Educational Impact and Perceptions of Dental Students on a Simulated Patient Protocol at the Start of Their Clinical Practice: A Mixed Methods Study

ABSTRACT

Introduction

Simulated patients in dental education are increasingly being adopted to help bridge the gap between preclinical learning and clinical practice. They develop essential clinical and communication skills in a controlled environment, boosting students' confidence and practical application of knowledge.

Aim

The objective of this study was to assess the effectiveness of a simulated patient interaction protocol in enhancing the clinical skills and confidence of 57 third‐year dental students during their initial patient interactions, as well as its impact on achieving the learning outcomes of a one‐semester semiology course.

Methods

Using a mixed‐methods quasi‐experimental design, the study employed actors highly trained as simulated patients in four structured simulation sessions, conducted alongside students’ first five clinical sessions. The evaluation of the simulated patient protocol included pre‐ and post‐intervention quantitative perception questionnaires and qualitative focus group interviews. Further, we also compared Mini‐CEX learning outcomes clinical scores of the participating students’ clinical work, with three historical cohorts (2017 N = 78, 2018 N = 72, and 2019 N = 64) without the simulation intervention, examining student perceptions, and tracking skill progression across encounters.

Results

The intervention group achieved significantly higher overall Mini‐CEX grades compared to the historical cohorts (p > 0.0001). Students also reported statistically significant improvements in self‐assessed patient interview and examination skills, along with increased confidence. Skill progression analysis demonstrated overall improvement, though with varying trajectories across eight different learning outcomes from the semiology course. Qualitative feedback further supported these findings, highlighting the value of simulated experiences and enhanced self‐assessment.

Conclusions

Integrating simulated patient protocols alongside students’ initial clinical work in dental education is highly beneficial, reinforcing both clinical and communicative skills while boosting confidence. This approach helps to bridge the gap between theoretical knowledge and practical patient care, significantly improving skills, reducing stress, and easing the transition from classroom learning to real‐world clinical practice.

1. Introduction

Classical undergraduate dental education traditionally incorporates diverse learning methods, encompassing the acquisition of theoretical knowledge and practical skills. This approach aims to equip future dentists with competencies to independently address clinical needs along with high‐quality patient care [1]. The transition from preclinical to clinical settings presents a formidable challenge, demanding that students swiftly shift from the role of learners to responsible caregivers within a brief timeframe [2, 3, 4]. The integration of theoretical knowledge into practical skills acquired during preclinical training is vital for effective teaching and learning, significantly influencing the development of clinical competencies when working with real patients [3]. However, this transition often induces stress and anxiety [5].

To bridge this gap, simulation‐based education has emerged as a valuable avenue, acclimating dental students to real‐world scenarios within controlled environments, particularly in preclinical training [6]. The increasing recognition of the significance of patient safety in healthcare education has led to significant progress in the utilization of simulation‐based education [7]. Although unable to replace authentic experiential learning [8], healthcare simulation has evolved into a fundamental element in contemporary health profession education and training [9], showing great potential for undergraduate education [10]. Despite its benefits, simulation is often viewed as complex and poses challenges for dental students in applying their knowledge to clinical practice [3, 4, 11].

To enhance the transition from classroom to clinical practice, a more interactive form of simulation learning and assessment involving simulated patients has been integrated into healthcare education [12] since the introduction of the “programmed patient” concept by Barrows and Abrahamson in 1964 [13]. Simulated patients, also known as standardized patients or simulated participants, undergo meticulous training to consistently and realistically portray patient roles in health professional education, facilitating a uniform student experience across various domains, including communication, consultation skills, physical examination, non‐invasive procedural skills, and professionalism [14, 15, 16].

This approach offers controlled training environments, enabling students to engage in practical exercises with patients and receive targeted feedback on specific outcomes. Simulated patients have been increasingly integrated into health professional education globally [17, 18]. In dental education, simulated patients are being introduced to enhance interviewing [19] and communication skills [20, 21, 22], particularly to prepare students for their first encounter with real patients [23], and help them manage patient medical histories [24]. Studies suggest that students find simulated patient encounters advantageous [25, 26], as they build self‐confidence [27].

This mixed‐methods quasi‐experimental study aims to evaluate the educational impact and perceptions of 57 dental undergraduate students regarding a protocol involving simulated patients before and during their initial real‐patient interactions in their third‐year one‐semester semiology course. The study focuses on two key areas: first, the impact of simulation sessions on student clinical grades and self‐assessment in conducting patient interviews and examinations (quantitative component); second, students’ experiences and perceptions of their interactions with simulated patients and how these influenced their early clinical encounters practicing examination skills, based on data gathered from in‐depth focus group interviews (qualitative component). The novelty of this study lies in its comprehensive approach, as it bridges quantitative and qualitative methodologies to provide a robust analysis.

2. Materials and Methods

2.1. Ethics Approval

This study received full approval from the University of the Andes Scientific Ethical Committee (reference number: CEC202021).

2.2. Designing Standardized Case Guides and Training of Simulated Patients

Staff members meticulously crafted four distinct standardized case guides aligned with the learning outcomes (LO) of the 2022 Dental School third‐year semiology course, presenting frequent dental complaints with systemic diseases. These guides served as comprehensive instructions and rehearsals for experienced actors, each boasting over 15 years of experience as simulated patients in medical education. These guides specified the main patient complaint, session objectives summarizing the activities students had to perform, demographic characteristics of the patients (e.g., name, age, gender, educational level, socioeconomic and civil status), physical characteristics the actors needed, morbid history, and the type of clothing they were required to wear. These were not word‐for‐word dialogues. Simulated patients were trained to ensure consistent content and checkpoints while responding in natural language to students’ questions.

Clinical cases included simulation of patients presenting with:

• Mild odontalgia in response to cold stimuli and sweet foods;

• Constant high‐intensity odontalgia not subsiding with any type of intervention;

• Loose teeth with untreated type II diabetes mellitus; and

• Pain in the back of the mandible, as well as untreated hypertension.

2.3. Simulated Patients’ Sessions

The semiology course was part of the fifth‐semester dentistry program and was, therefore, compulsory for all students. Prior to participating in the simulated sessions of this course, all 57 semiology students had successfully completed the preceding courses in the program. These courses included training in communication skills, professional identity, professionalism, and patient examination techniques. As part of the course's structured educational framework, on the first day of the simulation, all students attended a comprehensive briefing in alignment with recommended best practices [7]. This briefing detailed the simulation's objectives and clarified the roles and responsibilities of both participants and observers.

For each simulation session, a fully equipped, portable, foldable dental chair unit was set up in a classroom (Figure 1) with the necessary elements for patient care. Following the explained protocol, all students in the class were required to establish a dentist‐patient relationship, thereby facilitating the effective implementation of dental care. The class was split into two groups. Both groups completed their first simulated‐patient session before any clinical exposure. Thereafter, the groups alternated weekly between simulated sessions and clinical work. Thus, while one group engaged with simulated patients, the other worked in the clinic with real patients in pairs alongside fifth‐year students. This arrangement ensured that each simulated‐patient session was conducted twice (Figure 2).

FIGURE 1.

Classroom layout during the activity. The photograph captures students assessing a simulated patient on a foldable dental chair unit.

FIGURE 2.

Diagram summarizing the study protocol.

Upon completion of the protocol, all students had executed the assigned tasks. Working in pairs (while the rest of the class observed, took notes, and awaited their turn), students were tasked with obtaining and recording a comprehensive clinical history of the patient (Figure 1). This included one of seven steps: patient's chief complaint, personal and family medical history, general physical examination (including vital sign control), extraoral head and neck physical examination, intraoral examination, suggestion of a potential diagnosis, and treatment plan options. Each pair of students completed one of these steps in every session, with diagnostic studies (radiographs, laboratory results, and other records) projected on a screen. The activity was guided by three staff members who provided feedback at each stage of the protocol.

2.4. Perception Questionnaires and Focus Group Interviews

Based on previous studies [28, 29, 30, 31, 32], and on the semiology course LO, using the instrument employed to assess students' clinical competencies aligned with these LO (Mini‐CEX, Figure 3), three researchers developed two questionnaires to evaluate students’ perceptions of simulated patient sessions. First, a pre‐ and post‐intervention learning‐outcomes questionnaire included eight items rated on a 4‐point Likert scale to assess changes in students’ self‐perceived competencies in patient interviewing and examination (Table 1). Second, an overall perception questionnaire about the simulation experience included two questions rated on a 5‐point Likert scale (Table 2) and was administered once at the end of all sessions.

FIGURE 3.

The Mini‐CEX instrument used in the study.

TABLE 1.

Students’ perception of semiology course learning outcomes (LO) before and after the simulated patient experience (pre‐ and post‐intervention LO questionnaires). A chi‐squared test was performed to assess the p value of the difference between the perceived levels of patient interview and examination skills before (N = 52) and after (N = 57) the intervention.

		Before the simulated patients’ experience				After the simulated patients’ experience
Learning outcomes		Highly competent	Competent	Somewhat competent	Not competent	Highly competent	Competent	Somewhat competent	Not competent	p value
LO1	Gather and analyze medical, social, and dental histories	2%	42%	40%	15%	35%	65%	0%	0%	< 0.001
LO2	Effectively engage in communication with patients	19%	35%	25%	21%	54%	46%	0%	0%	< 0.001
LO3	Discuss treatment plans	0%	29%	44%	27%	7%	61%	32%	0%	< 0.001
LO4	Get informed consent	17%	35%	25%	23%	33%	54%	9%	4%	< 0.001
LO5	Analyze test results and historical data to formulate a diagnosis	6%	21%	42%	31%	5%	79%	14%	2%	< 0.001
LO6	Identify and address patients’ chief complaints	8%	38%	35%	19%	53%	44%	4%	0%	< 0.001
LO7	Accurately record the clinical history in the proper sequence using appropriate terminology	2%	35%	38%	25%	53%	46%	2%	0%	< 0.001
LO8	Undertake a comprehensive clinical, physical, and oral examination	6%	44%	38%	12%	30%	65%	5%	0%	< 0.001

TABLE 2.

Students’ perceptions after the simulated patient experience (overall perception questionnaire) (N = 57).

Statement	Completely agree	Agree	Neutral	Disagree	Completely disagree
I value the experience in a positive way	89%	11%	0%	0%	0%
I am able to face real patients with greater confidence	81%	19%	0%	0%	0%

Draft versions of both questionnaires were reviewed by four semiology course faculty members and five fourth‐year dental students who previously completed the course. Feedback regarding wording and content ensured the questionnaires accurately reflected the LO of the course and were appropriate for their intended purpose. After two rounds of revisions incorporating faculty and student suggestions, the questionnaires were finalized. All 57 students were invited to voluntarily and anonymously complete the pre‐ and post‐intervention learning‐outcomes questionnaire twice: at the start and after completion of the simulated‐patient sessions and concurrent clinical work.

Volunteer students signed a written consent and completed the pen‐and‐paper questionnaires in their own time and deposited them in a drop box without the instructors' presence. Once the protocol was finalized, all students enrolled in the course were invited to voluntarily participate in the qualitative component of the study. This involved in‐depth focus group interviews, guided by phenomenological theory, aimed at exploring students’ perceptions of their experiences with simulated patients and how these experiences influenced their early clinical encounters.

A triangulation approach was employed to strengthen the validity of the findings through two interviews conducted by the same researcher (G. A.), who was not a faculty member, using a digital platform (Zoom Video Communications, San José, California, USA).

Each focus group lasted approximately 90 min. Data saturation was continuously assessed during data collection, confirming the repetition of key themes and the absence of significant new themes in the second round. Immediately after the interviews were completed, they were transcribed verbatim by the same researcher using a word processor (MS Word, Microsoft, Redmond, Washington, USA). Subsequently, two researchers (G.A. and P.V.) repeatedly read the transcribed texts and independently analyzed the data. The most significant elements in the transcripts were identified and coded using specialized qualitative analysis software (ATLAS.ti Scientific Software Development GmbH, Berlin, Germany).

Emerging themes were detected, and typologies were developed from the independently analyzed data. In cases of discrepancies between the researchers, each theme was discussed, and the differences were resolved by reaching a consensus in group meetings.

2.5. Participants and Data Collection

All 57 students enrolled in the 2022 one‐semester‐long semiology course (fifth semester) were invited to participate in the study. Given the integrated nature of the simulated patients' protocol within the semiology course curriculum, each student actively engaged in all four planned sessions. However, participation in the questionnaires and focus groups was voluntary.

To assess the impact of the simulated patients’ protocol on student learning, a comparative analysis was conducted. After completing the semiology course, the clinical grades of the 2022 students (N = 57) were compared with those of the 2017 (N = 78), 2018 (N = 72), and 2019 (N = 64) semiology courses, in which simulated patients were not utilized. In 2017, 2018, and 2019, students initiated clinical training by working in pairs with fifth‐year students immediately after the theoretical segment of the semiology course.

Grades for all four cohorts (2017, 2018, 2019, and 2022) were based on cumulative semester scores from standardized workplace‐based assessments, one per patient across five clinical encounters, using the ten‐point Mini‐CEX instrument (Figure 3), where 140 points equaled 100%. For the 2022 cohort, individual Mini‐CEX scores from all 57 students were retrieved from the Canvas LMS and analyzed for each semiology course learning outcome to assess clinical skill progression across the five clinical sessions.

The Mini‐CEX has been used in this course for over a decade to assess clinical examination skills. Prior to COVID‐19, evaluations were completed on paper; they are now integrated digitally within Canvas assignments (Instructure Inc., Salt Lake City, Utah, USA). However, due to a one‐year record retention policy, individual session data from 2019 and before were unavailable for comparison.

As a widely used assessment tool in healthcare education, the Mini‐CEX enables structured, real‐time evaluation of clinical skills in authentic settings and supports formative feedback based on observed student–patient interactions [33].

Staff members were calibrated on six occasions over the past 6 years by the School of Dentistry Education Office to ensure consistent application of the assessment. A total of 11 staff members conducted the assessments. Students were evaluated by different assessors who were randomly assigned for each clinical encounter. After each of their five clinical encounters with real patients, students received immediate feedback. The same trained staff members evaluated the students in all years.

Data from the 2020 and 2021 semiology courses were excluded due to the altered format resulting from the COVID‐19 pandemic.

2.6. Data Analysis

All Likert‐scale questionnaire responses were first analyzed using descriptive statistics. The internal consistency of the pre‐ and post‐intervention learning‐outcomes questionnaires was assessed using Cronbach's alpha. Changes in students’ self‐perceived competencies were examined with chi‐square tests comparing pre‐ and post‐intervention responses. The overall perception questionnaire was analyzed using the same approach.

To compare Mini‐CEX cumulative grades between the 2017 (N = 78), 2018 (N = 72), 2019 (N = 64), and 2022 (N = 57) courses, three tests were used. First, a one‐way ANOVA test assessed differences in mean Mini‐CEX scores between 2017, 2018, and 2019. Second, an independent‐samples t‐test compared the mean Mini‐CEX scores from 2022 with those from all earlier cohorts (2017–2019 pooled). Significance was set at p < 0.05. Third, the effect size (Cohen's d) was calculated to report the magnitude of the difference between 2022 scores and those from earlier years combined.

For the 2022 cohort, repeated‐measures ANOVA was used to analyze Mini‐CEX scores by learning outcome across the five clinical sessions, tracking progression in clinical skills throughout the semiology course.

The data were organized into Microsoft Excel spreadsheets (Microsoft Excel, Microsoft Inc., Washington, USA) and statistically processed using the Statistical Package for Social Sciences Windows version 27 (SPSS IBM Inc., USA).

Two researchers (G.A. and P.V.) studied all qualitative comments from the students’ focus groups, identifying, analyzing, and reporting patterns to form themes and dimensions.

3. Results

Each of the eight simulation sessions lasted approximately 4 h, including a 15‐min break. The pre‐intervention questionnaire received responses from 52 students (91%; 41 females and 11 males), while the post‐intervention questionnaire was completed by all 57 students (100%; 44 females and 13 males). The mean age of the students was 21 years (SD = 1.1). The reliability of the pre‐intervention and post‐intervention questionnaires was 0.790 and 0.802, respectively, indicating a good level of internal consistency.

Table 1 presents the results of the pre‐ and post‐intervention questionnaires, which assessed students’ self‐perceived competencies in patient interview and examination skills, aligned with the courses LO. After the simulated patient sessions, students reported a statistically significant improvement across all LO (p < 0.001). The most notable gains were in LO1 (gather and analyze medical, social, and dental histories) and LO2 (effectively engage in communication with patients), where initial self‐ratings of highly competent or competent were 44% and 54%, respectively, and increased to 100% post‐intervention. These results suggest that the simulated patient experience was particularly effective in building confidence in foundational clinical skills.

While all outcomes showed significant improvement, smaller gains were observed in LO3 (discuss treatment plans) and LO5 (analyze test results and historical data to formulate a diagnosis), indicating that these complex reasoning skills may benefit from additional instructional reinforcement. Overall perception questionnaire (Table 2) showed strong student support for the simulation protocol: 100% of students endorsed both statements, valuing the experience and reporting greater confidence to interact with real patients.

Analysis of Mini‐CEX grades further supports these findings. The one‐way ANOVA test revealed no significant differences (F = 2.24, p = 0.60) in mean Mini‐CEX scores among those from 2017, 2018, and 2019 when simulated patients were not used. In contrast, the independent‐samples t‐test showed students from the 2022 cohort (N = 57), who participated in the simulated patient sessions, achieved significantly higher cumulative clinical scores (Mean = 79%, SD = 6.4) than the combined earlier 2017 (Mean = 66%, SD = 7.3), 2018 (Mean = 67%, SD = 5.4), and 2019 (Mean = 69%, SD = 4.3) cohorts without simulation; p < 0.001). Cohen's d effect size (1.52) confirms that the 2022 cohort performed better than earlier cohorts.

Expanding on this, Table 3 presents Mini‐CEX scores for the 2022 cohort analyzed by learning outcome across five clinical sessions. A clear improvement was observed from Session 1 to Session 5. The highest scoring outcomes after the simulated‐patient sessions were related to effective patient communication (LO2) and identification and management of patients’ chief complaints (LO6). LO2 began with the highest baseline score (77%), suggesting early proficiency and consistent refinement. Conversely, cognitively demanding competencies, such as discussing treatment plans (LO3), formulating diagnoses from test results (LO5), and obtaining informed consent (LO4), scored lower overall. This highlights the challenge students face in applying complex decision‐making skills, particularly during early clinical encounters.

TABLE 3.

Results of the 2022 course's session‐by‐session average grades for each learning outcome (LO), assessed via the Mini‐CEX instrument across five clinical encounters with real patients. A repeated‐measures ANOVA was conducted to determine the statistical significance of differences between sessions for each LO.

Learning outcomes		Clinical sessions					p value
		1	2	3	4	5
LO1	Gather and analyze medical, social, and dental histories	73%	79%	89%	89%	92%	< 0.001
LO2	Effectively engage in communication with patients	77%	85%	92%	96%	97%	< 0.001
LO3	Discuss treatment plans	54%	61%	69%	75%	80%	< 0.001
LO4	Get informed consent	54%	59%	65%	68%	75%	< 0.001
LO5	Analyze test results and historical data to formulate a diagnosis	56%	63%	71%	76%	79%	< 0.001
LO6	Identify and address patients’ chief complaints	75%	85%	93%	97%	96%	< 0.001
LO7	Accurately record the clinical history in the proper sequence using appropriate terminology	71%	74%	81%	86%	89%	< 0.001
LO8	Undertake a comprehensive clinical, physical, and oral examination	75%	81%	87%	89%	91%	< 0.001

Score improvement rates varied across outcomes. LO3 (discuss treatment plans), despite a lower initial performance, showed the greatest overall gain (+26 percentage points), reflecting strong growth following early difficulty. LO4 (get informed consent) also improved from a low baseline score (54%–75%) but at a slower pace. Meanwhile, LO2 (effectively engage in communication with patients) and LO8 (undertake a comprehensive clinical, physical, and oral examination) showed more modest score gains, consistent with their high initial proficiency and lower room for improvement.

Overall, Mini‐CEX performance closely mirrored the patterns seen in students’ self‐perceptions (Table 1). Competencies initially perceived as challenging (e.g., LO3 and LO4) showed slower but measurable progress in their Mini‐CEX scores along the five clinical sessions, while those associated with higher confidence (e.g., LO2 and LO8) showed both high self‐perception and robust and steady Mini‐CEX scores across clinical sessions (Table 3).

Finally, students’ experiences of the protocol were explored through two in‐depth post‐simulated‐patient intervention focus group interviews involving 16 volunteers from the 57 students enrolled in the semiology course, divided into a first group of nine and a second of seven participants. These sessions provided deeper insight into how simulated patient encounters shaped students’ readiness for real clinical interactions and contributed to their skill development.

Data saturation was achieved following the second focus group, with recurring themes such as the importance of feedback, communication skills, and anxiety during interactions with simulated patients. As the data sufficiently addressed the research questions, no additional interviews were deemed necessary.

Four thematic areas emerged from the analysis: (1) students’ perceptions of the protocol, (2) acquisition of clinical performance skills, (3) emotional well‐being of students, and (4) feedback to the students. These themes, along with their sub‐themes, are comprehensively detailed in Table 4, which highlights the diverse dimensions of students’ experiences and underscores the multifaceted impact of the simulated patient protocol.

TABLE 4.

Themes and emerging subtopics, dimensions, and representative quotes from the focus groups.

Themes and emerging subtopics	Dimensions	Quotes
Students’ perceptions of the protocol
Characteristics of the presented clinical cases	Similarity to reality and performance of the actors in the simulated clinical cases	“In all instances, I forgot that the person in front of me was acting because they really did it so well; it was super real. ” (Female student, 20 years old).
Evaluation of simulated patient activity	Positive aspects of activity	“I believe it wouldn't have been the same without the activity. I wouldn't have learned the clinical record's order as well as I did with the simulated patients. I think students should start with that and then send them to the clinic.” (Female student, 20 years old).
	Areas for improvement	“I would propose more complex clinical cases, such as uncooperative patients, challenging situations, or rare pathologies. Specifically, facing situations that make us uncomfortable” (Male student, 20 years old). “I would suggest that the activity with simulated patients be conducted in the clinic to have the complete trial scenario” (Female student, 20 years old).
Acquisition of clinical competence skills
Theoretical and practical knowledge and skills	Theoretical elements of the clinical history	“The simulated patients helped us learn the order of the clinical record and helped us identify relevant aspects of what we examined in real patients.” (Male student, 21 years old).
	Physical examination of the patient	“It was very helpful for me, especially in the part of taking vital signs and in muscle palpation. Trying out all the instruments on the actors and knowing how to examine them was super important for me as it would help me to do it well on a real patient in the clinic” (Male student, 20 years old).
	Patient communication skills	“The theoretical lectures were not enough for me to develop any kind of communication with the patient. The way to interact with the patient was learned through the activity with simulated patients, not the theoretical lectures.” (Female student, 21 years old).
Knowledge about the clinical setting	Knowledge of working areas and the use of personal protective equipment (PPE)	“The activity was very helpful to me because it made us realize the use and importance of personal protective equipment (PPE), the use of light, work areas, knowing what to do with sterile instruments, etc. Before going to the clinic, I didn't know how to do it or how to handle the elements of care” (Female student, 20 years old).
	Other aspects related to the clinic	“When you arrive at the clinic, no one tells you anything. You don't know where to go; you are completely lost. They assume you know everything, and I didn't even know where to request personal protective equipment” (Female student, 22 years old)
Emotional well‐being of students
Stress and anxiety of students	Anxiety and stress when facing real patients for the first time	“I think having the simulation and then going back to the clinic helps a lot. I wasn't anxious, I wasn't nervous. Having just one simulation already helped me a lot to reduce my stress.” (Female student, 21 years old).
Confidence and safety of students in the clinic	Contribution of the protocol to the student's confidence	“The practice with simulated patients, along with the support of the teacher, one gains confidence in oneself, in trusting that the knowledge one has is correct [.] I, with the simulated patients, gained confidence in what I knew, and that helped me in the clinic.” (Female student, 20 years old).

Feedback to the students
From the instructors	From the teacher of the deliberate practice protocol	“In the entire activity, the teacher is there and corrects you, giving us immediate feedback on what we need to improve” (Male student, 21 years old).
From the simulated patient	Feedback from the actors at the end of the activity	“The feedback from the actress was very positive, and it helped me a lot to reduce nervousness… That way, we knew what things we needed to improve on.” (Female student, 20 years old).

4. Discussion

This mixed‐methods study evaluated the impact of a simulated‐patient protocol on third‐year dental students’ preparedness during their transition from preclinical learning to real patient care. Focusing on a semiology course, the study examined both educational outcomes and students’ perceptions, analyzing changes in clinical grades and self‐assessed competencies in patient interview and examination skills. The findings support structured simulated patient encounters, integrating communication and physical examination skills development, and promote a smoother, more confident shift into clinical practice by providing a realistic yet safe learning environment.

Key outcomes indicate significant improvements in students’ self‐assessed interview and examination skills (Table 1). Post‐intervention questionnaire data aligned with qualitative insights from focus group discussions on communication and physical examination skills (Table 4). Following the intervention, 100% of students reported feeling “highly competent” or “competent” in both gathering and analyzing medical, social, and dental histories (LO1) and communicating effectively with patients (LO2), compared to just 44% and 54%, respectively, beforehand (Table 1). This positive evaluation closely reflects the findings of Hannah et al. [23], who reported that dental students highly valued a communication skills course using simulated patients and felt it meaningfully enhanced their clinical techniques.

The relevance of communication skills in dental education is underscored by studies such as Woelber et al. [34] and Kruse et al. [21], emphasizing its critical role in successful interactions between dentists, students, and patients. Consistent with Patel et al.’s [24] findings, the significant improvement in gathering and analyzing medical histories aligns with the enhanced competency reported after simulated geriatric patient interactions.

The smaller improvement observed in students’ self‐assessed competence for LO3 (discuss treatment plans), compared to LO1 and LO2, suggests that while students gained confidence in technical and communication skills, the ability to effectively discuss treatment plans, requiring the integration of clinical reasoning with patient communication, may need additional clinical and simulation‐based training [35]. This aligns with Denniston et al. [36], whose systematic review highlighted that fragmented teaching often fails to bridge reasoning and communication, resulting in persistent performance gaps. Similarly, the Clinical Reasoning in Medical Education consensus statement emphasizes the need for integrated curricular strategies to foster real‐world clinical synthesis [37].

Likewise, less pronounced gains in LO4 (get informed consent) and LO5 (analyze test results and historical data to formulate a diagnosis) revealed further challenges. Despite LO4's seemingly straightforward nature, 9% of students still rated themselves as ‘somewhat competent’ and 4% as ‘not competent’ post‐intervention. This may reflect the complexity of the consent process, which goes beyond form‐signing to include ethical, communicative, and legal dimensions that students find difficult to navigate [38]. Similarly, for LO5, while perceptions improved, 14% of students still felt ‘somewhat competent’ and 2% ‘not competent,’ underscoring the high cognitive demand of diagnostic reasoning. This is consistent with its relatively lower Mini‐CEX mean score (69%), supporting prior evidence that diagnostic competence develops gradually and benefits from additional structured learning [39, 40]. Despite the challenges posed by diagnostic reasoning, simulation, particularly with simulated patients, is widely recognized as an effective method for developing clinical competence, including diagnostic skills [12]. It offers students the opportunity to analyze case information and practice diagnostic formulation in a safe, structured setting.

Nonetheless, self‐assessment results indicate that combining clinical reasoning with communication (LO3), managing analytical/diagnostic tasks (LO5), and navigating the informed consent process (LO4) remained areas of relative difficulty even after the simulation protocol. These findings suggest that further instructional support may be needed to reinforce these more cognitively demanding skills.

Importantly, students in 2022, who completed four simulated‐patient sessions, achieved significantly higher cumulative Mini‐CEX scores (p < 0.0001) than the pre‐simulation cohorts (2017, 2018, and 2019). The analysis of the Mini‐CEX outcomes from these three consecutive cohorts, which did not differ significantly from one another (p = 0.60), indicates a stable baseline before introducing simulation. This improvement, associated with a large effect size (1.52), may be attributed to the enhanced learning experience provided by simulated patients.

These results align with Williams and Song [12], who emphasized the value of simulated patients in developing technical competencies. They also reflect Kruse et al.'s [21] findings of improved empathy and Woelber et al.'s [34] support for the role of simulation in clinical communication assessment. While McKenzie et al. [41] found limited benefits from a single standardized patient encounter, our study involved four structured simulated‐patients sessions, which may have contributed to more durable LO. Broder et al. [42] similarly found that communication improvements were sustained after three instructor‐led patient interviews, supporting the lasting impact of repeated, structured simulation.

The analysis of 2022 Mini‐CEX scores by learning outcome (Table 3) further revealed differentiated learning trajectories across clinical competencies. Mean scores rose from 67% in Session 1 to 87% in Session 5, reflecting progressive skill development. Foundational skills such as LO2 (communication), LO6 (addressing chief complaints), and LO8 (physical and oral examination) showed substantial gains and high final proficiency levels.

These results are consistent with Bock et al. [22], who demonstrated that targeted communication training with simulated patients significantly improved students' ability to ask open‐ended questions and perform well in clinical evaluations. Similarly, Wu et al. [43] reported that 100% of students exposed to situational simulation teaching felt more capable of communicating and understanding patient needs, reinforcing the efficacy of simulation in enhancing essential clinical communication competencies.

LO8 (physical and oral examination), beginning from a high baseline of 75%, improved moderately to 91%, reflecting steady refinement of early proficiency rather than dramatic gains. A similar trend was observed in LO7 (accurately record clinical history), which rose consistently from 71% to 89%. In contrast, outcomes involving complex clinical reasoning, LO3 (discuss treatment plans), LO5 (formulate a diagnosis), and LO4 (get informed consent), yielded comparatively lower overall scores. These results likely reflect the difficulty students face in integrating knowledge, decision‐making, and patient communication, especially during the transition to clinical practice, a challenge well documented in the literature [2, 35, 36]. Notably, LO4, which combines communication, knowledge, and ethical reasoning, had the lowest overall mean (64%), starting from a low baseline of 54%.

Improvement rates also varied across LO. LO3, despite its initial difficulty, showed the largest gain (+26 percentage points), reaching 80% by Session 5. This suggests that students benefited from repeated practice and feedback provided through the simulation protocol and parallel clinical exposure, an approach consistent with deliberate practice theory in skill development [44]. LO4 also improved from the same baseline (54%) but at a slower pace (+21 percentage points), indicative of the multifaceted nature of obtaining informed consent [38].

These patterns reflect established models of skill acquisition, where learning trajectories vary based on task complexity and prior familiarity [45]. Skills requiring intricate reasoning (LO3, LO4, and LO5) typically evolve gradually with experience [39, 40].In contrast, interpersonal or procedural competencies (e.g., LO2, LO6, and LO8) displayed early proficiency, followed by steady improvement, leaving less room for large percentage increases.

These findings underscore the need to tailor instructional strategies to the developmental pace of each competency. Areas like LO3, LO4, and LO5 may benefit from targeted interventions, such as guided practice and integrated simulation, while higher‐performing areas like LO2, LO6, and LO8 can emphasize refinement and mastery. Overall, this differentiated approach can guide future curriculum design to ensure students receive the necessary support to achieve all intended LO effectively [44, 45].

Students’ self‐perceived competence before and after the simulated patient sessions (Table 1) strongly mirrors the objective Mini‐CEX findings. Areas initially perceived as difficult, particularly LO3 (discuss treatment plans) and LO4 (get informed consent), remained relatively lower in perceived competence, consistent with their more gradual performance gains. In contrast, skills such as LO2 (communication) and LO8 (physical and oral examination), where students expressed early confidence, showed high post‐intervention self‐assessments and strong Mini‐CEX scores, reflecting early proficiency followed by steady refinement.

Qualitative data from focus groups reinforced these trends. Students credited the simulations with providing essential hands‐on experience, such as “taking vital signs,” “muscle palpation,” and “trying out all the instruments,” and emphasized that patient interaction skills were “learned through the activity with simulated patients, not the theoretical lectures” (Table 4).

Overall, students expressed highly positive views of the simulated patient experience: 89% completely agreed and 11% agreed that it was valuable, while 81% completely agreed and 19% agreed it boosted their confidence to interact with real patients (Table 2). These sentiments were echoed in focus group discussions, which highlighted the realism and engagement of the clinical cases. However, students also expressed a desire for exposure to more complex cases, suggesting opportunities for future curricular enhancement.

A particularly notable benefit was the reported reduction in student stress and anxiety, a theme emerging in both the. Overall perception questionnaire and focus groups (Tables 2 and 4). This finding aligns with prior studies emphasizing the confidence‐building effects of simulated patient interactions [23, 27]. Feedback emerged as a critical learning mechanism, with students valuing input from both instructors and simulated patients. This is consistent with prior findings, including McKenzie et al. [46], who noted improvements in patient care linked to structured feedback and debriefing. In our study, feedback was a recurring theme (Table 4), allowing students to identify and improve upon weaknesses, echoing the conclusions of Williams and Song [12], who highlighted feedback as central to simulation effectiveness.

While the mixed‐methods design and high participant engagement strengthen the study, limitations remain. The use of non‐randomized historical cohorts limits causal inference. Future randomized or stepped‐wedge studies are needed to isolate causality and confirm these findings. Long‐term follow‐up could assess the durability of skill and confidence gains. In addition, the cost of implementing simulated patient programs and the context‐specific nature of the study may limit generalizability. Finally, the use of a 4‐point Likert‐type scale in the pre‐ and post‐intervention learning‐outcomes questionnaire may have constrained students' ability to fully express nuanced perceptions.

5. Conclusion

The findings of this study underscore the high effectiveness of integrating a structured simulated‐patient protocol into dental education. Employing a mixed‐methods approach, which combined quantitative measures such as student grades and self‐assessed competencies with qualitative insights into student experiences, yielded a thorough analysis. This approach proved crucial in investigating the impact of simulated patients on dental students during a pivotal educational phase: the transition from theory to clinical practice. The study demonstrates through significantly improved clinical assessment scores and enhanced self‐perceptions that simulated patient experiences can significantly elevate students’ clinical and communication skills, boost their confidence, and alleviate anxiety and stress. These results hold particular significance, emphasizing the vital role of simulated patients in helping bridge the gap between preclinical training and real‐world patient care. In particular, the study highlights the multifaceted advantages of this educational strategy in dental education.

Conflicts of Interest

The authors declare no conflicts of interest.