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Abstract
While placements in external locations are being increasingly used in dental education globally, few studies have explored the student learning experience at such placements. The purpose of this study was to investigate student experiences while on external placement in a baccalaureate dental hygiene program. A self-reporting questionnaire was distributed to final-year dental hygiene students (n=77) at the University of Newcastle, Australia, in 2010. The questionnaire included questions regarding the type of placement, experiences offered, supervision, resources available, and lasting impressions. Responding students were generally positive about their external placement experience and indicated that the majority of facilities provided them with the opportunity to provide direct patient care and perform clinical tasks typical of a practicing hygienist. However, there was a statistically significant difference in their opinions about discipline-focused and community placements. Students indicated that their external placement experience provided opportunities to learn more about time and patient management, including hands-on experience with specific clinical tasks. Ongoing evaluations are necessary to ensure that external placements meet both student needs and intended learning outcomes within dental hygiene programs.
- dental hygiene education
- dental hygiene students
- community-based dental education
- community dentistry
- Australia
Expansion of students’ clinical experience via the use of placements remote from the home institution is being increasingly used in predoctoral dental and allied dental education and training internationally, including across Australia.1–5 Also referred to as service-learning or community-based experiences, these external placements aim to expose students to a different cohort of patients than those generally seen in teaching hospitals or university clinics and allow a more real-life approach to treatment planning and patient care.6–8 Students report that external placements contribute to improved time management and self-confidence in their abilities.5,9,10 External placements are often established in conjunction with the local oral health authorities, and it is hoped the experience will enhance staff recruitment and retention in these facilities and increase community access to services.1,11 Educational institutions can also benefit from the financial arrangements with such facilities.9,12 Since both dental education and dental hygiene education are expensive, utilizing existing clinics for external placements can reduce the burden on institutional resources.
Although studies have examined the process of establishing and developing community-based programs,3,13 it would be useful to have ongoing evaluations of both student and staff experiences for continued program development in established programs. Apart from a small number of studies,4,5 however, there is a surprising lack of research in this important area of dental education. In Australia, a number of new baccalaureate dental hygiene programs have been established in the last ten years, many of which utilize external placements for final-year students.14 Research studies of such placements might help inform the development of the teaching and learning experience of students and staff involved with clinical placement in dental hygiene programs; this should ensure that external placements meet both student needs and learning outcomes.
In Australia, registration as a dental hygienist with the Dental Board requires the completion of either a two-year advanced diploma or associate degree or a three-year bachelor’s degree. Numbers of incoming students vary widely depending on the size of the educational institution, but typically include between thirty and eighty students per class each year. Dental hygienists practicing in Australia perform under the direct supervision of a dentist and are expected to have competent skills in periodontal charting, debridement, subgingival curettage, fluoride application, taking impressions, pouring and trimming study models, taking radiographs, administering local anesthesia, placing fissure sealants, and performing orthodontic tasks. They are also educated in oral health promotion and the ethical and social responsibilities of the profession to the wider community. External placements in dental hygiene education and training are believed to help students acquire these skills, so they may graduate as competent practitioners with an awareness of community health issues.
The aim of our study was to investigate student experiences during external placement in a baccalaureate dental hygiene program. This research was part of a larger project, which collected both quantitative and qualitative feedback from both students and supervisory staff. This article will report on the feedback of students participating in external placements, following the completion of their rotation, as delivered to university placement coordinators.
Methods
This descriptive and exploratory research used a cross-sectional approach, using a questionnaire for data collection. The study was approved by the University of Newcastle Human Research and Ethics Committee (Approval No. H-2010-1091).
The entire cohort of final-year dental hygiene students at the University of Newcastle in 2010 (n=77) was selected to participate in this study. As part of their requirements for completing the bachelor of oral health program, students are required to attend compulsory external placements in a variety of settings, including discipline-focused clinics and community settings such as public clinics and teaching hospitals. They are required to attend a minimum of thirty-two hours in each discipline-focused clinic (periodontics, pediatrics, special care, and orthodontics) and 144 hours across three community clinics; this is usually achieved by attending one day per week for a six-week period for each placement. This variety ensures that students are clinically competent to work in a range of dental clinics upon graduation. During the placement hours, the student works as an operative chairside assistant and also observes clinical treatments. There were no restrictions or minimum requirements for these activities. Students will often be scheduled to complete more than one placement at a time and are also required to complete six hours per week at the university clinic. Students could elect to replace one of their community placements with a two-week block placement in a rural location.
The majority of external placement facilities are government-funded public clinics, where pensioners, low-income earners, and children receive essential treatment free of charge. The students attend external placements in groups of three or four. Where multiple chairs are available, more than one group is assigned to a facility. Students are required to keep a record of their clinical experience, are evaluated by their supervisors, and attempt to have clinical competencies assessed; however, there is no minimum requirement of procedures to be completed. Supervisors at each venue are either an existing staff member who has agreed to supervise the students or a university faculty member registered with the Dental Board of Australia as a dental practitioner (dentist, hygienist, oral health therapist, or specialist).
In 2010, the selected cohort was invited to complete a placement experience questionnaire for each external placement attended, after completion of the placement. The questionnaire was developed by the authors and was piloted amongst a selection of dental hygienists who were university faculty members and past hygiene students who were completing postgraduate study at the university (n=4). All indicated that the questionnaire was easy to read and understand. It consisted of both tick-box questions on rating scales and short-answer responses and covered the type of placement attended, experiences offered, supervision, resources available, and lasting impressions. A cover letter explaining the purpose of the research and emphasizing the voluntary nature of participation was attached to the front of the questionnaire. Consent was implied by the voluntary completion and return of the questionnaire.
Quantitative data were entered into a generic spreadsheet program and analyzed using the Stata Version 10 statistical software package. Qualitative responses were analyzed by a member of the research team and were managed by grouping responses according to the type of placement facility (community and discipline-focused, with observational discipline-focused facilities analyzed separately) and categorizing responses to identify common themes.
Results
A total of 294 surveys were returned from students, which was a 62 percent response rate. The respondents reported their experiences on external placement, reporting that 89.2 percent of the facilities offered students the opportunity to provide direct patient care and 79.3 percent supported students’ dental assisting for their peers. The clinical tasks experienced by the students were also reported. In the venues where students provided direct patient care, the respondents reported regularly performing oral examinations (72.7 percent), ultrasonic scaling (89.6 percent), handscaling (79.2 percent), prophylaxis (81.9 percent), and oral hygiene instruction (92.7 percent). All tasks pertinent to dental hygiene practice in Australia were available during the placement experience, including periodontal charting, impression taking, application of sealants, radiographs, and administering local anesthesia.
Overall, the students responded positively when asked about the appropriateness of placements, support and feedback, the learning experience, and their overall opinion of the placements (Table 1). Students reporting on rural block placements responded more positively than those reporting community settings, with both achieving more positive results that discipline-focused placements. The one-way analysis of variance (ANOVA) indicated a statistically significant difference in opinion of placement experience between the type of external placement facilities, with the Bonferroni pairwise comparison finding the difference in opinion between discipline-focused and community placements (p<0.001).
Mean scores of student perceptions of clinical placements, scored by type of placement
When asked about whether they felt the balance between clinic time on the university campus and on external placement was appropriate, almost half of the respondents (49.8 percent) indicated that they did feel the balance was appropriate. A further 23.7 percent indicated that they would like more time on placement, and 26.4 percent responded that they would like more time on campus.
The students provided a wide variety of responses when asked “What was the most valuable learning experience at this placement?” although common themes were found among types of facilities. Respondents indicated that the community clinics provided experience in patient and time management and administering local anesthesia and gave them valuable insight into the public health system. In regards to the discipline-focused placements, the students found specific hands-on experiences most valuable, such as providing individualized oral hygiene instruction and use of indices in periodontics, placing fissure sealants and liaising with dietitians in pediatrics, and performing orthodontic procedures in orthodontics. More than half of those who attended purely observational placements indicated that they were unsatisfied.
Discussion
High-quality teaching and learning opportunities are necessary in dental hygiene education. Exposing students to a variety of patients and environments as part of clinical placements not only improves educational outcomes, but encourages community engagement and increases access to dental care for the underserved.9 Students in the Bachelor of Oral Health program at the University of Newcastle participate in a variety of external placements in their final year of studies to achieve these aims and provided feedback on their experience in this study. Similar external placement programs in the United Kingdom and United States have demonstrated that this approach is advantageous in developing students’ clinical skills and increasing their confidence levels, facilitating the transition from education to practice.6,7,10
The majority of facilities in our study offered students the opportunity to provide direct patient care and assist chairside for their peers. It is worth noting that at our university the students are encouraged to provide chairside assistance for other students in the clinic on campus, as it is perceived to contribute to the learning experience by observing patient care and it encourages collaboration. Engaging in patient care in such facilities addresses community needs and is integral in today’s higher education, in which graduates should not only be clinically competent but knowledgeable about community health issues.15 Clinical tasks performed at the placement facilities in our study appeared to mostly include ultrasonic scaling, hand scaling, prophylaxis, and oral hygiene instruction; this is unsurprising as these tasks are typical of the daily tasks performed by graduates in general practice. This finding is also similar to a study examining a primary dental care outreach course in the United Kingdom, which found that clinical activity in outreach clinics was representative of working life in general practice.13
The students in our study responded favorably to the community and rural placements, more so than to the discipline-focused placements. Given that only a small proportion of dental hygiene graduates will work in discipline-specific practices,16 community and rural placements may more closely resemble their future careers and therefore increase the perceived benefit of such placements. The less favorable response to discipline-focused placements may have been influenced by the fact that a number of these placements provided observation rather than direct patient care; in select facilities, the patients were not suitable for treatment by undergraduate students. Many students at one particular observational placement facility did not perceive it to be a worthwhile learning experience and thought it a waste of time. It may be that students at these facilities require more direction and education about the benefits of observation and how they can learn from the experience.
Time management and patient management were common themes when our participants were asked about their most valuable learning experience in community facilities. Similarly, dental students in an outreach course in the United Kingdom also identified time management (42 percent) and treating the whole patient (23 percent) as benefits drawn from their experiences.4 These opportunities enhance the process by which students develop into competent practitioners, and previous research indicates that students find these experiences beneficial as they increase confidence and professional judgment.5
It is essential that these evaluations are used to help improve the teaching and learning experience of students and staff involved with clinical placement in dental hygiene programs. While the feedback from our study was generally positive, it should be recognized that a small number of placement facilities are not meeting the students’ expectations or needs; these need to be closely reviewed and their suitability should be reconsidered for future cohorts. Of course, evaluations of the external placement experience should be ongoing. Investigating the students’ expectations, challenges, and both personal and professional development would add depth to this research. Collection of such data would require focus groups or a lengthy survey; this would increase the obligations of students to report feedback and may in turn potentially reduce response rates. It is worth considering that completing these evaluations could be embedded into the curriculum as such through formative assessments, contributing to the students’ reflection on their learning experience.
It is important to acknowledge that the information gathered in our study was self-reported, which can introduce reporting bias. Future studies should consider measuring specific outcomes such as number of patients treated and number of treatments performed to match with self-reported data. Another potential source of bias may have been introduced since a single researcher was involved in the qualitative analysis; however, the themes identified were consistent with the type of facility. While the response rate in this study is reasonable, its modesty reflects the difficult nature of recruiting students for this kind of voluntary research. In particular, absenteeism from university classes is unavoidable and becomes a limitation in recruitment, as it often is in student-based investigations. Nevertheless, it is always important to investigate student groups to explore their educational experiences.
Conclusions
Our study found that these dental hygiene students had participated in a wide range of external placements, reported exposure to a variety of clinical skills, and on the whole felt positive about their experiences. When compared to community and rural placements, however, their feedback was less favorable for placements offering fewer typical clinical experiences. Continued research investigating student experiences is indicated for dental hygiene curriculum development and review; longitudinal studies would be particularly valuable.
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