|Year : 2013 | Volume
| Issue : 2 | Page : 100-106
Evaluation of undergraduate clinical learning experiences in the subject of pediatric dentistry using critical incident technique
S Vyawahare1, NR Banda1, S Choubey2, P Parvekar3, A Barodiya4, S Dutta5
1 Department of Pedodontics and Preventive Dentistry, Modern Dental College and Research Centre, Madhya Pradesh, India
2 Department of Pedodontics and Preventive Dentistry, Sri Aurobindo College of Dentistry, Indore, Madhya Pradesh, India
3 Department of Conservative Dentistry and Endodontics, Modern Dental College and Research Centre, Madhya Pradesh, India
4 Department of Oral and Maxillofacial Surgery, Modern Dental College and Research Centre, Madhya Pradesh, India
5 Department of Conservative Dentistry and Endodontics, Rajasthan Dental College, Jaipur, Rajasthan, India
|Date of Web Publication||26-Jul-2013|
N R Banda
Department of Pedodontics and Preventive Dentistry, Modern Dental College and Research Centre, Indore 453 112
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Introduction: In pediatric dentistry, the experiences of dental students may help dental educators better prepare graduates to treat the children. Research suggests that student's perceptions should be considered in any discussion of their education, but there has been no systematic examination of India's undergraduate dental students learning experiences. Aim: This qualitative investigation aimed to gather and analyze information about experiences in pediatric dentistry from the students' viewpoint using critical incident technique (CIT). Study Design: The sample group for this investigation came from all 240 3 rd and 4 th year dental students from all the four dental colleges in Indore. Using CIT, participants were asked to describe at least one positive and one negative experience in detail. Results: They described 308 positive and 359 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. Conclusion: The CIT is a useful data collection and analysis technique that provides rich, useful data and has many potential uses in dental education.
Keywords: Critical incident technique, dental education, dental student, pediatric dentistry, qualitative research, student′s viewpoint
|How to cite this article:|
Vyawahare S, Banda N R, Choubey S, Parvekar P, Barodiya A, Dutta S. Evaluation of undergraduate clinical learning experiences in the subject of pediatric dentistry using critical incident technique. J Indian Soc Pedod Prev Dent 2013;31:100-6
|How to cite this URL:|
Vyawahare S, Banda N R, Choubey S, Parvekar P, Barodiya A, Dutta S. Evaluation of undergraduate clinical learning experiences in the subject of pediatric dentistry using critical incident technique. J Indian Soc Pedod Prev Dent [serial online] 2013 [cited 2020 Feb 24];31:100-6. Available from: http://www.jisppd.com/text.asp?2013/31/2/100/115710
| Introduction|| |
The critical incident technique (CIT) is a well-established qualitative research tool that, in effect, "turns anecdotes into data."  CIT was developed during World War II in 1954 by John Flanagan, an American researcher in the field of occupational psychology.  Literature that explores student perceptions are important. Recent empirical evidence has suggested that the learning environment in health sciences education significantly influences the development of intellectual and professional skills in future practitioners. ,
However, published research that has explored student perceptions of their learning experiences has some limitations as when compared to other health professions; relatively, little dental education literature has focused on student perceptions of their education and learning environment, in particular, using a qualitative approach. , Many studies have underlined the need for further research in this field. 
As part of continuing efforts to evaluate and improve the educational experience in pediatric dentistry, an exploratory investigation was undertaken to evaluate the clinical component of the curriculum as seen from the student's viewpoint.
| Aim|| |
Aim of the study was to gather and analyze information about experiences in pediatric dentistry from the student's viewpoint using CIT.
| Materials and Methods|| |
Undergraduate students provide care for pediatric patients in the 3 rd and 4 th years of their dental education. In the 3 rd 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. In the 4 th year, students are required to provide comprehensive care for a specified number of patients. A total of 3 rd and 4 th year students were invited to participate in the study because they are involved in patient care activities in the pediatric clinic. The sample group for this investigation came from all 240 3 rd and 4 th year dental students (120 boys and 120 girls) from all the four dental colleges in Indore, Madhya Pradesh, India.
The following standardized open-ended questions were used for every interview:
Question 1: "Can you please enumerate about a positive experience you had in your pediatric posting?"
Question 2: "Can you please enumerate about a negative experience you had in the pediatric posting?"
The principal researcher collected the data through semistructured individual interviews with those who agreed to participate. 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; and the recordings were stored securely prior to, during, and after the data analysis. 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 postgraduate student, 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 principal researcher summarized each incident in text prior to the formal analysis. The positive and negative experiences were analyzed separately and similar incidents were grouped together using the "constant comparison" method.  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. "Key factors" and "subcategories" were identified and labelled and the results are presented in diagrammatic "mind map" format.
| Results|| |
A total of 240 dental students (120 3 rd year and 120 final year) were interviewed and the participants reported 308 positive and 359 negative incidents. The four key factors related to undergraduate clinical experiences that emerged were labelled as 1) the instructor; 2) the patient; 3) the learning process; and 4) the learning environment.
Positive experiences (n = 308)
Instructor (n = 157): [Figure 1]
Appropriate level of supervision (n = 87)
Positive experiences related to the instructor commonly consisted of situations in which the instructor achieved an appropriate level of supervision which included simply being available when needed, providing one-on-one chair-side instruction, and "checking in" from time to time.
Demonstration of techniques, tips, and tricks (n = 46)
helped participants grasp the procedures and aided the transition from the preclinical to the clinical course like in placement of rubber dam, matrix band, mixing and placement of cements, and so on.
Help with paperwork (n = 24)
Instructor helped the participants to fill the paperwork as the participants found the paperwork really extensive and confusing.
Patient (n = 32): [Figure 2]
Enjoyable experiences with patients (n = 26)
These ranged from simple appreciation of a patient's good behavior to descriptions of patients who were "a blast," "so cute," and "awesome." The participants were pleasantly surprised when the patients "did better than the adult patients".
Other types of positive encounters (n = 6)
For example personal bonding with patient, keeping in touch even after the treatment is over etc., formed the remainder of this key factor.
The learning process (n = 65): [Figure 3]
The community clinic (n = 55)
Many of the participants perceived community clinic as the "real world" as many of the constraints of the dental school clinic are absent there and the volume of work that is carried out during the day is generally high.
Successful application of foundation knowledge (n = 10)
The participants described feeling good when, after applying techniques they were taught in the preclinicals helped them in managing difficult or potentially difficult situations
The learning environment (n = 54): [Figure 4]
Departmental policies and procedures (n = 32)
Participants liked the departmental policy of discussing treatment plan of every case with the instructor. Participants also liked the flexibility of the administrative staff and system and the block rotation system in the department.
Support staff behavior (n = 22)
Participants liked the support staff having all the required materials prepared prior to every case.
Negative experiences (n = 359)
Instructor (n = 117): [Figure 5]
An inappropriate level of supervision (n = 76)
Participants disliked when the instructor showed insufficient or excessive level of supervision. Participants disliked when instructors did not actively participate in patient care, but instead "sat there reading a novel or magazine or when the instructor did all the treatment by himself."
Problem with advice (n = 18)
Participants were confused due to contradictory advices given by different instructors which made their time at the clinic more difficult.
Instructors who exhibited poor communication skills (n = 23)
Some participants reported that they were unable to understand the language spoken by the instructor.
The patient (n = 95): [Figure 6]
Patient behavior that caused treatment to be abandoned (n = 87)
Participants had to abandon the treatment due to uncooperative nature of the child. Mother's lack of control over her child was suggested by participants as being the source of the child's inappropriate behavior.
Other problems (n = 8)
with patients like inappropriate behavior by parent, missed appointment, and so on formed the remainder of this key factor.
The learning process (n = 132): [Figure 7]
Less number of total patients (n = 87)
Many participants were enthusiastic for treating pediatric patient, but they had no patient to work on.
Short supply of appropriate patients (n = 45)
Final year students were unable to complete their clinical quota due to short supply for patients requiring restorations, fillings, and so on, and also the majority of the patients were allotted only to the postgraduate students.
The learning environment (n = 15): [Figure 8]
Support staff behavior (n = 6)
Participants described multiple incidents involving support staff in various locations, who were "rude," "in a bad mood," "gave off a bad vibe," or being "really mean".
Paperwork (n = 9)
Some participants felt that the paperwork was excessive and confusing and different from all other department.
| Discussion|| |
The four key factors related to undergraduate clinical experiences that emerged were labelled as: 1) The instructor; 2) the patient; 3) the learning process; and 4) the learning environment. The factors such as instructor and the learning process have been intensively scrutinized in the literature on health professions education, while factors like the patient and the learning environment are relatively new. ,,
To the best of our knowledge, this is the first in-depth qualitative study of professional doctoral students' and graduates' educational experiences in India. Participants' responses provided rich, in-depth insights into their reflections and understandings of effective and ineffective approaches to supervision as it influenced their learning in the clinical and research settings. Overall, the findings from this study were largely similar to those from previous research on how dental students perceived their undergraduate learning experiences. ,,,
The role of the instructor and the relationship between instructor and student has already been identified as an important dimension in clinical learning. These include the following: The instructor as a role model; the value of continuous feedback; the benefit of a high level of interactivity;  the importance of the instructor's rapport, organization, and enthusiasm;  the worth of student autonomy and self-assessment; the usefulness of demonstration; and the merit of contextual teaching.  As outlined by the American Dental Education Association Commission on Change and Innovation in dental education,  participants asserted the importance of a humanistic pedagogy for facilitating effective learning.
Our findings indicate that students prefer that their instructors should be easy to approach and maintain an appropriate level of supervision. At times, for the students to observe and learn, it is needed that instructor perform the entire procedure in detail demonstrating the applied technique, while sometimes it is also required by the instructor to stand aside and allow the students to work at his or her own pace. Amidst these two extremes lie a multitude of levels of supervision. In between these two extremes, there lies varied level of guidance out of which the instructor is required to deduce the correct level of supervision to provide the adequate balance depending upon the situation and the student.
Additionally, the findings can be used to develop and/or refine curriculum and design academic staff development programs. As academic staff within the same institution may not be always informed of effective and/or innovative teaching strategies used by their colleagues, approaches to initiate professional staff development may include peer observation of teaching and provision of a forum for academic staff to share their ''best'' supervisory and/or mentoring practices. ,
Until recently, the patient's personal qualities like them being adorable, cooperative, and inquisitive were not considered to positively contribute to the dental education experience and before that the patient was just considered to provide a dentition for the clinician to work on. In our study, students had a fun time treating the children, some even liked child patient better than adults. Patient's cooperative behavior played a very important role in the treatment. Child psychology and behavior management of child patient should be taught to the students before entering the clinic so that they can effectively manage the patients. 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.
Students found that their community-based experience was a meaningful and rewarding learning endeavor. Findings also reveal that students were satisfied with having worked in the "real world." For many, this real world proved an eye-opening experience, aiding the process of personal and professional development. "No amount of coursework prepared me for this type of situation," wrote one student. Thus, by providing "real world" experience, community-based dental education helps cultivate the skills, knowledge, values, and attitudes that are needed for a dentist to succeed in today's dynamic health care environment. 
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 Masella  and Lempp and Seale,  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." 
Through describing actual events and analyzing them to make sense of a situation or process, the CIT encourages a process of reflection in the participants and the researcher. "Reflection-in-action" and "reflection-on-action," terms coined by Schon,  describe building on our understanding and experiences to inform our actions in the situations we encounter. Robert Elliott,  a leader in qualitative research, reminds us that, "ultimately, the value of any scientific method must be evaluated in the light of its ability to provide meaningful and useful answers to the questions that motivated the research in the first place." Thus, the CIT could be used as a method for faculty development and curriculum development and as a means of educating a reflective practitioner.
Qualitative research methods have some limitations. First, qualitative research is intended to provide detailed insights into a particular group, event, or process. This study includes data from a particular student body enrolled in a particular dental school. Were this study to be repeated in a dental school with a significantly different curriculum and/or student body, it is likely that many similar themes would emerge, but that some different ones would also. Second, students who have not yet graduated may hesitate to be entirely candid when interviewed. To address this limitation in this study, interviews were conducted by a postgraduate student, rather than a faculty member and participants were assured that identifiable comments would not be shared with any faculty members. 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 undergraduate pediatric program, but the ideas and themes may stimulate reflection in faculty and students alike.
| Conclusion|| |
The 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 undergraduate 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.
| References|| |
|1.||Bradley CP. Turning anecdotes into data-the critical incident technique. Fam Pract 1992;9:98-103. |
|2.||Fitzgerald K, Seale NS, Kerins CA, McElvaney R. The critical incident technique: A useful tool for conducting qualitative research. J Dent Educ 2008;72:299-304. |
|3.||Mayya SS, Roff S. Students' perceptions of educational environment: A comparison of academic achievers and underachievers at Kasturba Medical College, India. Educ Health (Abingdon) 2004;17:280-91. |
|4.||Al-Hazimi A, Zaini R, Al-Hyiani A, Hassan N, Gunaid A, Ponnamperuma G, et al. Educational environment in traditional and innovative medical schools: A study in four undergraduate medical schools. Educ Health (Abingdon) 2004;17:192-203. |
|5.||Till H. Climate studies: Can students' perceptions of the ideal educational environment be of use for institutional planning and resource utilization? Med Teach 2005;27:332-7. |
|6.||Henzi D, Davis E, Jasinevicius R, Hendricson W, Cintron L, Isaacs M. Appraisal of the dental school learning environment: The students' view. J Dent Educ 2005;69:1137-47. |
|7.||Rowland ML, Naidoo S, Abdulkadir R, Moraru R, Huang B, Pau A. Perceptions of intimidation and bullying in dental schools: A multi-national study. Int Dent J 2010;60:106-12. |
|8.||Pope C, Ziebland S, Mays N. Qualitative research in health care. Analysing qualitative data. BMJ 2000;320:114-6. |
|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;71:632-45. |
|10.||Manogue M, Brown G, Foster H. Clinical assessment of dental students: Values and practices of teachers in restorative dentistry. Med Educ 2001;35:364-70. |
|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;8:147-51. |
|12.||Fugill M. Teaching and learning in dental student clinical practice. Eur J Dent Educ 2005;9:131-6. |
|13.||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;70:124-32. |
|14.||Gerzina TM, McLean T, Fairley J. Dental clinical teaching: Perceptions of students and teachers. J Dent Educ 2005;69:1377-84. |
|15.||Schonwetter 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;70:624-35. |
|16.||Haden NK, Andrieu SC, Chadwick DG, Chmar JE, Cole JR, George MC, et al. ADEA Commission on Change and Innovation in Dental Education. The dental education environment. J Dent Educ 2006;70:1265-70. |
|17.||Behar-Horenstein LS, Mitchell GS, Dolan TA. A case study examining classroom instructional practices at a US dental school. J Dent Educ 2005;69:639-48. |
|18.||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;67:515-23. |
|19.||Masella RS. The hidden curriculum: Value added in dental education. J Dent Educ 2006;70:279-83. |
|20.||Lempp H, Seale C. The hidden curriculum in undergraduate medical education: Qualitative study of medical students' perceptions of teaching. BMJ 2004;329:770-3. |
|21.||Schön DA. Educating the reflective practitioner: Toward a new design for teaching and learning in the professions. San Francisco: Jossey-Bass, 1987. |
|22.||Elliott R, Fischer CT, Rennie DL. Evolving guidelines for publication of qualitative research studies in psychology and related fields. Br J Clin Psychol 1999;38(Pt3):215-29. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]