the instructional development of the faculty, such as education as system, teaching-learning principles/methods/media, assessment and evaluation principles/methods, and curriculum process. Medical educators of the university conducted the first phase of the training over an 8-month period. Subsequently, the Dental Education Unit was formed, which then conducted the second phase of training for the newly recruited faculty over 4 months. The immediate outcome was assessed with feedback and a posttest. Long-term outcome, at the end of the 3rd year, was evaluated using an online questionnaire that was sent to 56 dental educators who were trained in both phases.
Results: A response rate of 100% was obtained. About 94% of the faculty reported satisfaction toward the workshop and a positive attitudinal change; 85% of them reported knowledge/skill gain and changes in their teaching practices; 78% of the faculty perceived changes in educational policies of the institution; and 70% of them perceived an improvement in students' performance.
Conclusion: This 3-year follow-up evaluation showed acceptable changes in the dental educators' teaching competence, the institution's educational policies, and in the students' performance, as perceived by the study participants, after the FDP.
Keywords: Dental, faculty, Kirkpatrick's model, program evaluation, training programs
|How to cite this article:|
Sathyanarayanan U, Manivasakan S, John BM. Long-term outcome evaluation of faculty development program for dental educators: A questionnaire survey. J Educ Ethics Dent 2018;8:6-12
|How to cite this URL:|
Sathyanarayanan U, Manivasakan S, John BM. Long-term outcome evaluation of faculty development program for dental educators: A questionnaire survey. J Educ Ethics Dent [serial online] 2018 [cited 2023 Dec 8];8:6-12. Available from: https://www.jeed.in/text.asp?2018/8/1/6/309666
| Introduction|| |
Teachers are not “born” as it is usually thought, but “made;” notably if they must assume the multiple roles prescribed by Harden and Crosby. In primary and certain higher education sectors teachers' training is a mandatory qualification for recruitment. However, in health-professions education, clinical/research expertise and experience alone are considered to be the main criteria for recruitment. It is assumed that these competencies will automatically translate into effective teaching. However in health professions education, the quality of the 21st century health professions student, and the academic vitality of an institute, are dependent on certain additional skills and expertise of the teacher. The Lancet commission report in 2010, therefore, had recommended faculty development programs (FDP) as one of the significant reforms in health professions education.
FDP has become an essential part of the current health-professions education, to enhance the competencies of all, from a novice instructor to an administrator., Often known as capacity development, professional development or academic development, these are a set of broad range of planned activities and programs that focus on four types of developments, namely, personal, instructional, organizational, and professional.,, They are conducted as seminars, short courses, sabbaticals, and workshops or fellowships. The duration of FDP varies from short, one-shot activities to longitudinal programs with follow-up activities. The instructional methods used are multi-modal, involving lectures, small group discussions, role plays, simulations, and group works.,, The activities are based on theories of constructivism, social learning, self-efficacy, situated learning, adult learning, and experiential learning.,
Comprehensive evaluation of the outcome of an FDP serves as input for future enhancement of its content and context. Methods for evaluation include end-of-session evaluations, pretests, posttests, delayed posttests, follow-up interviews, direct observation of teaching behavior, student's outcomes, and self-efficacy rating of the faculty. Surveys, semi-structured interviews, and focus group discussions are also used. The long-term impact on the teachers, the students, and the institution is considered more important than the short-term outcomes of the program.
Kirkpatrick's level of evaluation is used as the gold standard for assessing the outcomes in education. The outcome is evaluated as follows: Level 1: Reaction: participants' satisfaction; Level 2a: Learning: attitudinal change among them; Level 2b: Learning: knowledge and skill gain in education; Level 3: Behaviour: transfer of learning to the practice; Level 4a: Results: change in the institutional practice; and Level 4b: Results: change in students' performance.
The literature on faculty development in dental education is sparse compared to other health-professions education.,,,,, In India, FDPs for medical educators have been reported in detail,, but similar programs for dental educators have not been documented. A recent survey among dental faculty in India stated that 80% of the faculty never attended any FDP The barriers reported by the teachers were the lack of initiation from authorities and excessive clinical/teaching load, rather than their lack of interest. Another questionnaire survey in India reported that though not trained, many of the faculty realized the importance of such training.
This questionnaire survey aimed to evaluate the long-term outcome of a longitudinal FDP done for dental educators in Indira Gandhi Institute of Dental Sciences, Sri Balaji Vidyapeeth University, Puducherry, India. The survey was done 3 years after the FDP, with an aim to evaluate the outcome on four levels of Kirkpatrick's model of evaluation, as perceived by the study participants.
| Methods|| |
Faculty development programs phase 1 and 2 description
Phase 1: Training of dental educators by medical educators
Sri Balaji Vidyapeeth University is a health-professions university with medical, dental, and nursing institutions. The Academy of Health-professions education and academic development (SBV-AHEAD) was started in 2013 with an objective of capacity development of educators in all three fields. SBV-AHEAD aimed to improve the quality of education in all the constitutional colleges of the university through FDP. While assessing the competence of the faculty in all the colleges, it was realized that nursing education had pedagogy embedded in their curriculum. The medical college had a medical education unit, as per the medical council of India. However, such a curriculum or training was absent in dental education. This need analysis finally led to the objective of training the dental educators of the University, through FDP, with prime focus on instructional development.
The entire teaching faculty (n = 40) of the institute underwent the training. They belonged to various cadres and disciplines of dentistry. The topics for the program were chosen to focus on the development of the faculty as the facilitator, information provider, assessor, role model, and curriculum planner. [Table 1] shows the topics covered in the program. A pretest was done on these topics. Experiential and adult learning models were adopted. The workshop mode of delivery included lectures, small group discussions, problem-solving exercises, reflections, feedback, and classroom projects. The course facilitators were medical educators from AHEAD, SBV. Provisions were made by the deanery for protected-time for the faculty, to attend the course every fortnight for 2–3 h on Saturdays. The course was conducted for 8 months, from May to December 2013.
Phase 2: Training of dental educators by dental educators
Successful formation of a Dental Education Unit (DEU) was a constructive outcome of the first phase. Nine faculties were chosen based on their volunteerism, active participation and posttest score. Sixteen freshly (n = 16) recruited dental faculty was trained by the DEU, like phase 1, from February to May 2015. The workshop was conducted over 4 months, in weekly sessions of 2 h.
The immediate outcome was evaluated by feedback after every session, and a posttest was conducted at the end of the training. Feedbacks enabled continuous quality improvement of the program and improved active participation of the faculty. Posttest was conducted at the end of the training. The posttest score in phase 1 was 75 ± 8 compared to pretest score of 41 ± 15. In phase 2 FDP, the posttest score was 79 ± 4 compared to the pretest score of 48 ± 7. Student's t-test showed that the difference was statistically significant at P < 0.001.
Faculty development programs long-term evaluation of the outcome
At the end of the 3rd year of conducting the FDP, a questionnaire survey was planned as part of the quality assurance strategy of the institute. Google Form app was used for the survey. The questionnaire addressed the four levels of Kirkpatrick's model of evaluation. It consisted of the following: a. Fifteen close-ended questions, at the level 1 satisfaction and 2a attitudinal change, using 5-point Likert's scale of responses (strongly agree/agree/unable to say/disagree/strongly disagree) and three open-ended.; b. Twenty-three close-ended questions at the level 2 b on knowledge gain in the topics covered, using 4-point Liker's scale (to a great extent/to a certain extent/not at all/can't say) c. Fifteen close-ended questions at level 3 of behavioral changes, on the concepts that were implemented by individual teacher, using 3-point Likert's scale (yes, always/occasionally/not yet) d. Thirteen close-ended questions on level 4 a and b on institutional policy changes and students' academic performance, using a 4-point Likert's scale (to a great extent/to a certain extent/not at all/can't say). The questionnaire was vetted by the medical educators in SBV-AHEAD, who were the prime facilitators and was validated by pilot testing on the members of DEU. The link was E-mailed to all 56 faculty (40 + 16) who underwent the training, along with informed consent form. They were given the option to remain anonymous, to maintain confidentiality. The Google app collated the data in Excel Spreadsheet, and further analysis was performed with descriptive statistics.
Obtaining faculty and student feedback on the educational environment and academic quality is a part of the annual academic audit of the internal quality assurance cell of the university. Therefore, the current evaluation was exempted from the research review board appraisal.
| Results|| |
All 56 of the faculty responded with 100% response rate. [Figure 1] shows the overall response obtained. The theme-based categorization was done for the responses obtained for individual questions and is represented in [Table 2],[Table 3],[Table 4],[Table 5].
|Figure 1: Percentage of faculty responses to the questionnaire at Kirkpatrick's level|
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|Table 2: Kirkpatrick's level 1 on satisfaction toward the faculty development program|
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|Table 3: Kirkpatrick's level 2a and 2b on attitudinal change and knowledge and skill gain|
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|Table 5: Kirkpatrick's level 4A and 4B on change in teaching practices and students' performance, respectively|
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[Table 2] shows the responses obtained at Kirkpatrick's Level 1 on satisfaction. A 95% faculty found the FDP to be useful and relevant; 92% felt that the topics met the objectives, were applicable, logically sequenced, and supported by appropriate resources; 95% of the faculty were satisfied with the open-learning method and the opportunity for active participation. As for the duration of the course, 67% of the faculty felt it appropriate and 30% thought it to be too long.
[Table 3] shows the responses obtained at Kirkpatrick's Level 2a on attitudinal change and 2b on knowledge and skill gain. About 94% of faculty reported a positive change of attitude towards assuming teaching as a long-term career; 92% had become more aware of the various other roles of the teacher, including mentoring the slow learners; about 90% of the faculty agreed that they played an essential role in changing the system by intending to implement new concepts in their teaching practices. Nearly 98% of the participants were also willing to recommend FDP to their peers.
[Table 3] also shows that 83% of the faculty reported that they gained adequate knowledge on topics under the educational principles, taxonomy, objectives; 85% self-reported gain in teaching-Learning media and methods media and methods; 84% self-reported gain in topics under assessment principles and practices, such as blueprinting, objectivized exams and evaluation; 92% of reported gain in topics related to student centeredness, such as mentoring and feedback system and 86% reported knowledge and skill gain in curriculum development.
[Table 4] shows the responses obtained at Kirkpatrick's Level 3 on a change in behavior and practices. On a regular basis, 72% of the teachers had implemented the feedback system, 64% had started mentoring the slow learners, 58% had incorporated lesson plans, active-learning principles, small group discussions, briefing/debriefing sessions regularly in chair-side teaching. About 68% of the faculty routinely did blueprints and used structured observed learning outcome taxonomy for assessment and performed postvalidation of the theory exam results. However, 35% of them had not implemented objectivization of clinical/practical examinations in the formative assessment.
[Figure 2] shows the response obtained from the faculty to an open-ended question, regarding the concepts that they intended to implement after FDP, and their report on knowledge and skill gain in these concepts and actual practice of these concepts, on a regular basis or occasionally. The concepts that around 90% of the faculty wanted to implement were the active learning principles, lesson plan, feedback system, small group teaching methods, mentoring of slow learners, and objectivization in examinations.
|Figure 2: Graphical illustration of the match between what the faculty intended to implement, their self-perceived knowledge/skill gain and the changes they had made in their teaching practices|
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[Table 5] shows the response at Kirkpatrick's Level 4a and b on a change in institutional practice and student performance, respectively. About 60% of the faculty perceived a significant institutional change on the undergraduate syllabus revision, which included content modification for relevance and blueprinting for assessment. It also included a provision of a structured syllabus for integrated teaching, chair-side clinical teaching, and early clinical exposure. About 51% perceived implementation of patient-centered training in the institute, such as comprehensive care, early clinical exposure, and community-based learning. With regard to e-portfolios for formative assessments and objectivization in summative assessment, 43% of them reported no significant change. Nearly 16% of the teachers perceived an improvement in the students' performance to a considerable extent, and 54% of them perceived to a moderate extent.
| Discussion|| |
Three years after the FDP, the outcome as perceived by the dental educators in this survey is positive at all levels of Kirkpatrick's model. The process of transfer of knowledge to practice happens over a long period when the teachers continue to learn to use and learn from use. Therefore, a long-term follow-up evaluation assumes significance in assessing the outcome of an FDP.,,
Satisfaction is at the lowest level of Kirkpatrick's model. Nevertheless, if the faculty were not satisfied with the program, they would neither be motivated nor recommend the course to others. A consistent satisfaction, irrespective of the mode of delivery and content of the FDP, has been reported in a systematic review in 2006. Similar satisfaction was noted in the current evaluation. Consequently, most of the participants expressed willingness to recommend the FDP to their peers.
Despite providing a protected-time, some of the participants felt the program to belong, overlapping with their teaching responsibilities. However, longitudinal programs have been reported to be more effective than short sessions, due to reflective and experiential learning., Nonetheless, many were satisfied with the duration. This could be also be attributed to the interactive action-learning model of the FDP. Both phase 1 and phase 2 programs were inter-disciplinary and were made interactive with fresh group dynamics in every session. A similar observation has been reported by McAndrew in 2010, that action learning model was useful in professional development.
Teaching as a career is not generally considered rewarding as a clinical practice career. While dissecting dental education in India, one study has pointed out the graduates' apparent preference for private practice. This trend seems to be global as well as reported by Chmar et al. in 2008. On the contrary, a positive attitudinal change toward teaching was observed among the participants in the current survey. Most of them reported a willingness to assume teaching as a long-term career. As teaching has a profound impact on both the individual student and society, this attitudinal shift can be considered as a significant outcome.
Nawabi et al. in 2015 studied teachers' perception of their roles in education and reported that most of the faculty perceived themselves to be information providers, whereas few took into cognizance the other responsibilities. However, in the current study, most of the dental educators agreed on the various nature of their roles, especially their role as mentors for slow learners.
A widely prevalent attitude of young teachers is that they do not have a significant role in changing the education system. However, the present evaluation shows that most of the dental educators were enthusiastic about changing the system, by implementing newer concepts at the classroom level. It has been reported that intention-to-change correlates well with behavioral change. In accordance with this, most participants expressed intent to implement what they had learned, and this intention correlated well with the educational practices. [Figure 2] shows the match between what the faculty intended to implement, their changes in classroom practices. Teaching-learning principles/methods, slow-learners' mentoring, and objectivization of assessment were expressed as the intentions to implement. It was observed that most of them practiced the same in their classrooms.
Although the reliability of self-reported knowledge gain has been a debatable point, it is still a widely used, cost-effective method of evaluation. A meta-analysis by Sitzmann et al. in 2010, reported that interactive and skill-focused training correlated well with self-reported knowledge gain. The present FDP was inter-disciplinary and was made interactive; therefore, knowledge gain reported in this survey can be considered valid. It was also observed from [Figure 2] that self-reported knowledge/skill gain matched with the concepts that the teachers intended to implement and those which they had implemented.
New educational practices were implemented at the institutional level immediately after the phase 1 training. Standardized lesson plan templates and feedback forms were introduced. A Mentor-mentee system became an integral part of the institute. Syllabus revision and standardization of theory exams evaluation were also noticeable changes. The current survey shows that the faculty were aware of all these policies in the institution. This trend indicates that the “outer circle” of faculty who implemented changes are in-sync with the “inner circle” of faculty who make decisions to implement, as has been stated by Hendricson et al. in 2007. These authors have elaborated on the process of “transfer,” by which an organization attempts to institutionalize new strategies in different stages. According to them, with awareness, motivation, confidence/competence build-up among the faculty, after initial implementation and monitoring phase, the new systems tend to gradually become institutionalized. This kind of internalization was evident from the current outcome evaluation of this FDP.
Student performance is placed at the highest level of Kirkpatrick's evaluation model. Very few studies have assessed this level of outcome. The dental educators in this evaluation had perceived a considerable improvement in the students' performance after the FDP. However, this is only a subjective perception, not an objective evaluation, thus requires further study and analysis.
The limitation of this survey is that it is based solely on the perception of the participating dental educators. Notably, the teachers' competence gain, is best evaluated by multiple measures that will enable triangulation. Pre/posttest measures, pre/postobjective structured teachers evaluation, pre/postself-assessment scores, and postsatisfaction survey have been used to evaluate the outcome. Delayed posttest after 7 months as well as student's rating on teachers' competence have also been used. Future evaluations should include such measures along with the teacher's portfolio. Similarly, students' performance enhancement should be evaluated by exam scores, patients' perception of improved competence, as well as by students' self-perception.
| Conclusion|| |
Long-term outcome of a longitudinal faculty development workshop conducted for multidisciplinary, multiple-cader dental educators is positive at all levels of the Kirkpatrick's model. There seems to be a domino effect, where highly satisfied faculty experienced a desirable attitudinal change, which then inspired them to translate their knowledge into practice in a classroom setting, while all along being aware and supportive of the educational changes in the institution.
Being a teacher in the 21st-century health-professions education should be thought of as a 360°, 24 × 7, 365 days responsibility that cannot be left to serendipity. Therefore, all preparations for a multi-dimensional development must be included and encouraged.
The authors would like to acknowledge Prof. K.R. Sethuraman, Vice-Chancellor, Prof. N. Ananthakrishnan, Dean-Research and Allied Health Sciences, Prof. K.A Narayan, Community Medicine, of Sri Balaji Vidyapeeth University, for conducting the workshops as well as mentoring the Dental Education Unit.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Harden RM, Crosby JO. AMEE guide no 20 : The good teacher is more than a lecturer – The twelve roles of the teacher. Med Teach 2000;22:334-47.
Haden NK, Hendricson WD, Killip JW, O'Neill PN, Reed MJ, Weinstein G, et al.
Developing dental faculty for the future: ADEA/AAL institute for teaching and learning, 2006-09. J Dent Educ 2009;73:1320-35.
Bierema LL. Adult learning in health-professions education. New Dir Adult Contin Educ 2018;157:27-40.
Greiner AC, Knebel E. Health Professions Education: A Bridge to Quality. Washington (DC): National Academies Press (US); 2003. p. 45-67.
Wilkerson L, Irby DM. Strategies for improving teaching practices: A comprehensive approach to faculty development. Acad Med 1998;73:387-96.
Frenk J, Chen L, Bhutta ZA, Cohen J, Crisp N, Evans T, et al.
Health professionals for a new century: Transforming education to strengthen health systems in an interdependent world. Lancet 2010;376:1923-58.
McLean M, Cilliers F, Van Wyk JM. Faculty development: Yesterday, Today and Tomorrow. Med Teach 2008;30:555-84.
O'Neill PN, Taylor CD. Responding to the need for faculty development: A survey of U.S. And Canadian dental schools. J Dent Educ 2001;65:768-76.
Sheets KJ, Schwenk TL. Faculty development for family medicine educators: An agenda for future activities. Teach Learn Med 1990;2:141-8.
Centra JA. Types of faculty development programs. J High Educ 1978;49:151-62.
Amundsen C, Abrami P, McAlpine L, Weston C, Krbavac M, Mundy A, et al
. The what and why of faculty development in higher education: A synthesis of the literature. In: Proceedings of the American Educational Research Association. Montreal: Faculty Teaching, Development and Evaluation SIG, American Educational Research Association Publishers; 2005.
Kamel AM. Role of faculty development programs in improving teaching and learning. Saudi J Oral Sci 2016;3:61-8. [Full text]
Barksdale DJ, Woodley L, Page JB, Bernhardt J, Kowlowitz V, Oermann MH, et al.
Faculty development: Doing more with less. J Contin Educ Nurs 2011;42:537-44.
Steinert Y. Faculty development in the new millennium: Key challenges and future directions. Med Teach 2000;22:44-50.
Steinert Y, Mann K, Centeno A, Dolmans D, Spencer J, Gelula M, et al.
A systematic review of faculty development initiatives designed to improve teaching effectiveness in medical education: BEME guide no 8. Med Teach 2006;28:497-526.
Steinert Y. Perspectives on faculty development: Aiming for 6/6 by 2020. Perspect Med Educ 2012;1:31-42.
Ramalanjaona G. Faculty development: How to evaluate the effectiveness of a faculty development program in emergency medicine. Acad Emerg Med 2003;10:891-2.
Chuenjitwongsa S, Oliver RG, Bullock AD. Developing educators of European undergraduate dental students : Towards an agreed curriculum. Eur J Dent Educ 2018;22:179-91.
Hendricson WD, Anderson E, Andrieu SC, Chadwick DG, Cole JR, George MC, et al.
Does faculty development enhance teaching effectiveness? J Dent Educ 2007;71:1513-33.
Dalrymple KR, Wuenschell C, Rosenblum A, Paine M, Crowe D, von Bergmann HC, et al.
PBL core skills faculty development workshop 1: An experiential exercise with the PBL process. J Dent Educ 2007;71:249-59.
Licari FW. Faculty development to support curriculum change and ensure the future vitality of dental education. J Dent Educ 2007;71:1509-12.
Christie C, Bowen D, Paarmann C. Effectiveness of faculty training to enhance clinical evaluation of student competence in ethical reasoning and professionalism. J Dent Educ 2007;71:1048-57.
Møystad A, Lycke KH, Barkvoll TA, Lauvås P. Faculty development for clinical teachers in dental education. Eur J Dent Educ 2015;19:149-55.
Adkoli BV, Sood R. Faculty development and medical education Units in India: A survey. Natl Med J India 2009;22:28-32.
Srinivas DK, Adkoli BV. Faculty development in medical education in India : The need of the day. Al Ammen J Med Sci 2009;2:6-13.
Guntupalli SN, Sanikommu S, Pachava S, Talluri D, Ravoori S, Pydi SK, et al
. Perceptions on faculty development among dental faculty in Andhra Pradesh. J Indian Assoc Public Health Dent 2017;15:151-6. [Full text]
Meenakshi S, Raghunath N, Shreeshyla HS. An assessment of teaching and learning practices: A questionnaire study for dental educators of karnataka. J Int Soc Prev Community Dent 2017;7:S179-85.
YelonSL, Ford JK, Golden S. Transfer over time: Stories about transfer years after training. Perform Improv Q 2013;25:43-66.
McAndrew M, Motwaly S, Kamens TE. Long-term follow-up of a dental faculty development program. J Dent Educ 2013;77:716-22.
Haden NK, Ranney RR, Weinstein G, Breeding LC, Bresch JE, Valachovic RW, et al.
Leadership development in dental education: Report on the ADEA leadership institute, 2000-08. J Dent Educ 2010;74:331-51.
Cole KA, Barker LR, Kolodner K, Williamson P, Wright SM, Kern DE, et al.
Faculty development in teaching skills: An intensive longitudinal model. Acad Med 2004;79:469-80.
Knight AM, Cole KA, Kern DE, Barker LR, Kolodner K, Wright SM, et al.
Long-term follow-up of a longitudinal faculty development program in teaching skills. J Gen Intern Med 2005;20:721-5.
McAndrew M. Use of an action learning model to create a dental faculty development program. J Dent Educ 2010;74:517-23.
Mahal AS, Shah N. Implications of the growth of dental education in India. J Dent Educ 2006;70:884-91.
Chmar JE, Weaver RG, Valachovic RW. Dental school vacant budgeted faculty positions, academic years 2005-06 and 2006-07. J Dent Educ 2008;72:370-85.
Lyon LJ. Development of teaching expertise viewed through the dreyfus model of skill acquisition. J Scholarsh Teach Learn 2014;15:88-105.
Nawabi S, Khan RA, Yasmin R. Teachers' perceptions of their roles in medical colleges. AHPE 2015;1:24-9.
Légaré F, Freitas A, Turcotte S, Borduas F, Jacques A, Luconi F, et al.
Responsiveness of a simple tool for assessing change in behavioral intention after continuing professional development activities. PLoS One 2017;12:e0176678.
Sitzmann T, Brown KG, Bauer KN. Self-assessment of knowledge : A cognitive learning or affective measure? Acad Manag Learn Educ 2010;9:169-91.
McAndrew M, Pierre GC. Using multiple measures to evaluate a dental faculty development program. Eur J Dent Educ 2013;17:1-8.
Naeem N. Which knowledge and skills do participants retain after attending medical education training workshops? Creat Educ 2016;7:870-7.
Dr. Usha Sathyanarayanan
No 7, Karnan Street, Kennedy Garden, Karuvadikuppam, Samipillaithottam, Puducherry - 605 008
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]