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Dental Clinical Teaching: Perceptions of Students and Teachers

Key words: dental clinical teaching, student/clinical teacher relationship, clinical supervision, professional skills

Submitted for publication 04/08/05; accepted 08/23/05

	Abstract

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The objective of this study was to explore perceptions of dental student clinicians and clinical teachers about dental clinical teaching to provide primary data for dental researchers and educators. Student focus group data provided background for development of a questionnaire that explored three themes related to clinical teaching. Twenty-one teachers and forty-five student respondents completed the twenty-five-item questionnaire in 2003. In the theme of the teacher/student relationship, no statistically significant differences were seen between teacher and student group perceptions. In the theme of educational theory applied in dental clinical teaching, a statistically significant difference was seen between teacher and student groups in the value of preclinical instruction in senior clinical years and in the value of a clinical log book. In the theme of skills required for clinical dental practice, a statistically significant difference was seen between teacher and student groups in the value of a critical appreciation of evidence-based practice as one of the skills. The study overall indicates that the dental clinical learning environment supports close perceptual conformity between students and clinical teachers in regard to what each group considers to be "good practice" in clinical teaching. The findings of this study indicate that some techniques that have been advocated to enhance clinical learning, such as evidence-based teaching methods, require further investigation.

The learning environment of the clinic or hospital is a challenging area for both teacher and student. In this setting, the student is a trainee clinician responsible for patient care, and the clinic is both a patient care facility and a learning environment. In clinic, students are expected to demonstrate diverse competencies simultaneously, including a range of skills, broad knowledge base, professionalism, and empathic ethical behavior. Recent reports in dental education point to the value of the early introduction of students to the clinical environment, largely because of the demonstrated value of contextual learning and the facilitation of integration of knowledge from basic to clinical sciences.¹ Clinical teaching typically involves the supervision of a trainee clinician by an experienced clinician, and as a consequence, clinical education usually involves a range of teaching modes. Clinical supervision may be defined as the "provision of monitoring, guidance, and feedback on matters of personal, professional, and educational development in the context of patient care."³ The student/clinical teacher relationship has also been suggested to mirror the therapeutic alliance that exists between patient and physician because it represents an educational alliance.⁴

Clinical teaching in medical education has been extensively examined.⁵ Effective medical clinical teachers are considered to be those who have empathy, are capable of providing support, exhibit flexibility, and have the ability to gauge student development, in addition to being interpretive, focused, and practical.³ Effective supervision of learners involves problem-solving by students and instructors together, along with feedback, reassurance, and theory-practice linking.⁶ There is preliminary evidence that effective clinical teaching in medicine may have a positive impact on patient outcomes. For example, Fallon et al. found that patient outcomes improved when direct supervision of the student clinician is combined with focused feedback.⁷

In a dental education context, clinical teaching has been less extensively examined, for example, by O’Connor et al.⁸ Effective clinical instruction in dentistry is associated with meeting teaching responsibilities, behavior conducive to clinical learning, technical competence, and work enjoyment.^7,9 The ability to motivate students, explain difficult concepts, display interest in the subject, show compassion and caring, and be proactive was also highly rated by students in a study reported by Chambers et al.¹⁰

Clinical teaching in dental programs is supported by a range of educational modalities supporting patient care such as large group (e.g., lectures), small group (e.g., tutorials), collaborative (e.g., PBL), clinical case-based, interactive (e.g., role play), simulation, and computer-assisted modalities. The perceived value of these modalities to clinical teaching and learning in dentistry can be considered in the light of making efficient use of teaching resources, being able to objectify clinical sessions, facilitating development of professional attributes, sharing common clinical concerns, and affording a degree of individual student interaction.¹⁰

This study presents the findings of an investigation of clinical teaching in an Australian dental school. A survey was used to elicit the perceptions of the central partners in that environment—namely, the students and the teachers. The study was implemented to test the hypothesis that these two groups have different views of the value of teaching methods to prepare students for independent clinical practice.

	Methods

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Two student focus groups were conducted in 2003 during a teaching semester to provide background for development of the questionnaire. The focus group discussions explored student ideas and perceptions about clinical teaching in dentistry. Volunteers for each of the two focus groups came from students enrolled in the new curriculum for the Bachelor of Dentistry (B.Dent.) program and from students enrolled in the older curriculum for the Bachelor of Dental Surgery (B.D.S.) program at the Faculty of Dentistry, University of Sydney. These programs are described in detail elsewhere.^11,12 Briefly, the B.D.S. program was a five-year, discipline-based program featuring a range of teaching styles such as lectures, seminars, and case-based learning. The B.Dent. program, which commenced in 2001, is a four-year competency-based program using problem-based learning (PBL) throughout the program. Clinical teaching styles used in both B.D.S. and B.Dent. programs are similar; dental clinician teachers provide close supervision of students in both.

One focus group consisted of four B.D.S. students; the other focus group consisted of four B.Dent. students. Each focus group discussion was one to three hours in length. This number of participants, which allowed discussion to proceed efficiently, reflects recommendations for composition of participatory focus groups.¹³ The focus group participants identified several aspects of clinical teaching that were united into three themes and that together were structured into a set of questionnaire statements used for data collection. These three themes were 1) the teacher/student relationship, 2) educational theory applied to dental clinical teaching, and 3) skills important for dental clinical practice. An example of a questionnaire item in the theme of "educational theory applied to dental clinical teaching" was the following: "small group teaching, such as tutorials, are valuable to the development of dental clinical skills." Questionnaire statements grouped into this theme were those that reflect evidence-based teaching practice and are applicable in a broad range of teaching, such as PBL teaching and formal lectures. Items presented in the other two themes of the questionnaire were constructed to be more uniquely relevant to the type of teaching that occurs within dental clinical sessions, when student clinicians complete patient care, such as clinical demonstrations of patient care and clinical interactivity. An example of a questionnaire item in the theme of "the teacher/student relationship" was the following: "empathic guidance from the clinical supervisor supports student preparation for independent practice of clinical dentistry." The final theme explored in the questionnaire was the range of skills required for clinical practice, namely decision-making skills, technical fine-motor skills, communication skills, broad knowledge base, critical appreciation of evidence-based practice, and skills in self-assessment and self-confidence. An example of a questionnaire item in this theme was the following: "whilst many skills are important for dental clinical practice, the most important part of dental clinical practice is decision-making."

The questionnaire utilized a six-point Likert attitude scale providing responses ranging from 1 (always agree) to 6 (strongly disagree) and was refined based on the qualitative data derived from focus group discussions. The questionnaire featured twenty-five items about dental clinical teaching. These statements appear in the left hand columns of Tables 2, 3, and 4. These statements aimed to determine the strength of agreement with some of the comments made during the focus group discussions in regard to the usefulness of various dental clinical styles employed by faculty.

	Results

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Comparisons of teacher and student perceptions of clinical teaching styles in regard to the application of educational themes are shown in Table 3. Two of the comparisons of results for teachers and students in this theme were statistically significant. Students and teachers expressed significantly different levels of agreement for the statement that there was a clear link between theory and clinical practice in the program (P<0.0029) and that a clinical log book was valuable for the preparation for clinical practice (P<0.0038). In regard to the theory/practice link, only 19 percent of teachers agreed, whereas 63 percent of students agreed with the statement. In regard to the clinical log book, students were divided in their view of the merit of this learning aid (27 percent agreed, 21 percent disagreed), whereas a majority of teachers were in agreement (46 percent, with 14 percent disagreement). These data also show that, in three of the ten statements presented in this theme, teacher and student groups showed a very similar direction and level of agreement with the statements listed. These three items were: the value of preclinical instruction (greater than 83 percent agreement in both student and teacher groups), benefit of small group teaching (greater than 52 percent agreement in both student and teacher groups), and the value of continuous assessment (as opposed to assessment at session end) through a clinical session (greater than 56 percent agreement in both student and teacher groups).

The data for skills important for dental clinical practice are shown in Table 4. Only one of the comparisons between results for teachers and students in this theme was statistically significant (P<0.0013). This statement was that a critical appreciation of evidence-based practice was an important part of dental clinical practice; 66 percent of teachers agreed (and no teachers disagreed) with this statement, whereas only 42 percent of students agreed and 20 percent disagreed.

	Discussion

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The learning environment of the clinic challenges the roles and responsibilities of both the learner and the clinical teacher substantially. The clinical teacher can be seen as role model, assessor, confidante, and facilitator for the student clinician. Valuable supervision is characterized by joint participation in decision making, shared vision, open access, and creative tension. Positive effects of these interactions can be seen in improved patient outcomes⁶ and student recognition of teacher effectiveness. In light of this, a mission for dental education ideally includes the enhancement of the education-care delivery relationship, even greater patient-centeredness, comprehensive care experiences, and teaching and learning reform encouraging reflective clinical practice.

The current study explored student and clinical teacher views of clinical teaching from three areas: the clinical teacher/student relationship, the application of educational theory in dental clinical teaching, and skills important for dental clinical practice. An overall significant level of alignment of views held by students and teacher was seen in the data presented. This common view of students and teachers in so many areas was unexpected and probably reflects the very close and cohesive relationship between clinical teachers and students fostered in that setting. It may also reflect the strong influence of teachers on students’ views. The intensity of the clinical environment may reinforce the tendency of teachers to teach in a way that has been perceived successful in terms of patient outcome and service needs in their own experience. It may also reflect a tendency of teachers to recognize and adopt a style of teaching they themselves experienced as student clinicians that is sometimes described as a teacher-centered style.¹⁴

In the clinical teacher/student relationship, an aspect of dental clinical teaching that the focus group participants frequently mentioned was "clinical demonstration." During a clinical demonstration, which occurs in the clinic during a patient clinical care session, a clinical teacher provides patient care whilst a student (or students) observes the procedure. Students in the focus group said this was one of the best forms of clinical teaching as it allowed students to "see how things are done so that you can understand them." Students value seeing the "expert" completing the task that they will be expected to complete over time and with practice. In direct reference to a clinical demonstration by a clinical supervisor, an illustrative comment in the student focus groups was: "It is very helpful to see theory work applied or demonstrated as this adds depth and reinforces the theory." Another student called this "interactive teaching," saying "there is a need for more interactive learning environments and demonstrations to reinforce clinical and theory. There is an appreciation for these but a demand for more." Questionnaire data supported the view that this style of teaching was perceived as a valuable teaching style by both teachers and students.

Another aspect in the theme of the clinical teacher/student relationship highlighted by the focus group discussions was the nature and level of interaction between clinical teacher and student during patient care. This complex aspect refers to a balance between student self-confidence in providing patient care independently and teacher interactivity (or assistance) in that care when required. This balance can represent a strong tension in the dental teaching clinic at times and is a likely motivator in the progression of clinical skill acquisition by the student clinician. This balance illustrates an example of a motivator described in the Dreyfus model of skill acquisition.¹⁴ This model describes progression from novice (reliance on rules, no discretionary judgment, and little situational perception) to expert (no reliance on rules, analytical approach only in novel and problematic times, intuitive approach based on deep understanding). These motivators—self-confidence and perception of competence—have been considered by Stewart et al.¹⁵ in medical students. These authors used a modified Delphi technique with a qualitative analysis to clarify house officers’ perceptions of these two important motivators, with an ultimate goal of designing a self-evaluation instrument. In view of the association with quality of patient care and development of professional attributes in clinicians, a clearer understanding of the relationship between self-confidence and motivation and how these factors influence students’ progression from novice to expert is an important avenue for future study.

The second theme explored in our study was that of the application of aspects of educational theory to dental clinical teaching. In the context of this study, this theme included clinical simulation, collaborative small group teaching, the use of log books to track student work, authentic student evaluation, and student-teacher debriefing after active teaching sessions as aspects of teaching styles adapted for use in dentistry from other educational fields. In our study, both student and teacher groups demonstrated an awareness of teaching styles reflecting educational theory. For example, a majority of respondents in both student and teacher groups strongly agreed that preclinical instruction was essential for student preparation for independent clinical practice. A smaller majority of respondents in both student and teacher groups agreed that small group teaching, grading of students during patient care sessions, and debriefing sessions with students and their clinical teachers were valuable in preparing students for independent clinical practice. A relative ambivalence by the majority of respondents on the value of PBL supports the findings of Colliver, although neither students nor faculty reported extensive current or past experience with this modality.¹⁶ The link between theory and practice is a central one in education, but in this study, more students than teachers perceived that the link was apparent in the program. The very central issue of evaluation of students in teaching and learning was also broached in our study, presented here in the issue of grading. Both teacher and student groups saw an important purpose in evaluation of student competence in clinical sessions, but neither group clearly agreed nor disagreed with the use of grade descriptors such as "pass" and "fail."

Teacher and student perceptions about the most important professional skills for dental clinical practice was the final theme considered in the study. Again, a level of similar strength and direction of view was seen in the two participant groups, with almost coincident high support for communication, decision making, and fine-motor skills. The study supports the observations of Werb and Matear¹⁷ in a recent review reporting the challenges in implementing evidence-based practice in dental education. That study notably reported the superior performance in national board examinations of dental students from PBL-based programs that emphasize evidence-based practice, but also proposed a comprehensive model for implementation.

It is likely that well-planned and innovative teaching adapted to the realities of the dental clinic would have a positive influence on student preparation for independent practice. PBL has been reported to have only modest effects on development of clinical skills, but it has been associated with student satisfaction with teaching and development of appropriate learning skills.^18,19 A well-structured student record of clinical accomplishment, such as a log book, enables provision for self-reflection in addition to an achievement in clinical services and has been favorably evaluated by medical students.²⁰ Enhancing the clinical learning environment in strategic ways has also been considered in the medical context and provides good advice for the dental clinical learning environment as well.²¹ The current study demonstrates that students and teachers value the clinical teaching styles they have experienced and also believe that prevailing teaching strategies serve to adequately prepare students for independent clinical practice in dentistry.

Many clinical teaching guidelines from the literature are relevant to clinical education in dental schools. Tiberius et al. suggested the following: reflection on assumptions underlying teaching; establishment of an early alliance with students by setting goals; building of trust and recognition; and addressing transference.⁴ To this, Gordon et al. have added understanding of the purpose and process of learning in a clinical environment and encouragement of students to develop "survival skills" given the range of climates in clinical settings.²¹ The current study has, in addition, shown that teachers and students valued the following characteristics of dental clinical teaching: empathic guidance, provision of objectives for the clinical session, discussion of alternative clinical treatments, clinical demonstrations, and continuous clinical feedback by the supervisor.

Guidelines for program directors responsible for organizing dental clinical programs are another valuable aspect. Tiberius et al. suggested assigning students to clinical teams that will unite individuals who interact well; revision of policy on factors that maintain power differentials between students and supervisors when these differentials serve no valuable purpose; and use of faculty development programs to enhance faculty skills pertinent to clinical teaching and mentorship.⁴ The current study points to the value of providing time and resources for clinical demonstrations, faculty development in empathic skills, and the restructuring of clinical sessions to include time for discussion of clinical objectives, clinical alternatives, adequate feedback, and clinical demonstrations. Providing faculty development related to evidence-based teaching and motivators for clinical learning may further illuminate the clinical learning environment for clinical students, clinical teachers, and classroom educators alike.

	Footnotes

 
Dr. Gerzina is a Senior Lecturer in the Faculty of Dentistry, University of Sydney, Sydney, Australia; Dr. McLean is a general dental practitioner, Sydney NSW, Australia; and Ms. Fairley is Assessment and Administration Officer, Faculty of Dentistry, University of Sydney, Sydney, Australia. Direct correspondence and requests for reprints to Dr. T.M. Gerzina, Faculty of Dentistry, University of Sydney, 2 Chalmers Street NSW 2010, Sydney, NSW, Australia; 612-92115912 fax; tgerzina{at}usyd.edu.au.

This project was supported by a grant from the Australian Dental Research Fund.

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