J Dent Educ. 72(5): 600-609 2008
© 2008 American Dental Education Association
From the Students' Corner |
Dental Education from the Students’ Perspective: Curriculum and Climate
Wes R. Cardall, D.M.D.;
R. Chad Rowan, D.D.S.;
Curt Bay, Ph.D.
Key words: dental students, dental schools, faculty, education, curriculum, students, morale, social environment
Submitted for publication 06/15/07;
accepted 01/25/08
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Abstract
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This cross-sectional study compares morale among dental students at five western U.S. dental schools, relates morale to various aspects of the school environment, and determines a prioritized list of the most important aspects of dental education from the students’ perspective. Survey data were collected from students at the end of their first, second, and third years. Respondents answered several questions associated with student morale and listed the three best aspects and three greatest challenges of their school. Lastly, respondents ranked seven different aspects of dental education in order of importance. Surveys were returned by 742 students (66 percent response). Student morale varied significantly in different educational institutions. Morale tended to be lower among third-year students and higher among first-year students. Poor student-faculty relations was the factor most strongly associated with decreased morale. Similarly, positive atmosphere was the factor most frequently associated with high morale. Faculty and clinic experience were the most frequently cited positive aspects of schools; curriculum and clinic experience were the most commonly cited negative aspects. Students commonly perceived clinical experience to be the most important aspect of their education. As students neared graduation, they perceived business management as more important and lab work as less important.
What is the perception of dental students regarding their experience in dental school? Until recently, few studies have addressed the climate and curriculum of dental education from the students’ perspective. Students, as the "consumers" of dental education, may be valuable assets in providing feedback and suggestions for curriculum revision and improvement of the learning environment. Unfortunately, the student voice largely remains an untapped resource, as dialogue regarding the future direction of dental education primarily emanates from faculty, practitioners, professional organizations, and alumni.1 Neglect of the student viewpoint may be the reason why Henzi et al., in the recently conducted Student Perspectives Project, found that current student perceptions of weaknesses in dental education are remarkably similar to those identified by dental students fifty years ago.2
It is sometimes reported in the dental community that dental students suffer from low morale. Can this assertion be validated? If so, what factors contribute to the perceived lack of morale among dental students? Bertolami3 gives several suggestions as to why "dental students do not, in general, like dental school." Among his suggestions are the lack of user-friendliness of dental school, the constant ranking and comparison of students, and the rigidity of dental school structure. However, little empirical documentation of dental student morale exists, and little effort has been made to formally determine the factors that might contribute to a morale problem. Furthermore, if low morale is indeed a problem, is it a universal phenomenon among all dental students, or does it vary across school or year in school?
The Student Perspectives Project has provided several interesting insights. Henzi et al. found that freshmen students rated several aspects of the educational climate of dental school differently than junior students; however, no significant differences were noted among students of different schools.1 Henzi et al. also found that students generally rate their clinical experience positively, with some notable exceptions.4 In a study in which students were asked to list strengths and weaknesses of their education, Henzi et al. stated that "the overall tone of the comments at most of the schools was decidedly positive, and this is an important ‘take-home’ message."2
One theory purports that "an overly stressful learning environment" is a primary contributor to students’ dislike of their dental educational experience.5 Much research has been conducted on the stresses experienced by students during dental school. Several authors have noted that dental students show high levels of stress-related psychosomatic activity and increased mood disturbances.6–10 Lloyd and Musser11 described psychiatric symptoms in dental students approaching those of clinical psychiatric patients. Naidu et al.12 reported that roughly half of the dental students in their study scored in the clinical range, indicating significant psychological disturbance on diagnostic tests. Tedesco13 stated that the continuous scrutiny of clinical professors in dental school creates a highly stressful environment, which becomes increasingly so as students progress through school. The sources of stress in dental school have been well analyzed. In surveys, students consistently rank examinations and student-faculty interactions as two of the most significant sources of stress.7,14 Another study found the limitation of leisure time and the emotional strain experienced during the transition from the security of the classroom to the demands of the clinical phase of dental education to be significant stressors.15 Several studies have examined the relationship between stress and academic performance, with most authors reporting weak to moderate inverse relationships between the two.16–18 Lloyd and Musser11 postulated that heightened interpersonal sensitivity in many dental students is a result of excessive demands on performance made by faculty. In a study by Andrews et al.,19 students enumerated stress as one of the dominant factors contributing to cheating and plagiarism in dental school.
What is the impact of such stressors on student morale? A study of Canadian dental students reported significant increases over time for symptoms of anxiety, depression, and hostility.20 A study of European dental students found that students who reported higher stress levels were more likely to suffer from emotional exhaustion and health problems.21 However, the impact of such symptoms on overall student morale and student attitudes regarding their dental school is largely unknown, including which factors in the dental school environment specifically contribute to lower morale. The current study compares morale among dental students at five western U.S. dental schools and correlates morale with various aspects of the dental school environment.
Aside from an assessment of dental student morale, we were interested in determining what aspects of dental education students consider most important. Until recently, little research has been conducted on how dental students prioritize the value of various components of their educational experience. Again, the Student Perspectives Project has yielded some insight into students’ educational priorities: "Simply stated, dental students cannot wait to get into the clinic and start working on patients. Dental students want as much exposure to patients and as much experience in the clinical setting as feasible." Besides wanting more clinical experience, students expressed a desire for increased participation in community-based service.2 To expand our understanding of these factors, the goal of our study was to produce a rank-ordered inventory of the most important aspects of dental education from the students’ perspective.
The concept of conducting a multischool study of dental education climate and curriculum grew out of a student-initiated year-end survey occurring at one of the dental schools participating in our study. The main intent of this survey was to summarize the feelings of dental students about their experiences at that specific dental school, so a report could be given to faculty and administration with suggestions for improvement. The project took on a broader scope when students at other dental institutions were informed about the study by the investigators. These students then volunteered to conduct parallel surveys at their schools.
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Methods
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Survey data were collected from students near the end of their first (Class of 2008), second (Class of 2007), and third years (Class of 2006) at five western U.S. dental schools. Institutional Review Board approval was obtained from the dental school where data collection was initiated. No identifiers were used in the survey, and participation was voluntary. Consent was implied if the student returned the survey. Surveys were administered either in a class meeting or after a course in which high percentages of students were in attendance. The surveys were completed using pencil or pen. Survey administrators at each school then compiled the surveys and mailed them to the authors for data entry and analysis.
Survey questions were developed by two of the authors (WRC and RCR) in consultation with senior faculty from the initiating school. Some questions were revised after obtaining faculty input. One survey question was deleted after initial data collection, based on comments from respondents who felt the question was ambiguous, leaving seven items total.
Respondents answered four questions associated with student morale. In the first two questions, they rated their personal morale and the perceived morale of their classmates from 1 (poor) to 10 (excellent). Next, using a 1 (very unlikely) to 5 (very likely) scale, participants reported how likely they were to recommend their dental school to predental students and how likely they were to donate their time or money to their dental school after graduation. Responses from these four items were standardized to a range of 1–5 and averaged to create a composite score reflecting overall morale. In two open-ended questions, students were also asked to nominate their school’s three best aspects and the three greatest challenges that needed to be addressed. Two authors (WRC and RCB) sorted the responses into categories, based on the subject (content) of the comment. The valence of the response was assumed to be positive if it was listed among the best aspects and negative if it was listed as a challenge. The authors sorted the responses together, and if they disagreed on category assignment, it was discussed and typically resolved. If agreement could not be reached, the response was omitted.
In addition, students ranked seven components of dental education in order of importance (1=least important to 7=most important). Categories included business management skills, clinical experience, didactic coursework, lab work, participation in organized dentistry, patient management skills, and research opportunities.
Student representatives at each of the participating dental schools received a report of their school’s individual results as well as comparative results among all participating institutions. Reports were then distributed to faculty at each participating school by student representatives. Institution names were withheld in these reports at the request of the participating schools, and labeled School A-through-School E. This study follows the same format by labeling the participating institutions School A-through-School E.
Data were entered into a customized spreadsheet and were then imported into SPSS (Version 14, SPSS Inc., Chicago, IL) and analyzed to identity invalid entries. Errors were checked against the original, numbered response and corrected. Descriptive statistics were calculated for all variables. Counts and percentages are reported for categorical variables and mean ±SD for continuous variables. Data were compared across schools and years using analysis of variance and Scheffe post-hoc tests or chi-square analyses as appropriate. Linear regression analysis was used to assess the relationship between morale scale score and comment categories.
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Results
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Surveys were distributed to 1,122 students and returned by 742 students (66 percent). Response rates by school varied from 57 percent to 93 percent, with an average rate of 72 percent. Percentage responses by school and year are provided in Table 1
. Among the five schools, a total of four classes did not receive surveys, as noted by N/A, either because the class did not exist (one case), the class had already graduated (one case), or there were difficulties related to assembling a large proportion of the class for survey distribution (two cases). In order to avoid identifying the schools, we have not linked the reasons for missing data or the number of respondents in each class to the school.
Morale
The composite morale score ranged from 1 (low morale) to 5 (high morale). Coefficient alpha (internal consistency) for the scale was 0.85. Means and 95 percent confidence intervals for morale are provided, by school, in Figure 1. In this analysis, data were limited to classes 2007 and 2008 and to the four schools with data from both of these classes. By limiting data in this manner, morale scores of students of the same graduation year are compared across schools, thus avoiding the potentially confounding factor of differing graduation year on students’ morale score. Analysis of variance showed two homogeneous subsets: morale at schools B (2.7 ±1.01) and E (2.9 ±1.00) was significantly lower than morale at schools A (3.9 ±0.87) and C (3.8 ±0.90), p<.0001.
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Figure 1. Mean morale and 95 percent confidence intervals at four schools, graduation classes 2007 and 2008
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The analysis was repeated but limited to the two schools having data for all three classes in order to assess trends in morale across year in school. A significant trend, with morale decreasing across graduation years (p<0.001), is noted in Figure 2: classes 2006 (2.5 ±0.97), 2007 (2.9 ±0.96), and 2008 (3.3 ±0.98). Finally, morale was compared for classes 2007 and 2008 for the four schools with these data. A significant difference was noted between the classes of 2007 (3.1 ±1.0) and 2008 (3.7 ±1.0), p<0.001.
Student responses to the open-ended questions eliciting positive and negative aspects of their schools were grouped by content area. A total of 1,576 positive and 1,477 negative comments were provided. Of these, 1,238 (78.6 percent) positive comments could be categorized into fourteen content areas, and 1,141 (77.3 percent) negative comments could be categorized into fourteen content areas. The content areas are ranked in descending order of frequency in Table 2, and counts and percentages for each content area are provided. Nine content areas appeared in both positive and negative comments: faculty, clinic experience, curriculum, facilities, patient pool, student/faculty relations, tuition, staff, and student/faculty ratio. Content areas with fewer than five responses were omitted. In many responses, the subject of the comment was associated with a modifier. As an example, when "faculty" was noted as one of the best aspects of a school, the word was modified by no fewer than twenty adjectives, including the following: strong, awesome, highly educated, experienced, world-renowned, etc. Most commonly (in 109 of the 229 mentions of faculty as a positive aspect), students simply noted "faculty," "professors," or "instructors."
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Table 2. Counts and percentages of total responses within each content category for positive and negative comments
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To assess the relationship between these response categories and morale, the morale scale score was regressed on positive and negative response categories (coded "0" or "1") using a stepwise linear regression analysis, with backward elimination, p<0.05. Those areas that remained uniquely significant, along with standardized regression coefficients and p-values, are provided in Table 3. A "P" prefix denotes a positive comment, and "N" denotes a negative comment. For each negative comment, the coefficient valence was negative, as anticipated. For each positive comment, the coefficient was positive, with one exception: comments concerning a school’s reputation were associated with significantly lower morale, a counterintuitive finding. Overall, the content areas accounted for 23 percent of the variance in morale score, p<0.001. From the original twenty-eight categories, twelve (six negative and six positive) were uniquely predictive of morale. A positive atmosphere and negative student-faculty relations were the strongest predictors of morale.
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Table 3. Standardized regression coefficients and p-values for morale scale score regressed on positive and negative response categories (multiple R2=.23)
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Education
Mean ratings of the importance of educational categories are provided in Figure 3. Data were limited to classes 2007 and 2008 and to the four schools with data from both classes. Every class at each institution ranked clinical experience and patient management skills as the most important factors in dental education; participation in organized dentistry and research opportunities were ranked as the least important factors.
The analysis was repeated, limiting data to the two schools having data for all three classes in order to assess trend in importance over time (Figure 4). Analysis of change in rated importance across years showed that lab work was less important (p<0.001) and business management was more important (p=0.001) as students neared graduation.
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Discussion
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Our data do not indicate widespread evidence of low morale among dental students at the participating schools. However, perceptions of morale varied significantly at different dental schools, and students reported lower morale at schools B and E than at schools A, C, and D. Poor student-faculty relations was the factor most strongly associated with decreased levels of morale. On the other hand, higher morale scores tended to be associated with comments about a positive atmosphere. Certainly, rapport between faculty and students, whether positive or negative, seems to have the largest impact upon dental student morale and dental students’ perceptions of their educational experience. Other factors that were frequently associated with high student morale, as listed by students in this study, included clinic experience and quality of faculty.
Our study confirms the importance of maintaining a positive atmosphere with collegial student-faculty relations in the dental school environment. It also supports previous studies of stress in dental school, which have consistently ranked student-faculty interactions as one of the most significant sources of stress.7,14 Other studies have also reported concerns regarding the faculty-student relationship in dental school. Henzi et al.’s widely distributed survey of dental students found that "emotional climate" and "faculty supportiveness" were given low ratings by students.1 Henzi et al. also noted that one of the most prevalent negative themes gathered from students’ written comments about their clinic experience focused on instructors’ inconsistent feedback and condescending feedback.4 Chambers et al. found that faculty members who conceive their roles as motivating students, showing compassion and caring, and being proactive tended to receive high ratings for teaching effectiveness from students; on the other hand, faculty members who placed emphasis on expertise as key to being a good instructor received much lower ratings for teaching effectiveness from students.22 This latter finding may seem counterintuitive, as did our finding that students’ comments about their school’s strong reputation were associated with significantly lower morale. One benefit of the current study is in establishing a significant direct correlation between student-faculty relations and student morale. Since the morale construct used in this study was comprised of questions that included willingness of respondents to contribute financially to their dental school after graduation and recommend their dental school to others, it could be concluded that students who enjoy positive relations with faculty report that they are also more likely to give back to their school. Consequently, dental schools seeking to increase alumni contributions may benefit from improving the student-faculty atmosphere.
Student morale appears to decrease as students progress through dental school. A similar trend was seen in an Australian study of medical students.23 In our study, the decrease in morale can be partially attributed to many of the factors shown in Table 3
, including poor student-faculty relations, problems with staff members, or concerns regarding patient pool. Each of these factors, which contribute significantly to decreased morale, are accentuated as the student transitions from the lecture halls of the first year to the preclinical environment of the second year and finally to the clinic. For example, first-year students have very limited personal interaction with faculty and staff members—as they spend the majority of their time in biomedical and preclinical lectures—and likely have no concerns about patient pool since they have yet to reach the clinic. However, third-year students tend to have close interaction with faculty and staff members on a regular basis, and their assigned patient pool may become an issue. A long-term prospective study documenting morale among students as they progress through dental school would be useful to validate the cross-sectional results obtained in this study. A prospective study would also provide faculty and administration with additional information regarding when morale begins to decline and what factors contribute to the decrease.
Of note, dental students at each school surveyed in our study perceived themselves as having higher morale than their classmates. This may be an extension of the "above-average effect," the oft-documented phenomenon named for the tendency of individuals to perceive themselves as above average when compared to their peers.24
Faculty and clinic experience were most frequently enumerated by students as the best aspects of their dental school. Interestingly, clinic experience was also cited most frequently as one of the main challenges that needed to be addressed—along with curriculum. Whether for better or for worse, clinic experience seems to be on the students’ minds. This finding agrees with Henzi et al.’s assessment2 and with the results of students’ educational prioritization rankings in this study, in which students almost universally perceived clinical experience to be the most important aspect of their dental education, regardless of year in school.
The relative order of dental educational prioritization reported in this study was consistent when comparing results among students at five dental institutions with large samples. Significant differences were seen in the mean importance rating given to lab work and business management skills when comparing results among students of different graduation years. Specifically, there was a notable decrease in the perceived importance of lab work as students progressed toward graduation. The respondents in the class of 2008—students who, at the time of survey distribution, were spending considerably more time completing lab work than students of other classes—ranked it higher in relative order of educational importance than did students in the classes of 2007 and 2006. In similar fashion, students in the class of 2006—those nearest to graduation—perceived business management skills to be much more important than students in the classes of 2007 and 2008. The upward trend in perceived importance of business management likely continues beyond graduation, as surveys of recent graduates routinely find that graduated students feel their education in practice management was inadequate.25–29
Several limitations of this study exist. We were not able to obtain a full complement of participants at all schools for varying reasons, so analyses were truncated to subsets in order to avoid potentially confounded results. Another limitation involves the inherent variation of student personalities at different dental schools. Because students choose to attend their dental school based on a variety of criteria, students with similar attitudes may be more likely to attend certain schools; thus, the data may reflect student type, as well as characteristics of the schools. Finally, standardization of the time of distribution of the morale survey proved challenging. Due to variation in school schedules and coordination difficulties with survey distributors, the exact time of distribution of the survey—whether mid-semester, end of semester, or beginning of the following semester—varied among schools.
The discrepancies in morale among students at different dental schools complicate generalization of these results. Further studies are needed to determine if students at other dental schools report morale similar to that obtained in this study. We recommend surveying recent graduates of dental school to see if their attitudes change with time, as well as to assess changes in graduates’ rankings of the importance of various aspects of dental education. We also recommend surveying dental school faculty to determine their ratings of the importance of components of the educational experience in order to compare responses between faculty and students and identify discordant areas.
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Acknowledgments
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We would like to thank Drs. Karen Lefever, Chris Olson, Jenny Vasillian, and Dezireh Sevanesian for their assistance in this project. We also acknowledge the National Institute of Dental and Craniofacial Research for generously supporting travel to the 2006 International Association of Dental Research Annual Session in Australia, where two of the authors (WRC and RCR) presented the findings reported here.
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Author Information
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Dr. Cardall recently graduated (Class of 2007) from the Arizona School of Dentistry & Oral Health, A.T. Still University, and is currently in private practice in Provo, UT; Dr. Rowan recently graduated from the University of California, Los Angeles School of Dentistry (Class of 2007) and is currently a postdoctoral orthodontic resident at St. Louis University; and Dr. Bay is Associate Professor, Biostatistics, Arizona School of Health Sciences, A.T. Still University. Direct correspondence and requests for reprints to Dr. Curt Bay, 5850 E. Still Circle, Mesa, AZ 85206; 480-219-6000 phone; 480-219-6110 fax; cbay{at}atsu.edu.
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Abstract
Methods
