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Students’ Perceptions of Effective Learning Experiences in Dental School: A Qualitative Study Using a Critical Incident Technique

Key words: dental students, dental education, curriculum

Submitted for publication 08/02/05; accepted 10/14/05

	Abstract

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Students’ views of their educational experience can be an important source of information for curriculum assessment. Although quantitative methods, particularly surveys, are frequently used to gather such data, fewer studies have employed qualitative methods to examine students’ dental education experiences. The purpose of this study is to explore characteristics of effective learning experiences in dental school using a qualitative method. All third-year (seventy) and fourth-year (seventy) dental students enrolled in one midwestern dental school were invited to participate. Fifty-three dental students (thirty-five male and eighteen female; thirty-two third-year and twenty-one fourth-year) were interviewed using a critical incident interview technique. Each student was asked to describe a specific, particularly effective learning incident that he or she had experienced in dental school and a specific, particularly ineffective learning incident, for comparison. Each interview was audiotaped. Students were assured that only the interviewer and one additional researcher would have access to the tapes. Data analysis resulted in identification of key themes in the data describing characteristics of effective learning experiences. The following characteristics of effective learning experiences were identified: 1) instructor characteristics (personal qualities, "checking-in" with students, and an interactive style); 2) characteristics of the learning process (focus on the "big picture," modeling and demonstrations, opportunities to apply new knowledge, high-quality feedback, focus, specificity and relevance, and peer interactions); and 3) learning environment (culture of the learning environment, technology). Common themes emerged across a wide variety of learning incidents. Although additional research is needed, the characteristics of effective learning experiences identified in this study may have implications for individual course design and for the dental school curriculum as a whole.

The current undergraduate dental curriculum at Case is primarily traditional, with emphasis on didactic and preclinical instruction in the first two years and clinical instruction and experiences in the final two years. There are three major exceptions. First, the curriculum includes a significant early clinical experience, in which first-year students receive all necessary training to prepare them to place sealants and then, midway through their first year, spend over 100 hours providing sealants to underserved children in the Cleveland Municipal School District.³ Second, the school has made a major investment in simulation technology, which is utilized in the pre-clinical components of the curriculum. Finally, the school has eliminated unit requirements in the clinical components of the curriculum, instituting instead a competency-based clinical training program with emphasis on comprehensive patient care.

To determine the current strengths of our curriculum and the learning experiences of our students, we needed to employ curriculum evaluation methods. In describing a strategy for effective curriculum evaluation, Dagenais et al.⁴ recommend the use of a multimethod approach, collection of both qualitative and quantitative data, and inclusion of feedback from a variety of stakeholders, including students. There is growing awareness that learners’ responses to and views of their educational experiences are important in shaping and modifying the educational process. Therefore, quantitative data collection methods, primarily surveys, have been widely used to assess dental students’ responses to, learning in relation to, and views on the effectiveness of curricula in areas such as operative dentistry,⁵ prosthodontics,⁶ problem-based learning,^7,8 tobacco cessation,⁹ oral cancer,¹⁰ web-based course materials,^11,12 gross anatomy,¹³ family violence,¹⁴ oral effects of carbonated beverage consumption,¹⁵ diversity education,¹⁶ special needs patient care,¹⁷ and HIV.¹⁸ Recently, the results of a survey of dental students regarding qualities of a good teacher were presented at the American Dental Education Association Annual Session.¹⁹ Based on the survey results, the authors identified several characteristics associated with effective teaching, including mastery of basic lecturing skills, clear organization, effective demonstrations, and punctuality/ availability. However, relatively few studies have employed qualitative methods to explore dental students’ perceptions of effective learning experiences.^20–24 The purpose of our study was to explore characteristics of effective learning experiences in dental school using a qualitative approach.

A qualitative approach offers several advantages, including the opportunity to collect data with a depth not usually available from survey data and to more fully understand the thoughts, feelings, and experiences of participants. Meadows et al.²⁵ note that the qualitative approach "expands the researcher’s repertoire of tools to investigate important questions. . . . [It provides the] ability to take into account information about people’s perspectives and experiences, focus on depth and richness of data, interest in process and context."

A specific qualitative data collection technique, the critical incident technique,²⁶ has been used to conduct research in disciplines such as nursing²⁷ and medicine²⁸ and was used in the study described here. When using the critical incident technique, participants are asked to recall a specific incident and to recount the incident to the interviewer, focusing on providing 1) a detailed description of the incident, 2) a description of the actions/behaviors of those involved in the incident, and 3) the results or outcome of the incident.²⁷ The aim is to capture a detailed description of the behaviors of the participants in a specific situation, rather than generalizations or opinions. In this way, theory generated from the data is grounded in the actual behaviors of the participants and can inform future behaviors in similar situations.

	Methods

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All third-year (seventy) and fourth-year (seventy) dental students enrolled in the School of Dental Medicine at Case Western Reserve University were sent a memo inviting them to participate in the study. Follow-up contact was made in person by one researcher (S.H.). Third- and fourth-year students were targeted for participation in the study because they had encountered all three major learning modalities in the curriculum (didactic, preclinical, and clinical). The study was approved by the institutional review board, and each participant signed a consent document.

The interviews were arranged and conducted by one researcher (S.H.), a dental student. We predicted that dental students would feel more comfortable and speak more candidly if interviewed by a fellow student rather than a faculty member. Therefore, all interviews were conducted by the dental student researcher (S.H.). Each interview was audio-taped. Participants were assured that only the interviewer and one other researcher (K.V.) would have access to their interview tapes and that no information would be reported in a way that would allow a participant to be personally identified. The interviews were conducted using the critical incident technique described above. Each interview consisted of two open-ended questions:

Q1: "Today I’m going to ask you about learning experiences you have had here at the dental school. First, I’m going to ask you to think of a specific, particularly effective learning incident and to describe the incident for me in detail, including your role in the incident, what you were thinking and feeling during the incident, and the outcome of the incident. (Participant is provided time to think about his or her response.) Okay, please describe the incident."

Q2: "Now I’d like you to think of a specific, particularly ineffective learning incident. (Participant is provided time to think about his or her response.) Okay, please describe the incident."

Prompts from the interviewer included: "Can you be more specific?," "What were you thinking?," "What did you do?," and "What was the outcome?" Participants were free to describe one or more effective and one or more ineffective incidents.

Data analysis proceeded concurrently with data collection. As recommended by Strauss and Corbin,²⁹ data collection continued to the point of theoretical saturation, that is, to the point at which collection and analysis of additional data failed to generate new insights. To analyze the data, two researchers (K.V. and S.H.) initially listened to each audiotaped interview, took detailed notes, and independently identified key themes. To ensure that the data were approached from more than one perspective, one researcher who listened to the audiotapes was a faculty member (K.V.) and one was a dental student (S.H.). The two researchers then compared and discussed the themes they had initially identified and came to consensus agreement on a list of final themes. One researcher (K.V.) then coded the interviews using the final themes. Inclusion of both effective and ineffective incidents provided the opportunity to compare and contrast effective and ineffective behaviors in order to identify patterns in the data.

	Results

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Fifty-three dental students (thirty-five male and eighteen female; thirty-two third-year and twenty-one fourth-year) were interviewed during June and July 2004. The students generated 128 learning incidents in didactic, preclinical, clinical, and other (e.g., independent study) settings. The characteristics of effective learning experiences identified in the data are listed in Table 1. These characteristics fell into three groups: 1) instructor characteristics (personal qualities, checking-in, and interactive style); 2) characteristics of the learning process (focus on the big picture, modeling and demonstrations, opportunities to apply new knowledge, high-quality feedback, focus, specificity, and relevance, and peer interactions); and 3) the learning environment (culture of the learning environment, technology). Each characteristic is described in detail below. In addition, although our focus was on characteristics of effective learning experiences, characteristics of ineffective experiences were also noted and are described briefly. The text in quotation marks represents quotes extracted from the interviews.

In addition to the personal qualities described above, two specific teaching skills were also important in effective learning incidents. We labeled these skills "checking-in" and "interactive style."

Checking-In: "[The instructor] would ask questions and if you didn’t know he would say, ok, we need to review this, let’s review it."
Instructors in effective learning incidents frequently demonstrated a skill we labeled "checking-in." These instructors were perceptive about classroom dynamics and continually monitored whether or not they were communicating effectively with the group. They took steps to determine the class’s background level of preparation and thus were able to use terminology and examples that matched the students’ current level of understanding. They could sense when a concept was not well understood and would say, "Okay, we need to review that."

Interactive Style: "It was more interactive; you could ask him questions."
Effective learning incidents were often characterized by a higher than average level of instructor interaction with the class, a skill that we labeled "interactive style." In the classroom, these instructors had a teaching style that went beyond the traditional method of reading text directly from slides or notes, with information flowing almost exclusively from instructor to student. These instructors were more likely to engage the students in a dialogue. The instructor posed a question to the class to stimulate thought, gave examples that illustrated a concept, encouraged student questions, and provided ample time for discussion. One student recalled an effective incident in which a small number of students stayed after class and interacted with the instructor:

"It was maybe down to a dozen people in the class and because of the small group size and his interest in us it felt more like a seminar than a class and he was able to answer all our questions and we were able to go more in depth. . . . There was more opportunity to interact and debate."

An instructor would often use personal stories or clinical cases to stimulate discussion and provoke thought, as described in this incident:

"He had different cases of a lot of the kids he had treated and then he would just throw it out . . . he didn’t sit there and lecture us . . . he just threw it out there and asked us what we thought and there were some people who knew a little who would say it and then he would expound on what they saw. There was no real lecture; there was just discussion. That allowed us to guess, and guess wrong, and it allowed some people to guess, and guess correctly, but either way we all really seemed to enjoy that class. . . . That would be in my top three in terms of walking away [with] knowledge."

In the lab or clinic, instructors who used an interactive style were eager to help and were actively involved with the students. These instructors went beyond a supervisory role to a more active role. For example, one instructor took the initiative to offer a spontaneous demonstration in the lab for a small group of students:

"He volunteered. He came up and he said, my group, come here, check this out, I’ll show you how to do it. . . . There were three or four of us that gathered around. . . . He showed us exactly how to do it; then he said you go do it yourselves and if you have a question ask me and so I really learned how to do it as opposed to struggling through it for two weeks and then finally figuring out, oh, you have to do it like this. . . . The learning curve was just [much faster]. . . . I was able to pick it up."

Instructors in both the lab and the clinic frequently shared with students "tips" and "tricks" from their own clinical experience. Students perceived this shared knowledge to be highly valuable, as it was not knowledge that was written in a textbook and often helped them to more fully understand a concept or learn how to complete a procedure successfully. For example, a student said of one effective incident: "[The instructor] took the time to show us how to do impressions on a real patient and some techniques that she has used."

Characteristics of the Learning Process
Focus on the Big Picture: "He painted a big picture of what it’s all about"; "You are able to see how the pieces fit together."
Effective learning incidents often helped students put the details they were learning into a broader framework of understanding, which we labeled "the big picture." These addressed both the specific facts and the broader concepts, both the how and the why behind the procedures and techniques students were learning. As one student said, "I don’t really know something until I have grasped why I am doing it." In the classroom, lab, and clinic, students appreciated opportunities to see how the individual pieces they were learning fit into the big picture, to grasp important concepts, to integrate their knowledge, and to cultivate their ability to transfer their learning into real clinical settings. As one student said of an instructor in the classroom:

"What helped me learn biochemistry was that [the instructor] painted a big picture of what it was all about. . . . He would talk about specific instances, he would take someone from the audience and use them as an example. [He would] say . . . you are out in the desert and you are in the fasted state . . . this is what happens sequentially, this is how your body is going to compensate. . . . It wasn’t just facts that he was laying out that we had to memorize, but it was something you could visualize, you could relate to."

A highly effective incident in the preclinical setting involved a demonstration that illustrated the rationale behind a procedure (the "why"):

"I couldn’t stand border molding. . . . It didn’t click in my mind why we actually did the border molding . . . until up in [the simulation lab] . . . [the instructor] showed basically what happens if you don’t do a good border molding, how a denture can unseat. They had an actual patient up there in the simulation lab . . . they had the cameras on and they were using that to show how basically the person’s denture now was ill-fitting and how it was improperly border molded. Then they actually did another border molding of it and it finally clicked why you need to do all that."

Finally, they appreciated experiences that helped them to bridge the gap from preclinical to clinical activities. Moving from the preclinical to the clinical setting was of great concern to students, and activities that helped them to feel prepared were highly effective. One student described an incident in which working on a simulated patient in the lab helped him to feel ready to work in the clinical setting:

"At the end of the second year we had a class where . . . we had to put together everything we’ve learned in all our prostho and restorative [classes] . . . we had to do amalgams and composites and crowns and bridges . . . we had to put it all together . . . you had to go back from throughout the whole year . . . it was a whole treatment plan. . . . It was a small step toward what we are going to do [in the clinic]."

Modeling and Demonstrations: "Learning is easier after I see it."
Modeling and demonstrations were often an important part of effective learning incidents, whether in the form of a demonstration in the classroom or lab, an opportunity to observe a senior student in the clinic, or a clinical instructor sitting down to show a student how to do a procedure. Demonstrations to the entire class were most effective when they were brief, specific, easily seen, and followed by an opportunity for the student to try it for him- or herself. A student described a particularly effective demonstration, aided by the use of technology, in an implant class:

"They went through and they explained everything to us really well and they were using the technology that we have up in the new lab . . . using the cameras and they had all these implant pieces that they had given each of us. . . . They went over everything. I felt like it made everything come together and just made a lot of sense. . . . They were using the overhead cameras . . . they were showing us while explaining. . . . It just really clicked."

One-on-one demonstrations by faculty also often provided powerful learning experiences. A student reported an incident in which he saw a carious lesion in a clinical setting for the first time. Despite his knowledge of dental caries, the student did not fully understand what he was looking at until the clinical instructor sat down with him. He described the incident:

"[The instructor said] listen to this, listen to the difference between healthy dentin and carious dentin . . . he showed me the difference in the way it sounds with an explorer and the way it feels with an explorer. . . . It’s just a night and day difference when you have someone that’ll sit you down and actually show you that and not just say, ‘there’s still caries in that tooth, get rid of it’. . . especially in your first year in the clinic."

The opportunity to observe senior students in the clinic was also valuable:

"I had done all the different preps [in the lab] on the typodont, but when I assisted a senior on boards I got to work very closely with him as he did the procedure, from giving the anesthesia and talking the issues out with the patient, watching him prep, seeing the finished product . . . and all the patient management skills that we didn’t [do in the lab]. It really became helpful . . . being able to see the procedure ahead of time before I actually had to do it."

Opportunity to Apply New Knowledge: "It’s one thing to have it on paper, it’s another thing to have hands-on experience."
Effective learning incidents involved opportunities not just to hear or memorize new information, but to apply that information immediately in a hands-on situation. An incident that stood out for several students was a course in orthodontics. The course was didactic, so students might have expected a semester-long lecture series. Instead, the instructor gave only three or four lectures at the beginning of the course, along with handouts as a reference. For the remainder of the course, students worked in small groups. According to one student:

"We had three or four lectures and then . . . we had to diagnose. . . . We got to choose our group and we chose one person in the group who we were going to work on. We took all the lecture knowledge . . . and we had to apply [it] to diagnosing one of the people in our group. . . . That was something that will . . . stick with me because . . . they gave us the lectures and then it was hands-on. . . . We had the handouts, we had the lectures and then we had to apply it to actually doing something and things seemed to stick better that way."

He noted that "there was no test at the end where I had to memorize facts" but that he went back to the handouts in order to do the case analysis and at the end of the class, he said, "I left that class going, oh, I know what an orthodontist does." Near the end of the course, each group presented their results to the class.

Students noted that some of their best learning experiences emerged when things didn’t go exactly as planned: "Every time I’ve made a mistake and corrected it, then next time I know what to watch for." The opportunity to apply what they had learned helped students to understand the nuances and complexities of what they were learning. For example, although a student did not fully appreciate a didactic course in treatment planning while going through it, after having the experience of developing a treatment plan for a patient in the clinic for the first time, the student said, "I realized that everything’s not cut and dried."

High-Quality Feedback.
Students reported that a crucial aspect of learning from application and experience was the availability of high-quality feedback. Effective feedback was timely, which was facilitated by having a number of instructors on the lab or clinic floor. In addition, effective feedback was constructive and specific, leaving the student with a plan for what to do next to achieve the desired result. One student reflected, for example, "If something’s wrong, it’s not just ‘it is wrong’ but why it is wrong, why it happened, so next time I know to do something different." Another said, "I did a crown prep but didn’t like what I’d done. My instructor came over and said, ‘It happened because . . .’ and showed me how to fix it." Of an instructor who offered particularly helpful feedback, one student said, "He looked at it and he said, ‘This is good, this is good, but what you want to do here . . .’ and then he just kind of walked you through it and stuck with you until you understood it." On the clinic floor, one student remembered an instructor reviewing a student’s treatment plan and saying, "You can do that, but did you think of these other options, too?"

Focus, Specificity, and Relevance: "Walked you through step by step."
Effective learning experiences were characterized by focus and efficiency on the part of the instructor. Information in class or instruction in the lab was presented in a clear, concise, and easily understood format. Goals for the session were made clear, and instructors were organized, focusing on the topic at hand and avoiding what the students termed "tangents." In effective incidents, instructors acted as guides for students, leading them through a large quantity of information, pointing out the most important details and helping the students to grasp essential concepts. Effective learning incidents were also high in relevance, meaning that instructors were able to communicate and students could clearly see how what they were learning related to situations and problems the students would encounter in the future.

Peer Interactions.
A number of effective learning incidents, in both didactic and clinical settings, involved learning from peers. For example, a group of students studied dental anatomy together before an examination:

"Studying for the final is when everybody kind of really got it as a group because some of us were strong in one part, the others were strong in another thing, so we’d go through all the practice problems and stand there and explain it and then do things inside out and backwards. . . . We would make up our own questions and give it to somebody and they’d have to answer it. . . . The light bulbs went on."

As discussed previously, many students commented that the opportunity to observe and assist senior students in the clinic was a valuable experience that helped ease the transition from lab to clinic.

Learning Environment
Culture of the Learning Environment.
The culture of the learning environment, in particular whether the focus was on performance (testing and grading) or learning, played a role in effective learning incidents. Counter-intuitively, learning incidents that did not involve testing or grading were often deemed to be highly effective, such as an orthodontics class in which a test was not given or an elective implant course that was not graded. Students frequently mentioned the importance of being able to ask questions and learn by making mistakes, actions that may be discouraged when the course is primarily focused on performance.

Technology.
Technology was used to great advantage and contributed to effective learning in many incidents. However, more sophisticated technology did not automatically result in better learning experiences. For example, use of PowerPoint, while technologically more advanced than using the chalkboard or overhead, did not always lead to more effective learning, especially if the instructor did not have an interactive style, but read directly from the slides. If the instructor did have an interactive style and used the PowerPoint images (e.g., pictures of cases) to stimulate discussion, students reported that the technology contributed to effective learning. Students indicated that it was not just the level of technology, but how a specific instructor used the technology that was important. A number of effective learning incidents described by students involved instructors who wrote on the board, but who possessed a very interactive teaching style. Students described numerous situations in which technology was highly effective in the laboratory setting because it enabled them to see demonstrations easily.

Characteristics of Ineffective Learning Incidents
Although we focused on characteristics of effective learning experiences, several characteristics of ineffective learning experiences were also noted. Ineffective learning experiences were often characterized by suboptimal communication between the instructor and students and/or problems with the organization or presentation of course material. Communication problems occurred when the instructor was perceived as unapproachable, uninterested in the students’ learning, or seemed to discourage questions. At times, instructors failed to determine students’ prior level of knowledge about a topic, and therefore used terminology that was unfamiliar and confusing to the students. Unclear directions about tasks to be completed and lack of timely and/or constructive feedback were also problems encountered during ineffective learning incidents.

Problems with the organization and/or presentation of course material included the absence of a clear agenda for each class session. Often, instructors would, as several students said, "go off on tangents," which was seen as ineffective, as were didactic sessions in which the instructor tried to present too much information in the time available. Lectures in which the instructor read directly, word for word, from slides or handouts were often seen as ineffective. In these instances, there was little interaction between the instructor and the students, and students felt that they could read the material outside of class much more efficiently than having it read to them by the instructor during class time. Learning experiences were also perceived to be ineffective when students felt that they had memorized many details and facts, but had not gained a thorough understanding of the underlying concepts or "big picture." Finally, learning experiences in which the relevance, link, or application of the material to dentistry was not communicated were typically viewed as ineffective.

	Discussion

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Several key characteristics of effective learning experiences were identified in this study. Instructor personal qualities such as approachability, enthusiasm, commitment, and willingness to give guidance and feedback contributed to effective learning experiences, as did the specific instructor skills of checking-in and employing an interactive style. Particular characteristics of the learning process also contributed to effective learning experiences.

These included a focus on the big picture, modeling and demonstrations, opportunities to apply new knowledge, availability of high-quality feedback, learning opportunities that were focused, specific, and relevant, and the opportunity for learning with and from peers. Finally, certain features of the learning environment, specifically the culture of the learning environment and technology, impacted students’ learning experiences.

These results are consistent with principles of adult learning.³⁰ For example, adult learners want their learning to be relevant to their learning goals, which parallels our "focus on the big picture" and "relevance" themes. Adults learn best in a supportive environment in which they can experiment with new behaviors and skills, which parallels our "instructor characteristics," "opportunity to apply new knowledge," and "culture of the learning environment" themes. Finally, adult learners need and want feedback, which parallels our "high-quality feedback" theme.

These results are also consistent with experiential learning theory as described by Kolb,³¹ in which both active experimentation, which parallels our "opportunity to apply new knowledge" theme, and reflective observation, which parallels our "modeling and demonstrations" theme, are integral components of the learning cycle. Learning style assessments of our incoming students over the past several years have shown that a variety of learning styles are represented within our student body, with some students favoring active experimentation, the "hands-on" opportunity to try things out for themselves, and some favoring reflective observation, the opportunity to observe a faculty member or senior student demonstrate a behavior, skill, or procedure. Instructors may want to provide a variety of modes of learning in order to meet the needs of learners with varied learning preferences.

A growing number of dental schools are moving toward increasing the amount of time their students spend in active learning situations, while decreasing the amount of time spent in the traditional lecture format. The enthusiasm of students in our study for the interactive teaching style and for opportunities to apply new knowledge provides some assurance that dental educators are moving in the right direction in adding more active learning to dental school curricula. At the same time, this study suggests that students desire guidance, in the form of modeling, demonstrations, and positive interactions with instructors who can provide tips and offer feedback.

The characteristics of effective learning experiences presented here may provide insights for instructors who wish to increase the effectiveness of their teaching and their students’ learning. For example, instructors may be able to quickly and relatively easily implement changes in how they give feedback to students, or in the extent to which their classroom sessions are interactive in nature, or in the frequency with which they "check-in" with the class. Instructors within the same institution may not be aware of effective and/or innovative teaching strategies used by their colleagues. One easy approach to faculty development may be to provide a forum for faculty to share their "best practices" for teaching.

Many effective learning experiences happen outside the formal curriculum. For example, studying with peers or assisting in the clinic for a more senior student are not necessarily formal curricular activities, yet they proved to be valuable for the students in this study. Curriculum planners should consider how to best capitalize on these effective modes of learning.

Qualitative research methods have limitations. First, qualitative research is intended to provide detailed insights into a particular group, event, or process. This study includes data from a particular student body enrolled in a particular dental school. Were this study to be repeated in a dental school with a significantly different curriculum and/or student body, it is likely that many similar themes would emerge, but that some different ones would also. Additional studies, both qualitative and quantitative, will lead to greater understanding of effective dental school learning experiences. Second, students who have not yet graduated may hesitate to be entirely candid when interviewed. To address this limitation in this study, interviews were conducted by a fellow student, rather than a faculty member, and participants were assured that identifiable comments would not be shared with any faculty members except the one faculty member involved in the research. However, it is still possible that students may have filtered their comments to some extent.

The qualitative data-gathering methods used in this study could be a useful tool for gathering feedback from students for purposes of curriculum evaluation. Qualitative data collection is time-consuming and labor-intensive, but, as seen here, can capture a depth of information that is not typically gathered using course evaluation forms.

	Footnotes

 
Dr. Victoroff is an Assistant Professor, Community Dentistry, and Ms. Hogan is a third-year dental student—both at the School of Dental Medicine, Case Western Reserve University. Direct correspondence and requests for reprints to Dr. K. Victoroff, School of Dental Medicine, Case Western Reserve University, 10900 Euclid Ave., Cleveland, OH 44106-4905; 216-368-6616 phone; 216-368-3204 fax; kristin.victoroff{at}case.edu.

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