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Abstract
Successful integration of critical thinking and evidence-based dentistry (EBD) concepts throughout didactic and clinical dental curricula require faculty support. Critical thinking and EBD definitions and practice continue to evolve, and not all dental faculty members were exposed to such concepts during their education. The objective of this study was to understand faculty members’ perspectives on both critical thinking and EBD. An online survey was designed to assess full- and part-time faculty members’ understanding, practice and teaching of critical thinking and EBD, interest in and perceived significance of EBD, and perceived barriers to teaching critical thinking and EBD at one U.S. dental school. Forty-three faculty members completed the survey for a 41 percent response rate. Most respondents (46 percent) defined critical thinking as the use of evidence or the scientific method in decision making and EBD as clinical practice based on “science only” (39 percent) or “quality science only” (34 percent). Based on their individual definitions, over 75 percent of the respondents reported incorporating critical thinking into didactic and clinical teaching; 79 percent and 47 percent, respectively, reported incorporating EBD into their didactic and clinical teaching. While these faculty members confirmed the importance of teaching students EBD, they identified barriers to teaching as time, knowledge, and resources. These results, which reflect one school’s efforts to understand faculty perceptions and practices of EBD, suggest that faculty training and resource support are necessary for successful curricular integration of critical thinking and EBD.
Current dental students are expected to be lifelong learners, adept at critical thinking and evidence-based dental practice.1 Critical thinking has been defined multiple ways in the dental literature;2–8 working definitions are currently being focused to fit the revised Commission on Dental Accreditation (CODA) standards to be implemented in 2013.1 CODA presents a metacognitive definition (i.e., thinking about one’s thinking) with professional application to decision making. Evidence-based dentistry (EBD) is defined as the integration of science, clinician experience, and patient values serving as the foundation for clinical care.9–11 EBD is not a new concept; however, the emphasis on critiquing science and focusing on quality science is relatively new.
Not all dentists, including dental school faculty, were taught about research design, critiquing the literature, and the five-step EBD process (ask, acquire, appraise, apply, and evaluate) during their education.12–15 In addition, many components of EBD practice, including the five-step process, critical appraisal, and use of critically appraised secondary sources, were developed during the past fifteen to twenty years and continue to evolve. Although dental faculty members may have had opportunities to pursue training in EBD through continuing education, the extent to which they have done so and their mastery of and comfort with EBD are unknown. As dental schools continue to integrate critical thinking and EBD into curricula, particularly when crossing from didactic literature review courses to the clinic floor, the acceptance, knowledge, and comfort level of floor clinicians need to be better understood. A review of the literature did not identify studies of either dental faculty members’ perspectives on or strategies for identifying faculty members’ perspectives on critical thinking or EBD.
At the University of Iowa College of Dentistry, faculty members are preparing revisions to the D2 and D3 critical thinking and EBD content to prepare students to independently apply evidence-based decision making skills in the clinical setting at the beginning of the D4 year. As part of the curricular revisions, we developed a survey to identify our faculty’s perspectives on EBD. Specifically, we sought to identify their current teaching and practice of critical thinking and EBD, interest in teaching critical thinking and EBD, perceived barriers to teaching critical thinking and EBD, and perceptions of the terms “critical thinking” and “evidence-based dentistry.” This article reports the results of this study.
Methods
The study design was descriptive; data were collected using Survey@Iowa (WebSurveyor Corporation, 1997–2006). The study was approved by the University of Iowa’s Institutional Review Board.
All full- and part-time faculty members (n=105), 92 percent of whom are dentists, employed by the College of Dentistry at the University of Iowa during the fall of 2010 were invited to participate. The three faculty members conducting the research and one faculty member with significant medical concerns were excluded from participation. Fortythree faculty members completed the survey for a 41 percent response rate.
The forty-one questions on the survey were designed to determine faculty members’ background (eight questions) and practice and teaching of critical thinking (eight questions) and EBD (eleven questions) throughout the dental curriculum. Two additional questions targeted the faculty member’s interest in and perceived significance of EBD for both the respondent and his or her students. Other questions addressed perceived barriers to implementation of teaching critical thinking (five questions) and EBD (five questions) and needed resources (two questions). Skip logic was employed to target questions based on earlier responses. Question format was categorical for behavior-based questions (e.g., Do you incorporate EBD into your didactic teaching?) and open-ended for mechanistic (e.g., How do you incorporate EBD into your didactic teaching?) and opinion (e.g., Why don’t you assess your students’ ability to practice EBD?) questions. Open-ended rather than multiple-choice questions were used to assess knowledge (e.g., How do you define critical thinking?), so that we did not lead respondents to provide a perceived correct response. Following development, the questionnaire was piloted with a sample of faculty members (n=5) with knowledge of EBD and/or educational research; feedback (primarily clarification of questions) was integrated into the survey.
Full- and part-time faculty members were invited by e-mail to participate in the survey, with an e-mail reminder sent three weeks following the initial e-mail. A second e-mail reminder was canceled as 95 percent of faculty members had opened and either aborted (54 percent) or completed (41 percent) the survey at that point and we did not feel that an additional e-mail would improve participation by those who had aborted the survey. Survey responses are automatically linked to e-mail addresses; thus, the survey was not anonymous. However, the survey was considered confidential as e-mail addresses were deleted when downloading the data to prevent responses being linked to individual faculty members.
Responses to open-ended questions were reviewed for the nature and consistency of response. Based on the nature of the responses, categories were developed, and responses were assigned to categories prior to statistical analyses. Descriptive statistics were calculated by Survey@Iowa, while bivariate analyses were conducted using SAS for Windows (v. 9.1, SAS Institute Inc., Cary, NC, USA). Bivariate analyses included chi-square test, Fisher’s exact test for categorical variables, and the nonparametric Wilcoxon rank-sum test for quantitative measures. A p-value of <0.05 was considered statistically significant.
Results
Responding faculty members were mostly male (69 percent) and older with 30 percent between forty-five and fifty-four years, 33 percent between fifty-five and sixty-four years, and 16 percent sixty-five years of age or older. Seven percent of respondents had been active professionally for less than ten years, 19 percent for ten to nineteen years, 28 percent for twenty to twenty-nine years, 35 percent for thirty to thirty-nine years, 9 percent for forty to forty-nine years, and 2 percent for more than fifty years. Years in dental education mirrored years in practice with 21 percent of respondents teaching less than ten years, 26 percent for ten to nineteen years, 23 percent for twenty to twenty-nine years, 19 percent for thirty to thirty-nine years, and 9 percent for more than forty years.
Thirty-five percent of the respondents reported attending an EBD conference, with five faculty members participating in the American Dental Association’s Champions conference, four faculty members attending a University of Iowa College of Dentistry-sponsored continuing education course, and the remaining faculty members attending specialty-sponsored events. Respondents with between twenty and thirty-nine years in professional practice were more likely to have attended an EBD conference than those with less than nineteen or forty or more years of practice (p=0.012). Most respondents had multiple teaching responsibilities including lecturing in didactic, simulation, or clinic courses; serving as a course director of didactic, simulation, or clinic courses; facilitating problem- or case-based learning; and teaching on the clinic floor.
The free responses defining critical thinking were collapsed into five categories: 46 percent of the respondents defined critical thinking as “use of evidence or the scientific method in decision making,” 27 percent as “asking questions and seeking answers during problem-solving,” 8 percent as “a decision making process,” 5 percent as “a reflective process evaluating one’s thinking,” and 5 percent as “using information to develop treatment plans.” Respondents aged forty-five to fifty-four were more likely to define critical thinking as “use of evidence or the scientific method in decision making,” while those aged fifty-five and older were more likely to define critical thinking as “asking questions and seeking answers during problem-solving” than other ages (p=0.041). Based on their own definitions, 79 percent of the respondents with didactic responsibilities and 77 percent of those with simulation or clinic courses incorporate critical thinking within their teaching. The free responses to “how do you incorporate critical thinking into your teaching?” were also collapsed. Use of literature (n=11) and question/answers (n=10) were reported most often by faculty members teaching didactic courses, while case studies/problems (n=9) and objective structured clinical exams (n=6) were reported most often by those teaching simulation and clinical courses. Eighty-one percent of respondents who reported including critical thinking in their instruction said they assess their students’ ability to think critically. Faculty members reported assessing critical thinking skills through use of daily evaluations (n=10), question/answer exams (n=10), clinical performance (n=5), treatment planning performance (n=5), self-evaluation (n=2), and literature evaluation (n=2).
Free responses defining EBD were collapsed into six categories: 39 percent of respondents defined EBD as clinical practice based on “science only,” 34 percent as “quality science only,” 5 percent as “clinical experience only,” 8 percent as “science combined with experience,” 5 percent as “quality science combined with experience,” and 8 percent as “science, experience, and patient values.” Based on their own definitions, 74 percent of these respondents incorporated EBD into their clinical practice, while 79 percent of those with didactic responsibilities and 47 percent of those with simulation or clinic courses incorporated EBD into their teaching. Faculty members reporting that they practiced EBD had been involved in dental education longer than those who did not practice EBD (21.0 vs. 8.8 years; p=0.042). Free responses to “how do you incorporate EBD into your teaching?” were collapsed: use of literature evidence was reported most often by both faculty members teaching didactic courses (n=21) and those teaching simulation or clinic courses (n=9). Thirty-five percent of respondents who reported including EBD in their instruction said they assess students’ ability to practice EBD. Of these, 28 percent said they assess the students’ ability to search the literature, 30 percent to appraise the literature, and 37 percent to apply the information to their patient. Of the respondents not currently incorporating critical thinking or EBD into their teaching, 75 percent indicated an interest in including critical thinking and 54 percent an interest in including EBD. Time (n=12), lack of scientific evidence (n=6), and knowledge (n=3) were identified as obstacles interfering with inclusion of critical thinking and EBD in teaching.
Faculty members’ perceptions relative to EBD were also explored. In response to the question “how strongly do you agree with the concept of EBD?” 77 percent of the respondents “strongly agreed” and 23 percent “agreed.” Faculty members were also asked “How important is it for the dental students to be taught EBD?” Among these responses, 79 percent said it was “extremely important,” 12 percent “very important,” and 9 percent “important.” Faculty members were asked to identify what educational support they needed to incorporate either critical thinking or EBD into their teaching. Multiple responses were allowed per respondent and included time (n=24), education (n=18), money (n=6), and resources (n=4). Respondents were also asked to identify what skills or background the students needed before faculty members could incorporate either critical thinking or EBD into their teaching. Again, multiple responses were allowed per respondent and included an understanding of “the literature—the ability to search, read, interpret, and evaluate the literature” (n=19), “basic sciences” (n=5), “the scientific process (i.e., an understanding of hypothesis development, experimental design, protocol execution, and statistical analyses)” (n=3), “independent learning skills” (n=3), “critical thinking skills” (n=3), and “the science of dentistry” (n=2).
Discussion
We are in the process of designing and expanding the critical thinking and EBD content in our curriculum. Students are currently introduced to critical thinking and EBD in the D1 year through problem-based learning, with limited conceptual reinforcement and varying levels of clinic integration in the D2 and D3 years. Successful integration of curricular content depends on a unified curricular presentation by a critical mass of faculty members across disciplines and years. Anecdotal reports suggested that some faculty members were willing and interested in both critical thinking and EBD, while some were uncomfortable with the topics. Thus, the primary objective of our survey was to understand our faculty’s perceptions and behaviors relative to critical thinking and EBD so that we had realistic expectations for development and implementation of an effective, cohesive critical thinking and EBD curriculum. Furthermore, although discussion of critical thinking and EBD is prevalent in the dental literature, the literature reporting faculty perceptions of critical thinking or EBD with respect to implementation of new curricular content is limited.
Faculty members responding to our survey were mostly older, with over twenty years of both clinical and teaching experience. One-third had attended some sort of EBD conference, suggesting that our respondents were biased in favor of EBD. The respondents reported multiple responsibilities and represented didactic, clinic, lecture, and small-group teaching across the four years. The majority of the respondents defined critical thinking within an applied framework—that is, the ability to process evidence or science in decision making and/or problem-solving as opposed to the metacognitive definition of evaluating one’s thinking processes.2,3 Older respondents were more likely to associate critical thinking with the Socratic method of teaching,16 while younger respondents associated critical thinking with use of science in decision making.6 These data are consistent with changes in thinking concepts throughout the dental and medical literature.4–7
Regardless of how individual respondents chose to define critical thinking, the majority incorporated their definition of critical thinking into their teaching. Teaching strategies reflected their definitions and included both use of the literature and question-answer strategies. Of those respondents who reported incorporating critical thinking into their teaching, approximately 80 percent said they chose to assess such skills both in clinic and didactic activities. Although these faculty members are not defining critical thinking from a metacognitive perspective, their definitions reflect a dental and/or science-based application. Assessment of critical thinking skills within the context of clinical practice is necessary to develop independent practitioners.4–8 We do not know whether students are critically thinking from a metacognitive perspective, which is necessary for self-assessment and lifelong learning and a component of the revised 2013 CODA standards.1 Our results suggest that evaluation of students’ critical thinking skills and/or further development of meta-cognitive processes through curricular efforts are in order. The vast majority of respondents to our survey associated EBD with science; few identified clinician experiences and patient values as components of EBD. Again, the vast majority of these respondents said they incorporate EBD into their clinical practice and didactic teaching, while less than half said they include EBD in simulation or clinical teaching. Use of the literature was reported to be the most common strategy for teaching EBD, and only about one-third of these respondents said they assess students’ ability to practice EBD.
Consistent with the 2013 CODA standards,1 our faculty respondents overwhelmingly supported the inclusion of both critical thinking and EBD in the dental school curriculum and agreed that today’s students need to be taught EBD. These respondents identified time, knowledge, and resources as impediments to their ability to teach both critical thinking and EBD. They also identified student preparation as a barrier to teaching EBD; before science can be applied to patient situations, the student must be able to read and critique the science and be able to think both independently and critically. Our respondents’ perception that students are not yet prepared to integrate critical thinking and EBD in clinic settings is consistent with clinic faculty members’ being less likely to report teaching critical thinking or EBD. Clinic faculty members anecdotally report that students are challenged to provide adequate patient care, particularly with complex patients in a timely fashion. The thought of adding critical thinking and EBD content on top of current clinic expectations could invite resistance. With this in mind, we are developing online curricular content with reference to clinic application for our D2 students and integrating it into current D3 clinic activities.
Many practicing faculty members, including the preponderance of our respondents, attended dental school when dental curricula were said to define the truth and developed clinical skills based on experience.12 Regardless of graduation year, practicing dentists report a greater use of continuing education courses than print journals when seeking information to support clinical decisions, and recent graduates report more peer consultation than use of print journals.17 Historically, few dentists were expected to read the literature, let alone critique research designs, statistical appropriateness, and interpretation of results. Introduction of the EBD concept into the dental literature has been resisted and perceived as threatening by some—pitting advocates of “in my hands” against proponents of “the science says.”9,11 Results from our faculty respondents who support EBD suggest that faculty education is necessary before faculty members can effectively guide student growth in EBD. Beginning with the three-domain definition of EBD, such education should emphasize key EBD elements (ask, acquire, appraise, apply, and evaluate) with emphasis on question formation and science appraisal.18 In addition, introduction to critical appraisal tools and EBD secondary sources is likely necessary for efficient clinical implementation.13,18,19 Evaluation of students’ critical thinking and EBD skills, including the provision of appropriate feedback, is time-intensive and will also require administrative support for additional resources.
The limitations of this study are numerous. The survey was designed to assess a topic that has not been reported on previously, which made it impossible to build upon earlier efforts. The survey was administered at one school at one time point, which precludes reliability determination. Critical thinking and EBD are evolving areas currently discussed in both the dental literature and our college, making examination of survey validity difficult. The data were self-reported and may reflect what respondents thought we wanted to hear rather than their true perceptions. To partially alleviate these concerns, we used open-ended questions rather than providing definitions of critical thinking or EBD either within questions or multiple-choice responses.
In addition, our response rate was less than 50 percent, with a high abort rate. Although some aborting non-respondents may have primarily administrative or research responsibilities and found the survey of little personal relevance, other non-respondents could perceive EBD as threatening and oppose curricular inclusion. The survey was long, so respondents may have aborted due to the perceived burden, in particular on the short-answer questions. Although confidential, the survey was not anonymous, and respondents may not have been comfortable communicating their true thoughts. The non-respondents’ perspective is of concern as their interest in and willingness to support curricular EBD efforts might differ significantly from respondents. The respondents could have reported what they thought we wanted to hear. Both of these issues could contribute to an inaccurate understanding of our faculty’s perceptions and lead to difficulty implementing our developing curriculum.
Conclusion
The study reported on here can serve as a model for dental educators who seek to understand their faculty needs as they develop and integrate new critical thinking and EBD content into their curricula. Our data, which reflect one school’s efforts to understand faculty perceptions and practices of EBD, suggest that our faculty respondents are currently teaching their understanding of critical thinking and EBD and are willing to do more. However, limitations in knowledge, time, and resources as well as student readiness limit current efforts to encourage critical thinking and EBD in clinical situations.
REFERENCES
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