HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Similar articles in this journal Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by FitzGerald, K. Articles by Fitzgerald, E. Search for Related Content PubMed Articles by FitzGerald, K. Articles by Fitzgerald, E.

The Critical Incident Technique and Pediatric Dentistry: A Worked Example

Key words: qualitative research, critical incident technique, pediatric dentistry, dental education, student viewpoint, dental students

Submitted for publication 06/22/07; accepted 11/10/07

	Abstract

Top Author information Abstract Materials and Methods Results: positive experiences Results: negative experiences Discussion Conclusions References

 
Evaluating dental students’ experiences in pediatric dentistry may help dental educators better prepare graduates to treat the children in their communities. This qualitative investigation aimed to collect and analyze data using the critical incident technique (CIT). Sixty dental students at one southwestern dental school participated in 103 recorded interviews. They described 150 positive and 134 negative experiences related to the pediatric dentistry clinic. Analysis of the data resulted in the identification of four key factors related to their experiences: 1) the instructor; 2) the patient; 3) the learning process; and 4) the learning environment. The contribution made by the patient to dental students’ education has not been previously addressed. The CIT is a useful data collection and analysis technique that provides rich, useful data and has many potential uses in dental education.

As part of continuing efforts to evaluate and improve the educational experience in pediatric dentistry at Baylor College of Dentistry, an exploratory investigation was undertaken to evaluate the clinical component of the curriculum as seen from the student viewpoint. This is the second of two companion articles; the first, published in this issue of the Journal of Dental Education, describes the origins, current state, and applications of the CIT.² Individuals who are not familiar with the basic approaches used in qualitative research and with the CIT in particular are encouraged to read the companion article first.

	Materials and Methods

Top Author information Abstract Materials and Methods Results: positive experiences Results: negative experiences Discussion Conclusions References

 
Currently, predoctoral students at Baylor College of Dentistry provide care for pediatric patients in the third and fourth years of their dental education. Preparation for entry to the clinic begins in the second year with an intensive, hands-on classroom and laboratory course. In the third year, when students begin to treat patients, a block rotation format is used in an effort to ensure all students have an equivalent experience with pediatric patients. There are no specific requirements for third-year students, as the emphasis is on facilitating learning at each student’s individual pace. In the fourth year, students are required to provide comprehensive care for a specified number of patients. Patients are screened for treatment need and adequate behavior by pediatric dentistry faculty prior to acceptance into the predoctoral program. Teaching in the clinic is provided by full-time and part-time faculty and by pediatric specialty residents. In addition to their clinical experiences at the school, third- and fourth-year student pairs provide care for pediatric patients at clinics in the city of Dallas in order to gain the experience of practicing dentistry in the community.

The sample group for this investigation came from all 173 third- and fourth-year dental students at Baylor College of Dentistry, all of whom were invited to participate in the study. The third-year students were contacted in small groups by the principal researcher (K.F.) at the start of their first rotation in pediatric dentistry. The fourth-year students were informed of the study at the beginning of the academic year at a single meeting that was attended by all students in that year. Follow-up contact was made in person by the principal researcher when the students were in attendance at the clinic. Third- and fourth-year students were invited to participate in the study because they are involved in patient care activities in the pediatric clinic. The Institutional Review Board of Baylor College of Dentistry approved the study, and written consent was obtained from all participants.

The principal researcher collected the data through semistructured individual interviews with those who agreed to participate. The interviews were arranged to take place at a time convenient to the students. For third-year students, this was usually at the end of the week-long rotation in the pediatric clinic. For the fourth-year students, who provide comprehensive care for their patients, the interviews were scheduled at the end of a clinic session or at a break time. An audio recording was made of the interview, using a digital voice recorder. Confidentiality was maintained at all times throughout the study: the interviews were conducted by the principal researcher in a private location; the participants were identified only by number on the audio recordings; and the recordings were stored securely prior to, during, and after the data analysis. The participants were assured that only the principal researcher and one other researcher (E.F.), a clinical psychologist who is not affiliated with the school, would be able to access the recordings. The participants were also assured that no data would be reported in such a way that they, or anyone else, could be identified. The principal researcher was a graduate student at the school, not a faculty member, and was not scheduled to teach in the clinic for the duration of the data collection portion of the study.

The interviews were conducted using the critical incident technique as described in the companion article.² Most of the participants gave two interviews. Participants were asked to contribute one positive and one negative experience relating to providing care for pediatric patients per interview, but were free to describe more incidents if they wished. The following standardized open-ended questions were used for every interview:

Question 1: "Can you tell me about a positive experience you had recently in the pediatric clinic? Tell me what was the lead-up, what happened, how you were feeling, and what was the result." (Participant is provided time to think and respond.)

Question 2: "Okay, now can you tell me about a negative experience?" (Participant is again provided time to think and respond.)

If necessary, prompts were given by the interviewer to clarify situations or obtain more detail. Prompts included the following: "How was he [the instructor] helpful?" "What did you like about that?" "Were you here at the school or at the CDC [community clinic]?" and "Did you get the work done?"

The principal researcher summarized each incident in text prior to the formal analysis. Direct quotations were used when possible. At a point approximately three-quarters through the study, the principal researcher and the clinical psychologist met to collaborate on the formulation of data categories. The data analysis procedures were informed by general guidelines from qualitative research³ and the grounded theory analysis method⁴ and by drawing on the existing literature.^5–7 The positive and negative experiences were analyzed separately, and the unit of analysis was an incident. Using the "constant comparison" method,⁸ similar incidents were grouped together. This method involves first scanning the entire data set, then individually examining each unit of analysis (the incident) for similarities with other units. Similar units are grouped together as they are examined. When no established group fits an incident, a new group is formed. Once all the incidents were analyzed and grouped, a hierarchy of organization emerged that was consistent with the findings of other published literature.⁶ Higher order categories—"key factors"—and lower order categories—"subcategories"—were identified and labeled. Statistical analysis consisted of a simple count of the number of incidents making up each subcategory. The results are presented in diagrammatic "mind map" format (Figures 1 and 2) and are illustrated using quotes from the interviews. A mind map is a diagram used to represent words, ideas, tasks, or other items linked to and arranged radially around a central key word or idea.

View larger version (139K): [in this window] [in a new window]   Figure 1. Mind map of positive experiences with incident frequencies (n)

View larger version (152K): [in this window] [in a new window]   Figure 2. Mind map of negative experiences with incident frequencies (n)

	Results: Positive Experiences

Top Author information Abstract Materials and Methods Results: positive experiences Results: negative experiences Discussion Conclusions References

The Instructor
For this key factor, the subcategories that emerged from the descriptions of positive incidents were appropriate level of supervision; just-in-time teaching; demonstration of tips, tricks, and techniques; teamwork; help with paperwork; and personal qualities of the instructor.

Appropriate level of supervision (n=29).

Positive experiences related to the instructor commonly consisted of situations in which the instructor achieved an appropriate level of supervision. This ranged from simply being available when needed, to checking in, providing one-on-one chair-side instruction, and "saving the day." In describing the instructors’ availability, one participant said, "The instructors were all there . . . willing and able, friendly, able to help or give out pointers, not . . . hovering around or gone all the time. There was just a happy medium there as far as their availability." The participants appreciated the instructors’ "checking in" from time to time. They often described their confidence being boosted by being allowed to work independently, safe in the knowledge that the instructor would interact frequently with them. Several participants enjoyed a "coaching" style of teaching. They described receiving one-on-one help from the instructor: "She walked me through it. I feel like I learned a lot from that." And "I was having a lot of problems [with the procedure]. Dr X came in and stayed with me the whole time and helped me . . . showed me exactly what to do, some tips and everything. I learned a lot from her." When participants were scared or apprehensive or were faced with a procedure that was more than they felt they could perform, the instructors "saved the day," "bailed me out," or "stepped up to the plate . . . took the role of leader . . . and performed the majority of the procedure." When attempting an indirect pulp cap, one student was "deadly afraid I was going to hit the pulp. Seeing somebody do [the caries removal] helps." These experiences were seen as positive by the students as they felt they could watch and learn and would be ready the next time they came across a similar situation.

Just-in-time teaching (n=7) occurred when students were about to encounter a new situation or procedure. They described how the instructor would "talk it through" initially and then give feedback and advice.

Demonstration of techniques, tips, and tricks (n=11) helped participants grasp the procedures and aided the transition from the preclinical to the clinical course: "It’s good doing it in the sim-lab but it’s not anything like doing it up here." They were exposed to a variety of what they called "tricks" and "tips" for carrying out tasks they sometimes perceived as difficult—in particular, rubber dam placement. They valued these nuggets of information, especially when "it’s not stuff you get at school." The instructors who had experience of private practice were particularly treasured: "It’s nice to have someone who was in private practice for so long."

Teamwork (n=11) was a feature of several positive incidents described by the participants: "Everyone left at the same time when everything was done." They saw the value in teamwork when caring for their patients. As one participant said, the patient was "crying and screaming, and she [the instructor] was able to help . . . it was really helping the child." An extra set of hands was appreciated for fissure sealants: "It was very hard to keep it dry, so it was very nice that she came over and assisted me."

Help with paperwork (n=7) was welcomed. In general, the students perceived the department paperwork as extensive and confusing. One student described a common occurrence: "Dr X is always just great with the paperwork because I think he knows it’s so tedious and takes a lot of our time. It’s hard with pediatric patients to go through all the paperwork with them right there. . . . He, kind of behind the scenes, takes your paperwork and fills it out."

Personal qualities of the instructor (n=12) such as flexibility, demeanor, and enthusiasm for teaching were recognized by the participants and were manifested in many ways. One participant praised an instructor because "he can see the reality. He can make sure things happen." Another instructor’s sunny disposition was noted: "She was very good at making me feel comfortable. She’s just upbeat and positive. . . . it may not be any one thing that she said; it’s just the way she says it." A particular enthusiasm for teaching was observed in one instructor, who "seemed genuinely like he wanted to help me out. . . . He actually wants to show us something cool." One participant even went so far as to say that "I guess pediatric dentists are just nicer than the people upstairs."

The Patient
For this key factor, the subcategories that emerged from the descriptions of positive incidents were enjoyable experiences with patients and the broad social context of oral care.

Many participants described enjoyable experiences with patients (n=21). These ranged from simple appreciation of a patient’s good behavior (for example, "She did great!") to descriptions of patients who were "a blast," "so cute," and "awesome." Many of the participants had initially perceived the treatment of children as difficult due to behavior problems (for example, "I thought I’d mess up"), but were often pleasantly surprised when the patients "did better than my adult patients." Some participants were charmed to be on the receiving end of affectionate treatment from their patients: "She told me she loved me when she left!" and "She gave me a hug!" Several participants commented that, having previously thought that treating children would be difficult, their patients provided such positive experiences that they decided they would treat children in their practice upon graduation. "It totally opened my eyes!" said one, who mentioned he might even like to specialize.

Participants recognized the broad social context of oral care (n=4) when treating child patients. They saw their patients as individuals, as part of a family unit, and as part of a community and observed the role they, as health care providers, have in their patients’ lives. One participant, during her first interview, described a patient who came from a foster home. He was "quiet and reserved." The student appreciated that "not everyone’s at an advantage like we are. It made me feel grateful." At her second interview, she related a subsequent encounter with the same boy. "He was a little more open," she said. "It showed me how we can form relationships with our patients when we get out in private practice." Another described feeling good about being able to communicate with a patient and parent in their native language: "I was the bridge to the Korean community."

Other (n=5) types of positive encounters with patients formed the remainder of this key factor.

The Learning Process
For this key factor, the subcategories that emerged from the descriptions of positive incidents were the continuum of learning, successful application of foundation knowledge, and the community clinic as the "real world."

The continuum of learning (n=11) was identified as part of the learning process. Participants saw themselves progressing and gaining confidence through their clinical experiences. The department tries to encourage observation and demonstration for students entering the clinic for the first time, and the participants appeared to recognize this: "When you come in [for the first rotation], you know for sure it’s not counted against you what you can and can’t do. . . . You just come here, try to do as much as you can. . . . There’s no pressure." As time progressed, students talked about gaining confidence: "This second rotation feels more positive. Being able to do the procedures correctly was a positive experience." The students have a preclinical series of classes designed to prepare them for entry to the pediatric clinic. A link between this classroom learning and the clinical reality was identified once the leap to the clinic was made in this example:

"I was under the impression that children would be difficult, and I understand the importance of having the preclinical experience, in terms of teaching us how to communicate with the children and the parents. But I was thinking that the reason why we had that special class was because the kids were so hard and so difficult and we needed all this special training to relate to them. But really, it’s what I realized with the first patient was it wasn’t so much because they’re so difficult, it’s just because they’re different and we forget."

Even patients with challenging behavior were viewed as a chance for a positive learning experience. One participant was even proud to have "finally met a ‘Frankl 1’ patient!" (The Frankl Behavior Rating Scale is used in pediatric dentistry to describe patient behavior. A score of 1 indicates a patient with "extreme negativism.")

Successful application of foundation knowledge (n=7), although sometimes a surprise, was a part of the learning process that the participants enjoyed: "It works!" They described using the techniques they had been taught in the preclinical course when managing difficult or potentially difficult situations: "It was kind of neat because I had to use the techniques we were taught . . . and it worked really well." An element of surprise was often a feature of their stories: "I’ve never really thought the ‘blow a little bubble’ thing was a very legitimate story [to describe local anesthetic to children]. . . . With him I told him the bubble was getting bigger, it’s almost about to pop, all he said was ‘ow’ and no fuss, nothing." The participants described feeling good when, after applying techniques they were taught in combination, things "finally came together."

The community clinic as the "real world" (n=7).

As part of the pediatric clinical program, students travel to outside clinics to perform patient care. Many of the constraints of the dental school clinic are absent there, and the volume of work they carry out during the day is generally high. A move towards greater independence is encouraged. The community clinic was often described as the "real world," and the participants stated that it made them feel like "real dentists." This rotation was universally appreciated, even by those who were not particularly interested in the treatment of children.

The Learning Environment
For this key factor, the subcategories that emerged from the descriptions of positive incidents were departmental policies and procedures, culture of support, and support staff behavior.

Departmental policies and procedures (n=11) were identified as helpful in a number of situations. As part of the department’s effort to streamline patient care, instructors collaborate on treatment planning for every case. Two instructors must agree on each treatment plan at the outset. One participant made the remark, "Everybody knows something that somebody else doesn’t know. In dentistry that’s just how it is." The availability of instructors to give multiple opinions was also noted. The instructor to student ratio was welcomed by the participants: "I was pretty nervous the night before. . . . When I entered the clinic, I actually didn’t feel nervous at all because the instructor-student ratio was small." And "What I really liked about it was that there was one instructor for every two students so that whenever I had a question . . . I could always go bother them and they could come over and take a peek. . . . I know a lot of people have had that same experience." Flexibility of the administrative staff and system also often impacted positively on the participants’ clinical experience. More than one student described how the front office staff rearranged the block schedule so that they could have a chance to do some operative work during their rotations. Fourth-year participants were grateful for opportunities given to them to assist in completing their requirements.

A culture of support (n=3) during episodes of stress or difficulty was advantageous to the participants. One participant was delighted to be paired up with an encouraging senior student as it "gave me the freedom to try out new things." Help from other students enabled the patient to have a good time and allowed the operator to concentrate on the procedure.

Support staff behavior (n=4), in particular having all the required materials prepared for the students before the procedure, made it "easy to adapt to the clinic" and "made the appointment go smoothly."

	Results: Negative Experiences

Top Author information Abstract Materials and Methods Results: positive experiences Results: negative experiences Discussion Conclusions References

 
The Instructor
For this key factor, the subcategories that emerged from the descriptions of negative incidents were an inappropriate level of supervision, incorrect advice, conflicting advice or opinions, and instructors who exhibited poor communication skills.

An inappropriate level of supervision (n=19), whether insufficient or excessive, often characterized a negative experience. Instructors who did not actively participate in patient care, but instead "sat there reading a novel or magazine" were poorly regarded. "You can’t sit on your derrière and not help!" exclaimed a participant who felt she had been pushed by the instructor to finish a case that day, but did not receive any practical help toward achieving this. A lack of team spirit characterized some instructors’ behavior at times. One participant, who finds sealants a "trying experience," felt like he "just needed an extra set of hands" to complete the procedure to a good standard. He felt that if the instructor "made an effort to be there, why not teach?" Although the participants felt knowledgeable—"Ask us a technical question and we can spit it out," remarked one—sometimes they just wanted a little guidance, "someone to hold my hand." An unavailable instructor created frustrating circumstances. This caused participants to feel "rushed," overwhelmed, or helpless. Conversely, excessive intervention by an instructor bothered some participants: "I feel like I won’t be able to learn if everyone comes over and does it for me." They frequently used the word "frustrated" when describing their emotions under these circumstances. It appeared that participants did not always wish to be "rescued" when the work got difficult or they made a mistake: "I kinda wish they might have told me what to do and then let me try it again."

A problem with advice (n=3) confused the participants and made their time at the clinic more difficult. While the department strongly advocates the use of the rubber dam, the advice of one instructor to go without it for a particular restoration "made my job very difficult," remarked the participant. "I just don’t think I had ideal isolation." In another instance, the advice to use a different bur than taught in the lab course caused some confusion, as the participant felt it was inappropriate for the task.

Conflicting advice or opinions from instructors (n=9) tended not to confuse participants, as they could generally to see the two sides to the argument, but it did tend to cause some frustration. The best interests of the patient were usually the main concern expressed by the participants when recounting these incidents.

Instructors who exhibited poor communication skills (n=4) were the focus of a small number of negative reports. One participant described an exchange with his instructor as "blunt" in contrast to the overall tone of the remainder of the staff. Difficulties arose when instructors made or enforced a decision or policy without proper explanation or discussion.

The Patient
For this key factor, the subcategories that emerged from the descriptions of negative incidents were patient behavior that disrupted an appointment, patient behavior that caused treatment to be abandoned, problems with parents or guardians, and language barriers.

Patient behavior that disrupted an appointment (n=8) was cited as a source of stress. Participants exhibited a degree of understanding of "the nature of the beast," as one put it. They sometimes acknowledged learning from these experiences, but at other times revealed that they felt "sad" or "defeated." Even behavior that could be considered normal for a child sometimes upset the participants. One participant sympathized with her patient who cried during a palatal injection: "It’s very hard to work on someone when you know you’re hurting them."

Patient behavior that caused treatment to be abandoned (n=7) created a negative experience for the operators involved. Some participants appeared to feel that they had failed in some way: "We couldn’t calm her down; we just ‘lost’ her." Others attributed the failure to the children, saying they were being "uncooperative." A mother’s lack of control over her child was suggested by one astute participant as being the source of the child’s inappropriate behavior. Occasionally, the participants perceived that time spent with these patients was wasted: "It almost takes an afternoon away from another clinic." The management of children who presented with a dental emergency caused difficulty as these children had not been previously screened for adequate behavior.

Problems with parents or guardians (n=5) usually related to treatment planning and appointment issues: "Somewhere along the line there was a breakdown of what was supposed to happen . . . and I got to deal with it." "It’s almost parent management first," put forth a participant who had spent a whole morning discussing a treatment plan, only to be met by anger when she informed the parent that no treatment could be done that day as all the available time had been used answering her questions.

Language barriers (n=3) emerged as an obstacle to effective patient care. If the participant and patient did not share a common language, they found it "difficult to say what [was] needed in order to make the children comfortable."

Other (n=3) problems with patients formed the remainder of this key factor.

The Learning Process
For this key factor, the subcategories that emerged from the descriptions of negative incidents were a perception that the available learning experiences were insufficient and a short supply of appropriate patients.

A perception that the available learning experiences were insufficient (n=11) emphasized the participants’ general enthusiasm for pediatric dentistry: they wanted to learn. Far from being pleased when they had no patient to work on, they expressed disappointment at a lost learning opportunity. Operative appointments were favored over preventive visits. Procedures they regarded as "less exciting" or "boring" were examination, prophylaxis, and placement of sealants; instead, they preferred to do operative treatment such as "doing fillings and pulling teeth," as one particularly candid participant revealed.

For the fourth-year students, who provide comprehensive care for children, the short supply of appropriate patients (n=6) who successfully attend their appointments was a point of contention: "I spent six weeks trying to get a patient in, but it never worked out." They expressed a feeling of injustice at the enforcement of requirements if the patient supply was inadequate to meet their demand: "They [the department] can’t guarantee the patients." The patient assignment system was considered "unfair," and an obstacle to graduating with their class.

The Learning Environment
For this key factor, the subcategories that emerged from the descriptions of negative incidents were support staff behavior, instrument checkout, paperwork, other policies and procedures, unfamiliar materials or materials perceived by the participants to be inadequate for the task, and errors by administrative staff.

Support staff behavior (n=17) affected the participants’ experiences at the pediatric clinic. Participants described multiple incidents involving support staff in various locations who were "rude," "in a bad mood," "gave off a bad vibe," "really mean," and "surly and brusque." Belittlement and bullying appeared to be central themes to the participants’ negative encounters with support staff.

Instrument checkout (n=11) was a problem for both third- and fourth-year students. At the pediatric clinic, students have to wait for their patient to arrive before being given the armamentarium for the appointment. In other departments at the school, they can check out and set up their instruments before the patient arrives. The participants frequently cited this policy as an obstacle to patient care, as they felt it took a significant portion of the appointment time to set up the necessary equipment. Some described their patients’ "getting restless" while sitting in the chair, waiting for the student during the setup process. Participants wanted to be "more efficient," to be "ready to work," to improve their patients’ experience. They described feeling rushed towards the end of an appointment, especially for the morning session, which is shorter than that in the afternoon.

Paperwork (n=10) created difficulties for participants at the pediatric clinic. The paperwork is different from that with which they were familiar from the adult clinics: "Half of the problem is . . . not knowing what to do with all the papers." "The paperwork is kinda confusing" was a common sentiment. Some participants felt that the paperwork was excessive; others recognized the need for each form, but felt that the papers could be completed when the patient had left, as "kids don’t want to watch me fill out QA forms." As previously noted in the positive reports, participants indicated that faculty assistance with the paperwork completion was greatly appreciated.

Other policies and procedures (n=8) that were criticized by the participants included the fourth-year requirement system, the student pairing system, and the leniency shown to patients who attended late for their appointments. Fourth-year participants complained about the administration of the comprehensive care system, describing it as "not equitable": "Why can’t they be assigned like other departments?" Those who had progressed well with their requirements felt punished for that because they had to wait until their classmates had caught up before they could get another patient. Students are paired to work in the community clinic, and this was generally welcomed by the participants, but one third-year student wanted to "mix up" the pairings, as he felt his fourth-year partner "did not know her stuff." Another participant was disappointed that the pairings did not extend to the clinic at the school. Patients who arrived late caused stress if they were allowed to have treatment carried out that day. If the school’s policy on patients’ tardiness was not adhered to, it created a rushed situation and stressful atmosphere for those involved.

Unfamiliar materials or materials perceived by the participants to be inadequate for the task (n=4) were frowned upon by the participants. Incidents involving unfamiliar materials were described as "frustrating."

Errors by administrative staff (n=4) resulted in confusion and struggle. Occasionally, patients who were designated for the graduate clinic were mistakenly booked to the third-year block. These patients have treatment needs in excess of the skills possessed by third-year students. The result was either an unpleasant or a "wasted" appointment.

Other (n=2) difficulties with the learning environment formed the remainder of this key factor.

	Discussion

Top Author information Abstract Materials and Methods Results: positive experiences Results: negative experiences Discussion Conclusions References

 
This investigation aimed to gather and analyze information about experiences in pediatric dentistry from the student viewpoint. The four key factors related to predoctoral clinical experiences that emerged were labeled as 1) the instructor; 2) the patient; 3) the learning process; and 4) the learning environment. Of these, the factors of the patient and the learning environment are relatively novel, while the factors of the instructor and the learning process have been intensively scrutinized in the literature on health professions education.^9–11

Available literature examining clinical learning in dental school has already identified important dimensions of the role of the instructor and the relationship between instructor and student. These include the following: the instructor as a role model; the value of continuous feedback; the benefit of a high level of interactivity;¹² the importance of the instructor’s rapport, organization, and enthusiasm;¹³ the worth of student autonomy and self-assessment; the usefulness of demonstration; and the merit of contextual teaching.¹⁴

The results of this investigation corroborate previous evidence and reinforce the importance of the instructor-student relationship for successful clinical teaching and learning. Our findings indicate that students prefer that their instructors maintain an appropriate level of supervision and interaction. At times, this may require that the instructor perform the entire procedure, demonstrating techniques while students observe and learn. At other times, it requires that the instructor should stand aside and allow the student to work at his or her own pace. Amidst these two extremes lie a multitude of levels of supervision. Finding the correct level of supervision might be the difficult part of teaching in clinical dentistry, and the right balance depends upon the situation and the student.

The participants in this investigation were free and able to discuss their needs while under the aegis of confidentiality. Had they felt as comfortable being so direct with their clinical instructors, they might have been able to better take advantage of the learning opportunities presented to them. Dialogue between students and instructors is necessary for a successful teaching-learning partnership. An instructor’s personal characteristics can either facilitate or complicate open dialogue and can either improve or impair the clinical experience. Being enthusiastic about the role of teacher, displaying a positive attitude, and encouraging a team approach were all considered constructive attributes of the instructors described in this investigation.

The value of the patient’s contribution to the education of dental professionals has, until recently, been limited to providing a dentition upon which students can practice. The idea that a patient’s personal qualities can positively contribute to the enrichment of the dental education experience is a new one. Patients who were fun, cute, or well behaved had a powerful influence on students, putting them at ease and triggering an often unexpected enthusiasm for pediatric dentistry. Further investigation to define the characteristics of patients who can cope well in a dental school clinical situation would be advantageous for clinical program directors.

The learning process designed by the department aims to prepare students for all aspects of oral care for children. The participants appeared to appreciate the value of the preclinical course that aims to prepare them for entry to the clinic. However, once at the clinic, the participants appeared not to value the full range of clinical experiences equally. It is worrying to find that some dental students feel their time is being wasted if they are providing services such as examination, prophylaxis, and sealants. Their enthusiasm for operative dentistry was not matched by their enthusiasm for preventive care. This is a complex issue and one that is outside the scope of this report, but dentists in general could often be accused of ignoring prevention and instead concentrating time and efforts on the surgical treatment of caries and its effects.

The perceived failure of traditional dental school clinical education to adequately prepare graduates for the "real world" was represented by the participants’ enthusiasm for the outside clinical rotation. Other students have also been found to enjoy and benefit from their extramural or selective rotations.^15–17 When possible, dental schools should consider providing their students with community-based experiences. This could not only increase their exposure to clinical dentistry in the "real world" but could also foster an improved sense of the role of dentistry in the community and enhance professional awareness and identity.¹⁶ Reflection on these experiences is crucial to capitalize on the full educational potential of these experiences.

Our results reflect problems with support staff in the clinic environment. The contribution made by support staff to the learning environment in dental schools, whether positive or negative, has gone unrecognized in the health professions education literature. Students interact on a daily basis with nonfaculty employees of their school. These interactions are related to the hidden curriculum as described by Masella¹⁸ and Lempp and Seale,¹⁹ which encompasses student learning outside of the traditional curriculum and "comes from the way individual and collective life is lived on a campus—from the way people employed there do their work, conduct their relationships, and otherwise reveal their true values."²⁰ Further study is needed to evaluate the effect on dental students’ educational experience by nonfaculty personnel.

Through describing actual events and analyzing them to make sense of a situation or process, the critical incident technique (CIT) encourages a process of reflection in the participants and the researcher. This process of reflection can be beneficial for students and faculty alike. "Reflection-in-action" and "reflection-on-action," terms coined by Schön,²¹ describe building on our understanding and experiences to inform our actions in the situations we encounter. For faculty, the cyclical process of reflection is immediately recognizable, as it involves getting in touch with what students are experiencing, seeing the situation, and trying to change it for the better. Thus, the CIT could be used as a method for faculty development and curriculum development and as a means of educating a reflective practitioner.

This investigation was limited to a convenience sample of a particular group of students in a particular dental school. The aim of qualitative research is to understand and represent the experiences and actions of people as they encounter, engage, and live through situations. On an institutional level, the aim has been achieved, and the results of this investigation have been helpful in guiding practical suggestions for change. The results cannot be generalized to every predoctoral pediatric program, but the ideas and themes may stimulate reflection in faculty and students alike. Qualitative research is well suited to researching uncharted territory, and the data collected and results obtained during this investigation could form the foundation for further research. The CIT is time-consuming and labor-intensive, but the process is immensely personally rewarding for the researcher.

	Conclusions

Top Author information Abstract Materials and Methods Results: positive experiences Results: negative experiences Discussion Conclusions References

 
The critical incident technique (CIT) is a versatile, flexible research method. In this instance, it allowed for the collection of rich, meaningful, concrete, and useful data. Four key factors—the instructor, the patient, the learning process, and the learning environment—were identified as potential influences on the participants’ perceptions of the clinical predoctoral pediatric dentistry experience.

The results have provided a foundation for suggestions for change at a departmental level and might also stimulate topics for discussion for other dental educators at both clinical and administrative levels. On a broader level, the methodology and outcomes of this study demonstrate how the CIT can be a useful tool for faculty and curriculum development.

	Acknowledgments

 
The openness and generosity of the students at Baylor College of Dentistry allowed us to gain a window into their world.

	Author Information

Top Author information Abstract Materials and Methods Results: positive experiences Results: negative experiences Discussion Conclusions References

 
Dr. FitzGerald is Clinical Fellow in Paediatric Dentistry at Our Lady’s Children’s Hospital, Crumlin, Ireland; Dr. Seale is Regents Professor and Chairman, Department of Pediatric Dentistry, Baylor College of Dentistry; Dr. Kerins is Assistant Professor, Department of Pediatric Dentistry, Baylor College of Dentistry; Ms. McElvaney is Research Fellow, School of Psychology, Trinity College, Dublin, Ireland; and Ms. Fitzgerald is Clinical Psychologist, Private Practice, Dublin, Ireland. Direct correspondence and requests for reprints to Dr. Kirsten FitzGerald, Dental Department, Our Lady’s Children’s Hospital, Crumlin, Dublin 12, Ireland; 011-353-1-409-6549 phone; 011-353-1-284-3028 fax; kirsten.fitzgerald{at}olchc.ie.

	REFERENCES

Top Author information Abstract Materials and Methods Results: positive experiences Results: negative experiences Discussion Conclusions References

 

1. Bradley CP. Turning anecdotes into data: the critical incident technique. Fam Pract 1992; 9(1):98–103.[Abstract/Free Full Text]
2. FitzGerald K, Seale NS, Kerins CA, McElvaney R. The critical incident technique: a useful tool for conducting qualitative research. J Dent Educ 2007; 72(3):299–304.
3. Taylor SJ, Bogdan R. Introduction to qualitative research methods: a guidebook and resource. 3^rd ed. New York: John Wiley & Sons, 1998.
4. Glaser BG, Strauss AL. The discovery of grounded theory: strategies for qualitative research. Chicago: Aldine Pub. Co., 1967.
5. Goertzen J, Stewart M, Weston W. Effective teaching behaviours of rural family medicine preceptors. CMAJ 1995; 153(2):161–8.[Abstract]
6. Victoroff KZ, Hogan S. Students’ perceptions of effective learning experiences in dental school: a qualitative study using a critical incident technique. J Dent Educ 2006; 70(2): 124–32.[Abstract/Free Full Text]
7. Henzi D, Davis E, Jasinevicius R, Hendricson W. North American dental students’ perspectives about their clinical education. J Dent Educ 2006; 70(4):361–77.[Abstract/Free Full Text]
8. Pope C, Ziebland S, Mays N. Qualitative research in health care: analysing qualitative data. BMJ 2000; 320(7227): 114–6.[Free Full Text]
9. Henzi D, Davis E, Jasinevicius R, Hendricson W. In the students’ own words: what are the strengths and weaknesses of the dental school curriculum? J Dent Educ 2007; 71(5):632–45.[Abstract/Free Full Text]
10. Manogue M, Brown G, Foster H. Clinical assessment of dental students: values and practices of teachers in restorative dentistry. Med Educ 2001; 35(4):364–70.[Medline]
11. Chambers DW, Geissberger M, Leknius C. Association amongst factors thought to be important by instructors in dental education and perceived effectiveness of these instructors by students. Eur J Dent Educ 2004; 8(4): 147–51.[Medline]
12. Gerzina TM, McLean T, Fairley J. Dental clinical teaching: perceptions of students and teachers. J Dent Educ 2005; 69(12):1377–84.[Abstract/Free Full Text]
13. Schönwetter DJ, Lavigne S, Mazurat R, Nazarko O. Students’ perceptions of effective classroom and clinical teaching in dental and dental hygiene education. J Dent Educ 2006; 70(6):624–35.[Abstract/Free Full Text]
14. Fugill M. Teaching and learning in dental student clinical practice. Eur J Dent Educ 2005; 9(3):131–6.[Medline]
15. Thind A, Atchison K, Andersen R. What determines positive student perceptions of extramural clinical rotations? An analysis using 2003 ADEA senior survey data. J Dent Educ 2005; 69(3):355–62.[Abstract/Free Full Text]
16. Mofidi M, Strauss R, Pitner LL, Sandler ES. Dental students’ reflections on their community-based experiences: the use of critical incidents. J Dent Educ 2003; 67(5): 515–23.[Abstract]
17. Hunter ML, Oliver R, Lewis R. The effect of a community dental service outreach programme on the confidence of undergraduate students to treat children: a pilot study. Eur J Dent Educ 2007; 11(1):10–3.[Medline]
18. Masella RS. The hidden curriculum: value added in dental education. J Dent Educ 2006; 70(3):279–83.[Free Full Text]
19. Lempp H, Seale C. The hidden curriculum in undergraduate medical education: qualitative study of medical students’ perceptions of teaching. BMJ 2004; 329(7469):770–3.[Abstract/Free Full Text]
20. McDonald WM. Creating campus community: in search of Ernest Boyer’s legacy. San Francisco: Jossey-Bass, 2002.
21. Schön DA. Educating the reflective practitioner: toward a new design for teaching and learning in the professions. San Francisco: Jossey-Bass, 1987.

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Similar articles in this journal Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by FitzGerald, K. Articles by Fitzgerald, E. Search for Related Content PubMed Articles by FitzGerald, K. Articles by Fitzgerald, E.