Evaluating Pakistani dental graduates’ preparedness for practice: a mixed methods study using the conscious competence model

Abstract

Background

Dental graduates often feel underprepared for independent practice, particularly in challenging work environments. This mixed-methods study explored self-perceived preparedness among final-year dental students, recent graduates, and house officers training for full registration in Karachi, Pakistan. This study correlated preparedness with personality type and aligned it with the Conscious Competence Model (CCM), which is comprised of four stages of learner self-perception as they proceed toward acquiring new competencies: Unconscious incompetent (don’t know what you don’t know); conscious incompetent (now aware of skill deficits); conscious competent (performs skill but with conscious effort and deep concentration); unconscious competent (performs with minimal conscious thought).

Methods

A total of 44 participants (86% female, mean age 23.2 ± 3.43 years) completed the Dental Undergraduates Preparedness Assessment Scale (DU-PAS), with high reliability (Cronbach’s alpha: overall = 0.89, Part A = 0.91, Part B = 0.82). Thirty of these 44 participants also completed a Myers-Briggs Type Indicator (MBTI) inventory, provided a global rating for self-perceived preparedness on a scale ranging from 0%–not ready to 100%–completely ready, and also engaged in semi-structured interviews. Quantitative data were analysed using chi-squared, Mann-Whitney U, and Kruskal-Wallis tests, while qualitative data (themes identified from interviews) were thematically analysed and mapped to the CCM.

Results

The mean overall DU-PAS score was 64.12 ± 5.18 (clinical skills 62.0 ± 5.04, non-clinical skills 65.95 ± 8.09). High confidence levels were reported for foundational skills, such as taking medical history (95%). Conversely, lower confidence was reported for specialised procedures, such as bitewing radiography (29.5%), and non-clinical skills, such as managing pediatric patients (25%) and anxious patients (31.8%). DU-PAS scores demonstrated a significant decline across training stages. Final-year students scored highest (67.9 ± 4.2), followed by house officers (62.4 ± 3.5), and recent graduates (59.4 ± 4.8). The differences were statistically significant (H(2) = 18.42, Kruskal–Wallis p < 0.001), indicating a progressive reduction in perceived preparedness with increasing training experience. Of the 30 participants who completed the MBTI, 60% were classified as extroverts, who reported a median global self-perceived preparedness score of 70% on the 0–100 scale, compared with a median score of 57% among introverts. Six themes were identified from the interviews: effective undergraduate experiences, deliberate professional development, patient care, emergency preparedness, practice management, and ethical reflection were identified that charted movement from unconscious to conscious incompetence once graduates faced real clinical demands.

Conclusions

Although participants felt that basic skills contributed to some preparedness to practice, they did not feel equipped to manage complex clinical and managerial tasks. In relation to the CCM learning process, the progressively declining preparedness rankings among final year students, house officers and recent graduates suggests that the transition from unconscious to conscious incompetence did not occur until entering professional practice. Possible interventions were suggested by identifying enablers and barriers to preparedness. These include increased earlier supervised exposure to advanced endodontics, radiography, paediatric and anxious-patient care, along with structured modules in practice management and reflective mentoring, leading to consolidating conscious competence before graduation.

Introduction

Preparing for dental practice requires mastering a combination of skills, knowledge and attitudes [1]. Globally, dental education curricula focus on students’ acquisition of clinical competencies needed for unsupervised, entry-level professional practice. However, recent graduates are often not prepared for the challenging work environment of contemporary dental practice [2, 3]. In many nations, these challenges include some combination of saturated workplaces, unemployment, the poor economic viability of private practices, and low remuneration [2]. In Pakistan, as in other low to middle-income countries, additional challenges include time, faculty, and resource constraints in delivering an undergraduate dental curriculum, leaving students inexperienced in complex skills [4].

A systematic review of preparedness for dental graduates highlighted six domains: academic and technical competence, communication and interpersonal skills, protective mechanisms and adaptive skills, professional attitude and ethical judgement, clinical entrepreneurship and financial solvency skills, and social and community orientation [5]. Considering these challenges, some domains such as clinical entrepreneurship and financial solvency may not be covered, impacting students’ preparedness to practice [4, 6].

The Pakistan Medical and Dental Council (PMDC) has published dental graduate competencies; however, training is not standardised and varies among institutions [7]. This inconsistency leads to a sense of graduate unpreparedness, which adversely affects the standards of dental care. Therefore, research is needed to evaluate and enhance graduates’ preparedness for dental practice. Preparedness for practice encompasses several elements, including competence in performing tasks, self-efficacy, and confidence in one’s abilities. Students’ preparedness for the practice pathway, acquiring skills, knowledge, and attitudes can be aligned with the Conscious Competence model (CCM) [8]. This model describes the four stages of awareness in the transition to professional practice (Fig. 1). After graduation, practitioners are consciously incompetent or unconsciously competent, where they can safely accomplish tasks. For undergraduate training, aligning CCM with expected competencies, educators can tailor teaching strategies and learning opportunities to support dental students to progress in the model, thereby enhancing preparedness to practice.

Fig. 1.

The four stages of the conscious competence model. (1) Unconscious incompetence: individuals are unaware of their lack of skill or knowledge. (2) Conscious Incompetence. Individuals are aware they lack specific skills and knowledge and recognise they need to learn and understand. (3) Conscious competence. Individuals have acquired the necessary skills and knowledge but need to concentrate to perform correctly. (4) Unconscious competence. Individuals reach the stage where they can perform effortlessly without conscious thought

The Pakistan Medical and Dental Council (PMDC) has published dental graduate competencies; however, training and assessment of practice-readiness are not standardised and varies among institutions [7]. This variation contributes to self-reported feelings of unpreparedness among final-year students, house officers, and recent graduates, which may undermine confidence and potentially affect patient care [4, 9]. Therefore, research is needed to evaluate graduates’ actual level of preparedness for dental practice, which can identify strategies for enhancement of the educational process. Preparedness for practice encompasses several elements, including competence in performing tasks, self-efficacy, and confidence in one’s abilities. Students’ preparedness for the practice pathway, acquiring skills, knowledge, and attitudes can be aligned with the Conscious Competence Model (CCM) [8]. This model describes the four stages of learner self-awareness in the transition to professional practice (Fig. 1). Based on the CCM, dental graduates are expected to move beyond unconscious incompetence during their training. After graduation, they should at least demonstrate conscious incompetence, where they recognise the limits of their skills and seek supervision or referral rather than attempting procedures beyond their capacity. With progressive experience and support, they then advance to conscious competence and eventually unconscious competence, where core clinical tasks can be performed safely and efficiently with minimal conscious effort. For undergraduate training, by aligning CCM with expected competencies, educators can tailor teaching strategies and learning opportunities to support dental students to progress in the model, thereby enhancing preparedness to practice.

The self-perceived preparedness of graduates is dependent on several factors, including experience and demographics, and can be influenced by personality characteristics. Traits such as high self-confidence, self-efficacy, conscientiousness, resilience, intrinsic motivation, and extrovertism can affect how individuals perceive their preparedness [3, 10]. Personality traits can be assessed using personality assessment tools such as the Myers-Briggs Type Indicator^® (MBTI^®). Based on Jung’s theory of psychological types, this tool has proven insightful in studies mapping medical students’ performances [11–18].

This study aimed to explore preparedness for dental practice among a group of dental graduates and undergraduates in Pakistan by harnessing insights based on the MBTI and aligning their perceived ability with CCM. By identifying enabling and hindering elements, this study sought to gain a further understanding of the factors that influence preparedness for practice and thus inform educational interventions. These insights have the potential to enhance the delivery of an authentic educational programme that equips graduates for successful professional practice.

Methods

Study design

This study used a mixed-method design to measure preparedness objectively and obtain narratives of experiences and emotions, thus capturing the complexities concerned with feelings of preparedness. Ethical approval was granted by the Ethics Committee of the parent university of each of the study participants.

Theoretical framework

The CCM forms a theoretical framework to map the pathway of skill mastery and competence and to understand participants’ perceptions of their preparedness for practice through awareness of their abilities [8].

Study site

This study was conducted at Dow University of Health Sciences, Karachi, Pakistan. However, students, interns and recent graduates were from multiple institutions.

Sample population and recruitment

Participants included final-year undergraduate dental students enrolled at the three dental colleges affiliated with Dow University of Health Sciences, dental house officers from various institutions undergoing a one-year internship after leaving university, and recent dental graduates from all over the country who have already completed their degrees and internships and are now in professional practice. Sampling was purposive, and the criteria were based on professional status (student/house officer/graduate). Final-year dental undergraduate students were invited by course representatives. Dental graduates and house officers were invited by standardised email. For those who expressed interest, a participant information sheet was provided, and written consent was obtained.

Quantitative data collection and analysis

The data collection process involved three assessments: the Dental Undergraduates Preparedness Assessment Scale (DU-PAS), the Myers-Briggs Type Indicator (MBTI), and the Individual Global Rating of Self-perceived Preparedness for independent dental practice.

Participants completed the DU-PAS questionnaire, a tool with previously demonstrated high validity comprising two sections - Part A (clinical procedures) and Part B (non-clinical and behavioural skills) [19].

Participants also completed an online MBTI personality test [20]. This test categorises individuals into 16 personality types based on their preferences across four dimensions: Extraversion (E) versus Introversion (I), Sensing (S) versus Intuition (N), Thinking (T) versus Feeling (F), and Judging (J) versus Perceiving (P) [13].

Finally, participants rated their self-perceived preparedness levels on a global scale (0%–not ready to 100%–completely ready).

Descriptive statistics were calculated using Statistical Package for Social Science (SPSS) software 23 (IBM Corporation, Armonk, NY, USA). The reliability of the DU-PAS was assessed using Cronbach’s alpha. Further analysis was performed using the chi-squared, Mann-Whitney U, and Kruskal-Wallis tests.

Qualitative data collection and analysis

Semi-structured interviews were conducted by a single interviewer. All interviews were recorded using the Audacity software (NCH Software Inc. Greenwood Village, CO, USA), converted to mp3 format, and transcribed manually. Notes taken during the interviews were matched with transcripts for accuracy. The guide used for interviews is shown in Table 1. Study data were reported using the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist [21]. Participants had the opportunity to review and comment on the interview transcripts before thematic analysis.

Table 1.

Topic guide used in semi-structured interviews

• How well are our dental graduates prepared for independent practice?

• What core dental skills are needed to prepare new dental graduates for independent dental practice in Pakistan?

• Which clinical skills related to independent dental practice are deficient in our dental graduates?

• Which clinical skills related to independent dental practice are adequate for our dental graduates?

Manual stepwise thematic analysis was conducted using Braun and Clarke’s six-step framework [22, 23]. Two researchers independently coded the data, focusing on themes related to CCM stages. Discrepancies were resolved through discussions. Codes were analysed for overarching themes and reviewed to ensure coherence and relevance by checking against the dataset [24]. A structured report was formed from the analysis, integrating the identified themes with supporting data excerpts. Reflexivity was maintained throughout the study.

The CCM was integrated into thematic qualitative analysis to explore participants’ perceptions of their level of competency based on the CCM’s four stages. Preliminary codes were assigned, and responses were analysed using the four CCM stages. Participants’ reflections were then mapped to these stages. For instance, those unaware of skill gaps before practice were mapped to unconscious incompetence, and those who recognised gaps upon entering clinical practice were mapped to conscious incompetence. Graduates with skills but lower confidence mapped to conscious competence, whereas those who could perform tasks effortlessly mapped to unconscious competence. The final synthesis of themes and alignment with CCM mapped the progression of dental graduates through different competency stages.

Results

Participants’ selection and characteristics

A total of fifty-three participants were invited to take part in the study. Forty-four completed the DU-PAS for a 83% response rate. Eighteen DU-PAS completers (41%) were final-year undergraduate dental students, 18 (41%) were dental house officers, and 8 (18%) were recent dental graduates. Thirty-eight DU-PAS completers (86%) were female and 6 (14%) were male. The age range for participants who completed the DU-PAS was 21 to 25 years (mean age 23.2 years (SD ± 3.43)).

Thirty study subjects completed the MBTI personality questionnaire, the Individual Global Rating of Self-Perceived Preparedness, and participated in one-on-one interviews. Among these 30 subjects, 12 (40%) were final-year undergraduate dental students, 12 (40%) were dental house officers, and 6 (20%) were recent dental graduates.

Quantitative results

DU-PAS questionnaire

The total DU-PAS score was calculated by summing the individual scores for all 50 items in the questionnaire. Reliability was high - overall Cronbach’s alpha was 0.89 (subscale A reliability 0.91 subscale B reliability 0.82).

The mean DU-PAS score for participants was 64.12 (± 5.18 SD). The mean score for Part A of the questionnaire was 62.2 (+ 5.04 SD) and 65.9 (± 8.08 SD) for Part B, as shown in Fig. 2.

Fig. 2.

Distribution of DU-PAS Scores for Participants in Part A (Clinical Skills) and Part B (Non-clinical Skills). The total DU-PAS score represents the sum of scores from all 50 items of the questionnaire, reflecting participants’ overall perceived preparedness for practice

Table 2 outlines the results from Part A, showing participants’ high confidence in performing basic clinical procedures, such as taking medical history (95%) and performing oral examinations independently (86%). However, lower confidence levels were reported in specialised tasks such as independently assessing the treatment needs of patients requiring orthodontics (38.6%) and the ability to undertake bitewing radiographs (29.5%).

Table 2.

Participant scores on Part A of DU-PAS by item

Item	Question	No Experience (%)	With help (%)	Independently (%)
A1	I can obtain a complete medical history from my patients	0.0	4.5	95.5
A2	I am able to undertake a comprehensive, clinical oral examination	0.0	11.4	88.6
A3	I am able to prescribe appropriate dental radiographs	0.0	15.9	84.1
A4	I am able to undertake periapical radiographs	0.0	4.5	95.5
A5	I am able to undertake bitewing radiographs	31.8	38.6	29.5
A6	I am able to interpret common findings on dental radiographs	2.3	27.3	70.5
A7	I am able to assess the treatment needs of patients requiring orthodontics	4.5	56.8	38.6
A8	I am able to formulate a comprehensive treatment plan which addresses all treatment needs of my patients	2.3	40.9	56.8
A9	I am able to provide a range of treatment options to my patients based on their individual circumstances	0.0	27.3	72.7
A10	I am able to explain the merits and demerits of various treatment options to my patients	0.0	25	75
A11	I am able to obtain valid consent from my patients prior to undertaking any treatment.	0.0	4.5	95.5
A12	I am able to carry out patients’ treatment sessions in an appropriate order	0.0	25.0	75
A13	I am able to prescribe drugs to my patients appropriately	2.3	22.7	75
A14	I am able to administer inferior dental nerve blocks effectively	0.0	4.5	95.5
A15	I am able to perform non-surgical periodontal treatment using appropriate methods	0.0	4.5	95.5
A16	I am able to remove dental caries effectively	2.3	4.5	93.2
A17	I am able to restore teeth with tooth-coloured fillings appropriately	2.3	6.8	90.9
A18	I am able to restore teeth with amalgam fillings appropriately	2.3	15.9	81.8
A19	I am able to perform endodontic treatment on single-rooted teeth appropriately	9.1	4.5	86.4
A20	I am able to perform endodontic treatment on multi-rooted teeth appropriately	6.8	27.3	65.9
A21	I am able to provide crowns using principles of tooth preservation	13.6	25	61.4
A22	I am able to provide mechanically sound partial dentures	2.3	31.8	65.9
A23	I am able to provide mechanically sound complete dentures	6.8	38.6	54.5
A24	I am able to undertake non-surgical tooth extractions appropriately	0.0	9.1	90.9

Table 3 outlines the results from Part B, showing participants’ higher confidence levels in areas such as the awareness of legal responsibilities (65.9%) and safeguarding patient confidentiality (65.9%). However, lower confidence levels were reported in patient management, pediatric patients (25%), and anxious patients (31.8%).

Table 3.

Participant scores on Part B of DU-PAS by item

Item	Question	No Experience (%)	Mostly (%)	Always (%)
B25	I feel I can manage peoples’ expectations of their treatment	2.3	77.3	20.5
B26	I feel able to motivate my patients to encourage self-care for their dental needs	0.0	52.3	47.7
B27	I recognise my personal limitations in clinical practice	4.5	47.7	47.7
B28	I feel comfortable asking for help from my supervisor or colleague if needed	0.0	29.5	70.5
B29	I am able to refer patients with complex treatment needs appropriately	0.0	38.6	61.4
B30	I feel confident referring patients with suspected oral cancer	18.2	34.1	47.7
B31	I reflect on my clinical practice in order to address my learning needs	0.0	54.5	45.5
B32	I have sufficient knowledge of scientific principles which underpin my dental practice	2.3	61.4	36.4
B33	I am confident in evaluating new dental materials and products using an evidence-based approach	15.9	56.8	27.3
B34	I am confident in interpreting the results of research, which may influence my practice	11.4	56.8	31.8
B35	I use an evidence-informed approach in my clinical practice.	11.4	54.5	34.1
B36	I feel I can manage to communicate effectively with my patients	0.0	40.9	59.1
B37	I provide opportunities for my patients to express their expectations of dental treatment	0.0	47.7	52.3
B38	I feel confident to address barriers to effective communication with patients appropriately	0.0	47.7	52.3
B39	I feel confident in communicating the potential risks of operative procedures to patients	0.0	52.3	47.7
B40	I feel confident to communicate appropriately with my colleagues	0.0	38.6	61.4
B41	I feel confident managing anxious patients with appropriate behavioural techniques	2.3	65.9	31.8
B42	I am able to manage the behaviour of children to enable appropriate dental treatment	13.6	61.4	25
B43	I am able to fulfil my responsibilities as an effective member of the dental team	2.3	50.0	47.7
B44	I maintain accurate records of my clinical notes	2.3	54.5	43.2
B45	I am able to work within the constraints of clinical appointment schedules	0.0	54.5	45.5
B46	I take responsibility for my continuing professional development	0.0	45.5	54.5
B47	I am aware of my legal responsibilities as a dental professional	4.5	31.8	63.6
B48	I restrict my relations with my patients to a professional level	0.0	36.4	63.6
B49	I feel able to raise concerns about the inappropriate behaviour of my colleagues	4.5	50	45.5
B50	I take appropriate measures to protect patient confidentiality	0.0	34.1	65.9

In this study, the correlation between DU-PAS scores and gender was statistically insignificant. However, there were noticeable discrepancies in particular clinical skills where those identifying as female reported more confidence than males in restoring teeth with tooth colour fillings independently (94.7% versus 66.7%) and performing multi-rooted root canal treatments (71% versus 33.3%).

A comparison of the DU-PAS scores across the entire cohort is presented in Table 4. There was a clear and statistically significant decline in overall DU-PAS scores across the three training groups. Final-year students reported the highest level of preparedness (67.9 ± 4.2), followed by house officers (62.4 ± 3.5), with recent graduates scoring the lowest (59.4 ± 4.8). This trend was similarly observed when comparing the clinical (Part A) and non-clinical (Part B) subscale scores separately. A Kruskal–Wallis test confirmed that these differences were statistically significant (H(2) = 18.42, p < 0.001). Post-hoc Dunn–Bonferroni comparisons further demonstrated that each pair of groups differed significantly, reflecting a stepwise decline in self-assessed competence as graduates progressed from student to practitioner roles.

Table 4.

Comparison of DU-PAS scores between dental students, house officers and graduates

		N	Mean	Std. Deviation	Minimum	Maximum
Mean DU-PAS score	Dental Students	18	67.89	4.24	60.50	74.50
	Dental House Officers	18	62.44	3.53	54.00	67.00
	Dental Graduates	8	59.44	4.77	51.50	62.50
	Total	44	64.13	5.19	51.50	74.50
DU-PAS Score Part B	Dental Students	18	71.00	7.93	53.00	81.00
	Dental House Officers	18	63.22	4.81	57.00	72.00
	Dental Graduates	8	60.75	8.78	49.00	73.00
	Total	44	65.95	8.09	49.00	81.00
DU-PAS Score Part A	Dental Students	18	64.78	3.28	57.00	69.00
	Dental House Officers	18	61.67	4.87	50.00	69.00
	Dental Graduates	8	58.13	5.96	50.00	69.00
	Total	44	62.29	5.04	50.00	69.00

MBTI and self-perceived preparedness for practice

Table 5 outlines the relationship between the MBTI personality type and self-perceived preparedness score (global rating).

Table 5.

Participant self-perceived preparedness to practice based on the global rating scale, with corresponding MBTI personality type. FY = Final Year Undergraduate Dental Student, DH = Dental House Officer, RG= Recent Dental graduate

Participant	Self-perceived preparedness to practice (Global rating %)	MBTI personality type
FY1	60	ISTJ
FY2	80	ESFJ
FY3	70	INFP
FY4	70	ENTP
FY5	70	INTP
FY6	80	ENFP
FY7	50	ISTJ
FY8	80	ENTJ
FY9	70	ENFP
FY10	90	ISTP
FY11	70	ENFJ
FY12	80	ESFJ
DH1	70	ENTJ
DH2	50	ENFP
DH3	70	ENFJ
DH4	60	ENTJ
DH5	80	ENFP
DH6	40	ISTJ
DH7	70	INFP
DH8	60	ISTJ
DH9	70	ENFJ
DH10	80	ENTJ
DH11	60	INFJ
DH12	70	ENTJ
RG1	60	ENFP
RG2	40	ISTJ
RG3	60	INTP
RG4	70	ISFJ
RG5	70	ENTP
RG6	50	ENFT

Of the 30 participants who completed the MBTI, 60% were classified as extroverts and 40% as introverts. Extroverted participants reported higher self-perceived preparedness on the global rating scale (median 70%) than introverts (median 57%). These percentages represent median preparedness scores rather than proportions of individuals who felt prepared. Self-perceived preparedness declined in value according to experience: final-year students (72.5%), dental house officers (65%), and recent graduates (58%). This trend was statistically significant (Kruskal-Wallis test, p = 0.03), indicating an increasing awareness of competency gaps post-graduation and upon transition into practice (Table 5).

Quantitative results

Six themes emerged from the one-to-one interviews and were aligned to the CCM stages (Table 6).

Table 6.

Emergent themes from coded data analysis, aligned with stages of the CCM

Theme	CCM Stage	Code	Description	Quote
Theme 1: The importance of effective learning experiences in dental school training	Unconscious Incompetence	3	Admission to dentistry is due to a lack of other options.	“I got admitted to dentistry because I couldn’t secure admission elsewhere.” (FY7)
	Unconscious Incompetence	14	Inadequate supervision during dental training.	“Our clinical supervision is often by peers or house officers. Senior faculty interaction is minimal.“(DH8)
	Conscious Incompetence	26	Lack of practical experience in crown preparations and orthodontics	“We are good at the theoretical aspects of orthodontics, but practical applications are missing.”(FY9)
	Conscious Incompetence	25	Proficient in operative dentistry, endodontics, and oral surgery; lacking in molar endodontics.	“I’m confident in operative dentistry but lack experience in molar endodontics.“(FY2)
Theme 2: Intentional Practice and Professional Development	Conscious Competence	18	The continuous need for knowledge and updates.	“Dentistry is ever-changing, and new materials are constantly coming into the market…“(DH8)
	Conscious Incompetence	4	Future plans and postgraduate aspirations.	“I’m planning to pursue further specialisation to improve my skills.“(FY6)
	Conscious Incompetence	4	Future plans and postgraduate aspirations.	“I have postgraduate plans to pursue FCPS in periodontics”(DH1)
	Conscious Competence	5	Voluntary private practice internship.	“I’ve done internships in private clinics, which makes me feel somewhat prepared.“(FY6)
	Conscious Competence	2	Confidence gained from work experience	“I did an extra internship in operative dentistry for about six months, so I had a lot of exposure and experience of operative procedures, and I am very confident.“(FY5)
Theme 3: Care and management of patients	Conscious Incompetence	15	Pediatric treatment limitations	“We haven’t had enough exposure to pediatric patients, so I don’t feel confident treating them.“(FY1)
	Conscious Incompetence	17	Confusion and lack of confidence with elderly patients	“I get confused, and I am less confident in treating the elderly and immunocompromised.” (FY8)
	Conscious competence	40	Confidence in treating children and elderly	“I am very good at handling children and the elderly, as I have been living in a joint family system and have been used to communicating with the elderly and children.” (DH3)
	Unconscious Incompetence	17	Poor communication skills	“We judge the patient based on their socio-economic background and try to explain the dental treatment at par with their level of understanding and in layman’s terms.” (DH8)
	Unconscious Incompetence	17	Poor communication	“We should not give a lot of options to patients, as they get confused.” (DH1)
	Conscious Incompetence	8	Medical history and drug interaction knowledge	“I can write for normal patients, but those with comorbidities, or immunocompromised or if the patient is taking medications for heart disease. Then I would need supervision and advice accordingly. (DH7)
	Conscious Incompetence	12	Dependence on the supervisor for reading prescriptions with unknown drug brands.	“I often need help from seniors to understand unfamiliar drug brands.” (FY9)
	Unconscious Incompetence	13	Prescription writing confidence	“I am 100% confident in writing prescriptions.”(DH1)
	Conscious Incompetence	27	Inability to take X-rays independently.	“In dental school, the X-ray technician usually takes radiographs; I haven’t done it myself.“(DH4)
		28	X-ray knowledge & skills	“I do not know about radiation protection and how to use collimation to reduce radiation. We were taught these concepts theoretically, but in clinics, they are not shown or taught. (FY5)
	Conscious Incompetence	27	Inability to take X-rays independently	“We were taught radiography theoretically but had little hands-on experience.” (DH10)
Theme 4: Medical Knowledge and Emergency Preparedness	Conscious Incompetence	8	Medical history and drug interaction knowledge	“I am good at taking medical and dental history taking, and I am 100% confident in conducting a medical and dental history…… I can take drug history for common diseases such as blood pressure and diabetes drugs, and their drug interactions can be comprehended, but for rare diseases, I am unaware of them. For instance, recently, a patient came with a prostate problem, and he was taking medications which I was unaware of, and I had no idea about its interactions with dental interventions. (FY6)
	Conscious Incompetence	7	Medical emergency preparedness	“I’m not confident dealing with cardiac arrest as we haven’t had BLS training.“(FY10)
Theme 5: Financial, business and statutory requirements of clinic management	Unconscious Incompetence	31	Lack of financial planning education.	“Financial planning isn’t part of our curriculum; we weren’t taught about managing a clinic’s finances.“(DH2)
		31	Lack of financial planning education.	“I do not know how to negotiate with patients in terms of financial agreement. I am lacking in financial solving skills.” (DH5)
	Conscious Incompetence	31	Lack of financial planning education	“Nowadays, dental clinics have become studios, and we must sell unique products to attract patients. Dental schools do not teach this aspect.” (DH2)
		31	Lack of financial planning education	“Even if financial management is not part of our curriculum. All our clinical teachers have their own private clinics. These teachers could have shared their experiences about financial planning of private clinics.” (DH9)
		26		“We have not been taught Sindh healthcare regulations or vaccination requirements.”(FY7)
	Unconscious Incompetence	30	Unaware of healthcare regulations, vaccination requirements	“We haven’t been taught about state regulatory requirements or necessary vaccinations.“(DH8)
Theme 6: Ethical and Reflective Practice	Conscious Competence	34	Reflective skills, handling mistakes and mishaps	“If a file breaks during endodontic treatment, I believe we should inform the patient…” (DH2)
		33	The belief that general dentists can place implants, not practice orthodontics	“As far as practising orthodontics by general dentists is concerned, I believe that every orthodontist follows their own theory and rules.” (DH5)
		26	Lack of practical experience in crown preparations and orthodontics	“So, there are diversity and different schools of thought in terms of orthodontics. Practical skills in orthodontics are lacking.” (DH6)
	Conscious Competence	41	Importance of positive/growth mindset.	“Some students have positive mindsets and do not rely on the dental school for all their dental skills. Personal choices matter. Students need to think about their bread-and-butter skills and actively acquire them during their undergraduate and internship years rather than waiting for dental schools to feed them on a plate. A single institute cannot teach all the necessary skills.”(DH6)

Theme one – The importance of effective learning experiences in dental school training

Participants discussed varied experiences in dental schools, from career choice to learning events. There were expressions over study choice, stating entrance into dentistry as incidental and not deliberate choice,

“I got admitted to dentistry because I could not find admission elsewhere.” (FY7)

This reflects a common trend in which students opt for dentistry when other medical fields are inaccessible, impacting their motivation to succeed [25].

Insufficient supervision by senior faculty and a lack of clinical exposure were mentioned, and as a result, participants felt that specific skills were undeveloped.

“Our clinical supervision is often by peers or house officers. Senior faculty interaction is minimal.“(FY3)

“We are good at the theoretical aspects of orthodontics, but practical applications are missing.” (FY9)

“I’m confident in operative dentistry but lack experience in molar endodontics.” (FY2)

The participants noted that their clinical supervision was mostly from peers or near peers. This power dynamic may impact participants’ confidence owing to insufficient expertise in providing guidance and feedback. Without effective supervisory relationships, it is challenging to develop professional competence and confidence [26].

Theme two – Intentional practice and professional development

Lifelong learning and updating of knowledge and skills post-graduation were identified as important to participants’ professional development.

“Dentistry is ever-changing, and new materials are constantly coming into the market, so we need to keep updated by attending workshops or teaching.” (DH4)

The participants felt that after graduation, there were opportunities to enhance their skills and develop expertise in specific areas of dentistry.

“I’m planning to pursue further specialisation to improve my skills.” (FY6)

“I have postgraduate plans to pursue FCPS in periodontics” (DH1)

Overall, there was an agreement that clinical exposure to skills would positively impact confidence upon entering professional practice.

“I have done internships in different clinics and workshops. I feel very confident.” (DH4)

“I did an extra internship in operative dentistry for about six months, so I had a lot of exposure and experience of operative procedures, and I am very confident.” (FY5)

Lifelong learning is essential for the development of confident and skilled practitioners. Combining experiential workplace learning with authentic cases ensures clinical competence and fosters professional growth, critical thinking, and problem solving, which are vital for patient care [27].

Theme three – Care and management of patients

Confidence levels in treating medically complex patients were highlighted and dependent on clinical experience and lived experiences outside of training.

“I get confused, and I am less confident in treating the elderly and immunocompromised.” (FY8)

“We haven’t had enough exposure to pediatric patients, so I don’t feel confident treating them.” (FY1)

“I am very good at handling children and the elderly, as I have been living in a joint family system and have been used to communicating with the elderly and children.” (DH3)

Participants’ comments during interviews hinted at communication skills training not being emphasised in dental education, nor did they appreciate the value of these skills [28]. When discussing practice, key skills such as listening, empathising, and building patient trust were not reflected upon.

“We judge the patient based on their socio-economic background and try to explain the dental treatment at par with their level of understanding and in layman’s terms.” (DH8)

“We should not give a lot of options to patients, as they get confused.” (DH1)

Ineffective communication can have serious consequences, such as errors and compromised patient [29]. Effective communication skills are a key competency in dental practice, enhancing patient satisfaction. The lack of awareness about the importance of communication skills may result from insufficient training or inadequate role modelling and supervision by experienced practitioners.

Various essential clinical skills were also identified as low confidence and required supervision.

“I can write for normal patients, but those with comorbidities, or immunocompromised or if the patient is taking medications for heart disease. Then I would need supervision and advise accordingly.”(DH7)

“I often need help from seniors to understand unfamiliar drug brands.“(FY9)

As prescription writing is a critical component of patient care, confidence in prescription writing does not necessarily equate to competence [30, 31].

There was an overall lack of knowledge and experience around dental radiography, a key skill required for practice.

“In dental school, the X-ray technician usually takes radiographs; I haven’t done it myself.” (DH4)

“I do not know about radiation protection and how to use collimation to reduce radiation. We were taught these concepts theoretically, but they are not shown or taught in clinics. (FY5)

“We were taught radiography theoretically but had little hands-on experience.” (DH10)

According to Samejo et al., dental radiography is inconsistently taught in dental schools [32]. The competencies are embedded within broader clinical subjects and, as a result, often lack the dedicated attention they deserve despite their significant impact on patient care.

Theme four – Medical knowledge and emergency preparedness

There was a conflict between self-perceived confidence and competence in specific patient skills, indicating a lack of awareness of ability.

“I am good at taking medical and dental history taking, and I am 100% confident in conducting a medical and dental history…. I can take drug history for common diseases … but for rare diseases, I am unaware of. For instance, recently, a patient came with a prostate problem, and he was taking medications that I was unaware of. I had no idea about its interactions with dental interventions.” (FY6)

“I am not confident in dealing with cardiac arrest as I have not done basic life support (BLS) training. We are not trained in BLS as it is not part of our training.”(DH4)

Medical knowledge and emergency preparedness are crucial in dental education. However, inconsistent training, varying clinical opportunities and a lack of standardised protocols lead to varied preparedness levels, resulting in poor patient outcomes.

Theme five – Financial, business and statutory requirements of clinic management

Aspects of non-clinical dental practice not experienced in dental school contributed to feelings of unpreparedness.

“Financial planning isn’t part of our curriculum; we weren’t taught about managing a clinic’s finances.” (DH2)

“Nowadays, dental clinics have become studios, and we must sell unique products to attract patients. Dental schools do not teach this aspect.” (DH2)

However, participants identified relevant expertise within the dental school.

“Even if financial management is not part of our curriculum. All our clinical teachers have their own private clinics. These teachers could have shared their experiences about financial planning of private clinics.” (DH9)

Regulatory compliance and treating a diverse community were not taught, leaving participants unprepared for professional practice.

“We have not been taught Sindh healthcare regulations or vaccination requirements.” (FY7)

“We are unaware of state regulatory requirements and have not been taught about this.” (DH1)

Skills for successful dental practice extend beyond clinical elements. Participants with postgraduate degrees identified areas to enhance curriculum provision. Recognising these needs and harnessing practitioner expertise could bridge knowledge gaps and ease the transition into professional practice.

Theme six – Ethical and reflective practice

Interviews revealed that subjects considered high levels of reflection and ethical considerations to be key elements of clinical practice.

“If a file breaks during endodontic treatment, colleagues have told us not to tell the patient what is wrong and not to take X-rays. But I personally disagree with this notion. I think that the patient should be told.” (DH2)

Understanding the ethical framework in dental practice is essential for making legally compliant and ethically sound decisions. Participants noted variations in treatment approaches not covered in the curriculum, but clinical experience enhances critical insight and professional judgment.

“As far as practising orthodontics by general dentists is concerned, I believe that every orthodontist follows their own theory and rules.” (DH5)

“So, there are diversity and different schools of thought in terms of orthodontics (DH6)

Self-directed and self-regulated learning behaviours were identified as key enablers for development.

“Some students have positive mindsets and do not rely on the dental school for all their dental skills. Personal choices matter. Students need to think about their bread-and-butter skills and actively acquire them during their undergraduate and internship years rather than waiting for dental schools to feed them on a plate. A single institute cannot teach all the necessary skills.” (DH6)

A curriculum cannot fully reflect workplace challenges; students must commit to lifelong learning. A growth mindset, nurtured in students through self-reflection and mentorship, is essential.

Discussion

This study found participants confident in foundational skills but less in complex procedures. Quantitative data showed that final-year students felt more prepared than house officers and recent graduates, revealing that skill gaps were realised once they encountered real-world clinical challenges. Qualitative findings, mapped to the CCM, showed participants often moved from unconscious incompetence to conscious incompetence in clinical practice settings, echoing quantitative results. The finding that extroverts reported a higher median preparedness score (70%) than introverts (57%) reflects differences in self-perception rather than categorical readiness. Extroverted participants may be more comfortable expressing confidence, seeking help, or engaging socially within clinical environments, which can positively influence self-ratings. However, given the small group size and modest difference, this should be interpreted as a trend in perceived preparedness rather than a definitive indicator of competence. From the results, insights into factors that hinder or enable preparedness for dental practice could be generated.

Enablers for preparedness for dental practice

The results of the DU-PAS questionnaire showed the participants’ high confidence in basic clinical skills (Table 1). This foundational training supports further skills development, similar to a spiral curriculum philosophy where students build on basic concepts with increasing complexity. Applying previous learning to new scenarios mirrors professional practice, promoting critical thinking and problem-solving [33]. The statistically significant decline in DU-PAS scores observed across the three training stages suggests that graduates experience a reduction in perceived competence as they transition from supervised learning to independent clinical practice. While final-year students reported the strongest sense of preparedness, this confidence diminished during the house officer year and declined further among recent graduates. This pattern may reflect the realities of early clinical work, including increased responsibility, reduced supervision, and limited structured feedback. The significant differences between all three groups indicate that this reduction is not incidental, but instead represents a consistent trend requiring attention. Aligning this enabler with CCM suggests conscious incompetence, where skill gaps are identified and developed with support and supervision for progression within the model [34, 35]. Consistent with earlier studies, our research confirms that theoretical knowledge alone does not translate seamlessly into confident practice [5, 6].

Self-awareness and reflection are key enablers. Understanding strengths and weaknesses and continuously reflecting on experiences is crucial for development. Participants who identified skills they needed to develop were aware of helpful strategies and opportunities (Table 4).

Specific personality traits can enhance preparedness for practice [36]. Growth mindsets highlight the role of psychological traits in development [37, 38]. Extroverts may be more likely to seek support, build networks and actively participate, creating learning opportunities (Table 5).

Authentic experiences boost confidence and are key enablers for preparedness for practice. Learning experiences with a real-world context hold educational value, as they integrate clinical theory with technical, communication, and ethical considerations, enhancing understanding [39–41].

Barriers to preparedness for dental practice

A significant barrier was curriculum gaps, particularly the absence of essential learning experiences. Individuals entering the workforce had reduced confidence in managing complex cases, radiographic procedures, and areas like fixed orthodontics and fixed prosthodontics, indicating inadequate curriculum coverage (Table 4).

Despite confidence in theoretical knowledge, lack of practical experience hindered preparedness. Without exposure to diverse clinical cases, competence progression was stalled [34]. This aligns with CCM’s unconscious incompetence, reflected in the drop in self-perceived preparedness when participants entered the workplace [33] (Table 4).

Globally, a disconnect exists between training outcomes and workplace needs, especially in orthodontics and radiology [2, 19]. Similar curriculum gaps in Pakistan affect clinical and non-clinical competencies [42]. Mapping these findings into CCM shows that recent graduates may enter the “unconscious incompetence” stage if training in specialised areas such as paediatric care, advanced endodontics, and radiographic safety is lacking [32].

Reduced interactions with senior faculty negatively impacted preparedness to practice. Senior faculty brings clinical and academic experience that can be imparted in teaching and supervision. They serve as role models, demonstrating the professionalism, skills, and knowledge required for safe and competent practices. Without this expert guidance, students miss feedback on performance and validation of competence, which are crucial for confidence and progress [26, 30, 43]. This interaction is necessary for CCM progression; without it, students may have unrealistic perceptions of their abilities, remaining unconsciously incompetent. This affects the provision of safe patient care.

Dental schools should realign curricula with workplace competencies integrating practice management, financial literacy, regulations, advanced communication skills, and emerging technologies such as clear aligner orthodontics, digital radiography, and cone-beam- computed tomography into clinical teaching. This would ensure faculty-guided exposure to complex procedures, thus closing the gap between perceived and actual competence [29]. Curricular reform should be complemented by robust mentorship and supervision, where senior faculty and experienced clinicians guide students through clinical tasks, supported by near-peer assistance that augments, rather than replaces, expert feedback [26, 30, 31]. Expanding experiential learning through community clinics and private practices will enhance clinical reasoning, practice management, and regulatory awareness in real-world contexts. Reflective practice with learning portfolios and self-assessment tools helps identify and address limitations before independent practice. Programs should align learning outcomes with competency-based assessments to verify preparedness in the clinical, managerial, and ethical domains, fostering lifelong learning and growth mindsets for resilient, adaptable, and continuously developing dental professionals.

This study has limitations, relying primarily on self-assessment measures (DU-PAS scores and global preparedness ratings), which can be subject to over- or underestimation and social desirability bias. The validity of the MBTI in predicting professional performance is debated, offering only an approximate view of complex behaviours [44]. The cross-sectional design prevents causal inferences about how preparedness for practice evolves. These findings may not be representative of dental graduates or practitioners in different regions or cultures. Longitudinal studies following cohorts from training to practice would offer more profound insights into the development of competence.

Conclusion

This study combined the Dental Undergraduates Preparedness Assessment Scale (DU-PAS), a validated preparedness scale, MBTI personality profiling, a global perception of practice readiness, and qualitative interviews mapped to the Conscious Competence Model (CCM) to construct a multidimensional picture of Pakistani dental graduates’ preparedness for clinical practice. Preparedness scores were highest in final year students but declined among house officers and recent graduates once they faced independent clinical duties, mirroring a shift from unconscious to conscious incompetence in complex endodontics, radiography, paediatric and anxious patient management, and clinic administration. Extroverted participants reported higher confidence than introverts; however, the small effect size suggests that sociability primarily facilitated help seeking rather than reflecting superior competence. Thematic analysis identified six experiential domains, enhanced clinical exposure, structured professional development, patient care mastery, emergency management, business and regulatory knowledge, and ethical reflection, which together explained progression through the CCM competence perception stages. These findings can guide educators in timing focused curricular interventions to help learners consolidate conscious competence before entering unsupervised practice, and longitudinal follow up is recommended to evaluate the influence of such reforms on early career performance and patient outcomes.

Abbreviations

CCM

Conscious Competence Model

DU-PAS

Dental Undergraduates Preparedness Assessment Scale

MBTI

Myers–Briggs Type Indicator

SPSS

Statistical Package for Social Science

PMDC

Pakistan Medical and Dental Council

COREQ

Consolidated Criteria for Reporting Qualitative Research

BLS

Basic Life Support

CBCT

Cone Beam Computed Tomography

FCPS

Fellowship of the College of Physicians and Surgeons

ISTJ, ENFP, ENTJ

MBTI Personality Types (Introversion, Sensing, Thinking, Judging)

FY

Final–Year Undergraduate Dental Student

DH

Dental House Officer

RG

Recent Graduate

IBM

International Business Machines Corporation (related to SPSS software)

SD

Standard Deviation

Authors’ contributions

SJAZ, CD, and QAB conceived the idea of study and experimental design and data collection. SJAZ wrote the paper, QAB performed statistical analyses, and CD revised the manuscript. All authors reviewed the paper, gave final approval, and agreed to be accountable for all aspects of the work.

Funding

This study was self‑funded by the authors. This study was not funded by any agency in public, commercial or not-for-profit sectors.

Data availability

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Declarations

Ethics approval and consent to participate

This study received ethical approval from the Institutional Review Board of Dow University of Health Sciences (IRB-2854/DUHS/Approval/2023/77). Informed consent was obtained from all subjects. All experiments were performed in accordance with relevant guidelines and regulations (such as the Declaration of Helsinki).

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.