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Milieu in Dental School and Practice

Dental Clinical Teaching: Perceptions of


Students and Teachers
Tania M. Gerzina, Ph.D.; Tim McLean, B.D.S.; Jo Fairley, B.A. (Hons)
Abstract: The objective of this study was to explore perceptions of dental student clinicians and clinical teachers about dental
clinical teaching to provide primary data for dental researchers and educators. Student focus group data provided background for
development of a questionnaire that explored three themes related to clinical teaching. Twenty-one teachers and forty-five student
respondents completed the twenty-five-item questionnaire in 2003. In the theme of the teacher/student relationship, no statistically significant differences were seen between teacher and student group perceptions. In the theme of educational theory applied
in dental clinical teaching, a statistically significant difference was seen between teacher and student groups in the value of
preclinical instruction in senior clinical years and in the value of a clinical log book. In the theme of skills required for clinical
dental practice, a statistically significant difference was seen between teacher and student groups in the value of a critical
appreciation of evidence-based practice as one of the skills. The study overall indicates that the dental clinical learning environment supports close perceptual conformity between students and clinical teachers in regard to what each group considers to be
good practice in clinical teaching. The findings of this study indicate that some techniques that have been advocated to enhance
clinical learning, such as evidence-based teaching methods, require further investigation.
Dr. Gerzina is a Senior Lecturer in the Faculty of Dentistry, University of Sydney, Sydney, Australia; Dr. McLean is a
general dental practitioner, Sydney NSW, Australia; and Ms. Fairley is Assessment and Administration Officer, Faculty of
Dentistry, University of Sydney, Sydney, Australia. Direct correspondence and requests for reprints to Dr. T.M. Gerzina,
Faculty of Dentistry, University of Sydney, 2 Chalmers Street NSW 2010, Sydney, NSW, Australia; 612-92115912 fax;
tgerzina@usyd.edu.au.
This project was supported by a grant from the Australian Dental Research Fund.
Key words: dental clinical teaching, student/clinical teacher relationship, clinical supervision, professional skills
Submitted for publication 4/8/05; accepted 8/23/05

n regard to dental education, it has been suggested that the clinic is the learning environment to which all our students aspire,1 requiring the transfer of knowledge from the basic
sciences to the clinic by tuning and restructuring of
knowledge.2 How learning and teaching best occur
in this environment for the preparation of dental students to advance to independently provide patient
clinical care is an important central business of dental educators and clinical supervisors alike.
The learning environment of the clinic or hospital is a challenging area for both teacher and student. In this setting, the student is a trainee clinician
responsible for patient care, and the clinic is both a
patient care facility and a learning environment. In
clinic, students are expected to demonstrate diverse
competencies simultaneously, including a range of
skills, broad knowledge base, professionalism, and
empathic ethical behavior. Recent reports in dental
education point to the value of the early introduction
of students to the clinical environment, largely be-

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Journal of Dental Education

cause of the demonstrated value of contextual learning and the facilitation of integration of knowledge
from basic to clinical sciences.1 Clinical teaching
typically involves the supervision of a trainee clinician by an experienced clinician, and as a consequence, clinical education usually involves a range
of teaching modes. Clinical supervision may be defined as the provision of monitoring, guidance, and
feedback on matters of personal, professional, and
educational development in the context of patient
care.3 The student/clinical teacher relationship has
also been suggested to mirror the therapeutic alliance that exists between patient and physician because it represents an educational alliance.4
Clinical teaching in medical education has been
extensively examined.5 Effective medical clinical
teachers are considered to be those who have empathy, are capable of providing support, exhibit flexibility, and have the ability to gauge student development, in addition to being interpretive, focused,
and practical.3 Effective supervision of learners in-

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volves problem-solving by students and instructors


together, along with feedback, reassurance, and
theory-practice linking.6 There is preliminary evidence that effective clinical teaching in medicine may
have a positive impact on patient outcomes. For example, Fallon et al. found that patient outcomes improved when direct supervision of the student clinician is combined with focused feedback.7
In a dental education context, clinical teaching
has been less extensively examined, for example, by
OConnor et al.8 Effective clinical instruction in dentistry is associated with meeting teaching responsibilities, behavior conducive to clinical learning, technical competence, and work enjoyment.7,9 The ability
to motivate students, explain difficult concepts, display interest in the subject, show compassion and
caring, and be proactive was also highly rated by
students in a study reported by Chambers et al.10
Clinical teaching in dental programs is supported by a range of educational modalities supporting patient care such as large group (e.g., lectures),
small group (e.g., tutorials), collaborative (e.g., PBL),
clinical case-based, interactive (e.g., role play), simulation, and computer-assisted modalities. The perceived value of these modalities to clinical teaching
and learning in dentistry can be considered in the
light of making efficient use of teaching resources,
being able to objectify clinical sessions, facilitating
development of professional attributes, sharing common clinical concerns, and affording a degree of individual student interaction.10
This study presents the findings of an investigation of clinical teaching in an Australian dental school.
A survey was used to elicit the perceptions of the central partners in that environmentnamely, the students
and the teachers. The study was implemented to test
the hypothesis that these two groups have different
views of the value of teaching methods to prepare students for independent clinical practice.

Methods
Two student focus groups were conducted in
2003 during a teaching semester to provide background for development of the questionnaire. The
focus group discussions explored student ideas and
perceptions about clinical teaching in dentistry. Volunteers for each of the two focus groups came from
students enrolled in the new curriculum for the Bachelor of Dentistry (B.Dent.) program and from students enrolled in the older curriculum for the Bach-

1378

elor of Dental Surgery (B.D.S.) program at the Faculty of Dentistry, University of Sydney. These programs are described in detail elsewhere.11,12 Briefly,
the B.D.S. program was a five-year, discipline-based
program featuring a range of teaching styles such as
lectures, seminars, and case-based learning. The
B.Dent. program, which commenced in 2001, is a
four-year competency-based program using problembased learning (PBL) throughout the program. Clinical teaching styles used in both B.D.S. and B.Dent.
programs are similar; dental clinician teachers provide close supervision of students in both.
One focus group consisted of four B.D.S. students; the other focus group consisted of four B.Dent.
students. Each focus group discussion was one to
three hours in length. This number of participants,
which allowed discussion to proceed efficiently, reflects recommendations for composition of participatory focus groups.13 The focus group participants
identified several aspects of clinical teaching that
were united into three themes and that together were
structured into a set of questionnaire statements used
for data collection. These three themes were 1) the
teacher/student relationship, 2) educational theory
applied to dental clinical teaching, and 3) skills important for dental clinical practice. An example of a
questionnaire item in the theme of educational
theory applied to dental clinical teaching was the
following: small group teaching, such as tutorials,
are valuable to the development of dental clinical
skills. Questionnaire statements grouped into this
theme were those that reflect evidence-based teaching practice and are applicable in a broad range of
teaching, such as PBL teaching and formal lectures.
Items presented in the other two themes of the questionnaire were constructed to be more uniquely relevant to the type of teaching that occurs within dental clinical sessions, when student clinicians complete
patient care, such as clinical demonstrations of patient care and clinical interactivity. An example of a
questionnaire item in the theme of the teacher/student relationship was the following: empathic guidance from the clinical supervisor supports student
preparation for independent practice of clinical dentistry. The final theme explored in the questionnaire
was the range of skills required for clinical practice,
namely decision-making skills, technical finemotor skills, communication skills, broad knowledge
base, critical appreciation of evidence-based practice, and skills in self-assessment and self-confidence.
An example of a questionnaire item in this theme
was the following: whilst many skills are impor-

Journal of Dental Education Volume 69, Number 12

tant for dental clinical practice, the most important


part of dental clinical practice is decision-making.
The questionnaire utilized a six-point Likert
attitude scale providing responses ranging from 1
(always agree) to 6 (strongly disagree) and was refined based on the qualitative data derived from focus group discussions. The questionnaire featured
twenty-five items about dental clinical teaching.
These statements appear in the left hand columns of
Tables 2, 3, and 4. These statements aimed to determine the strength of agreement with some of the
comments made during the focus group discussions
in regard to the usefulness of various dental clinical
styles employed by faculty.
B.Dent. and B.D.S. students and teachers completed the anonymous questionnaires. The response
rate from B.Dent. students was unfortunately too low
to be of value in the study, and these data were abandoned. Comparative demographic data of the B.D.S.
student and teacher groups are shown in Table 1. In
summary, forty-five B.D.S. students completed the
questionnaires (response rate of 76 percent). Twentyone teachers completed the questionnaires (response
rate of approximately 69 percent, taking into account
the relative availability of fractionally appointed
teachers to complete the questionnaire). A short briefing about the study was delivered to the students in
both programs at the end of a lecture during a teaching semester, and students were then invited to participate in the questionnaire. The study was described
to individual teachers who were invited to participate in the study by one of the researchers. All participants were asked to return their completed questionnaires to the researchers. Scores from the
questionnaire for the different groups were analyzed
to provide comparisons using Student t-test with
Bonferroni correction setting P<0.005.

Results
Comparisons of teacher and student perceptions of clinical teaching styles in regard to ten aspects of the clinical teacher/student relationship are
shown in Table 2. The data presented there and in
Tables 3 and 4 represent the mean scores of the student and faculty respondents based on the six point
rating scale. In describing the results, we will also
report the percentages of students and faculty who
agreed or disagreed with various survey items. However, the response percentages are not displayed in
the tables to simplify data presentation. None of the

December 2005

Journal of Dental Education

comparisons between results for teachers and students in this theme were statistically significant.
These data also show that, in six of the ten aspects,
teacher and student groups showed a very similar
level and direction of agreement with the statements
listed. In the remaining four items, there were some
small differences between students and teachers. For
the statement providing clinical objectives for clinical sessions would support students preparation for
their independent practice of clinical dentistry, students neither agreed nor disagreed strongly, whereas
teachers tended to agree. Conversely, teachers neither agreed nor disagreed strongly with the statement
the passive involvement of the clinical tutor in teaching during clinical sessions, such as not readily completing the clinical procedure, assists student preparation for independent clinical practice, whereas
students tended to agree with this statement.
Comparisons of teacher and student perceptions of clinical teaching styles in regard to the application of educational themes are shown in Table
3. Two of the comparisons of results for teachers and
students in this theme were statistically significant.
Students and teachers expressed significantly different levels of agreement for the statement that there
was a clear link between theory and clinical practice
in the program (P<0.0029) and that a clinical log book
was valuable for the preparation for clinical practice
(P<0.0038). In regard to the theory/practice link, only
19 percent of teachers agreed, whereas 63 percent of
students agreed with the statement. In regard to the
clinical log book, students were divided in their view
of the merit of this learning aid (27 percent agreed,
21 percent disagreed), whereas a majority of teachers were in agreement (46 percent, with 14 percent
disagreement). These data also show that, in three of
the ten statements presented in this theme, teacher
and student groups showed a very similar direction
and level of agreement with the statements listed.
These three items were: the value of preclinical in-

Table 1. Comparison of teacher and student perceptions about the student/clinical teacher relationship

Response rate
Percentage female
Average age
Age range

Students

Teachers

76%
(n=45)

Approximately 69%
(n=21)

69%

52%

23.7Y

37.8Y

21-33Y

24-78Y

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Table 2. Comparison of teacher and student perceptions about the student/clinical teacher relationship
Questionnaire Statement

Teachers
Median Mean S.D.

Students
Median Mean S.D.

Significance

Empathic guidance from the clinical supervisor


supports student preparation for independent
practice of clinical dentistry.

2.0

0.4

2.0

0.5

NS

Providing clinical objectives for clinical sessions


would support student preparation for their
independent practice of clinical dentistry.

2.2

0.3

2.6

0.2

NS

A high level of interactivity, such as completing


part of the clinical procedure, by the clinical
tutor during clinical sessions assists student
preparation for independent clinical practice.

2.7

0.1

3.0

0.1

NS

The clinical tutor is an important role model for


student clinicians.

1.6

0.6

2.5

0.5

NS

The passive involvement of the clinical tutor in


teaching during clinical sessions, such as not
readily completing the clinical procedure, assists
student preparation for independent clinical practice.

2.9

0.1

2.3

0.2

NS

Discussion of alternative treatments and procedures


during clinical sessions assists student preparation
for independent clinical practice.

1.6

0.8

1.6

0.7

NS

Clinical demonstrations of procedures assists


student preparation for independent clinical practice.

1.9

0.3

1.9

0.4

NS

The practice of the clinical tutor providing continuous


feedback during the clinical session assists student
preparation for independent clinical practice.

2.0

0.3

1.9

0.2

NS

The practice of the clinical tutor providing feedback


only at the end of a clinical session assists student
preparation for independent clinical practice.

3.7

0.6

2.8

0.7

NS

Followup during the first year after graduation by


a faculty mentor would assist student confidence in
their dental clinical practice.

2.3

0.3

2.5

0.2

NS

Rating scale: 1=always agree, 2=agree, 5=disagree, 6=strongly disagree.

struction (greater than 83 percent agreement in both


student and teacher groups), benefit of small group
teaching (greater than 52 percent agreement in both
student and teacher groups), and the value of continuous assessment (as opposed to assessment at session end) through a clinical session (greater than 56
percent agreement in both student and teacher
groups).
The data for skills important for dental clinical
practice are shown in Table 4. Only one of the comparisons between results for teachers and students in
this theme was statistically significant (P<0.0013).
This statement was that a critical appreciation of
evidence-based practice was an important part of
dental clinical practice; 66 percent of teachers agreed
(and no teachers disagreed) with this statement,
whereas only 42 percent of students agreed and 20
percent disagreed.

1380

Discussion
The learning environment of the clinic challenges the roles and responsibilities of both the
learner and the clinical teacher substantially. The
clinical teacher can be seen as role model, assessor,
confidante, and facilitator for the student clinician.
Valuable supervision is characterized by joint participation in decision making, shared vision, open
access, and creative tension. Positive effects of these
interactions can be seen in improved patient outcomes6 and student recognition of teacher effectiveness. In light of this, a mission for dental education
ideally includes the enhancement of the educationcare delivery relationship, even greater patientcenteredness, comprehensive care experiences, and
teaching and learning reform encouraging reflective
clinical practice.

Journal of Dental Education Volume 69, Number 12

Table 3. Comparison of teacher and student perceptions in regard to the application of educational theory in dental
clinical teaching
Questionnaire Statement

Teachers
Median Mean S.D.

Students
Median Mean S.D.

Significance

Preclinical instruction is essential for student


preparation for independent practice of clinical
dentistry.

1.5

0.7

1.7

0.8

NS

Preclinical practice in the senior clinical years


would be helpful for student preparation for
independent practice of clinical dentistry.

2.4

0.9

3.0

0.8

NS

The PBL form of teaching has supported the


development of the ability to provide dental
clinical care of patients.

3.4

0.5

4.2

0.5

NS

Small group teaching, such as tutorials, is valuable


to the development of dental clinical skills.

2.2

0.6

2.5

0.4

NS

There is a clear link between the theory and the


clinical practice of dentistry in the dental program.

3.3

0.3

2.3

0.2

SP<0.0029

Formal lectures are valuable to the development


of dental clinical skills.

2.6

0.9

2.3

0.5

NS

Continuous clinical sessional assessment supports


the development of the ability of students to provide
independent clinical patient dental care.

2.3

1.0

2.4

1.4

NS

Student performance in clinical sessions should


be graded.

2.3

1.3

2.9

1.5

NS

Grading student performance in clinical sessions


should use a pass, credit, etc. system to best
support student development as dental practitioners.

3.2

0.7

3.4

1.5

NS

A student record of their completed patient care,


such as a clinical log book, assists student preparation
for independent practice.

2.9

0.3

3.7

0.2

SP<0.0038

The ability to discuss learning needs with a clinical


tutor assists student preparation for independent
practice.

1.8

1.0

2.1

0.9

NS

Rating scale: 1=always agree, 2=agree, 5=disagree, 6=strongly disagree.

The current study explored student and clinical teacher views of clinical teaching from three
areas: the clinical teacher/student relationship, the
application of educational theory in dental clinical
teaching, and skills important for dental clinical practice. An overall significant level of alignment of
views held by students and teacher was seen in the
data presented. This common view of students and
teachers in so many areas was unexpected and probably reflects the very close and cohesive relationship between clinical teachers and students fostered
in that setting. It may also reflect the strong influence of teachers on students views. The intensity of
the clinical environment may reinforce the tendency
of teachers to teach in a way that has been perceived
successful in terms of patient outcome and service
needs in their own experience. It may also reflect a
tendency of teachers to recognize and adopt a style

December 2005

Journal of Dental Education

of teaching they themselves experienced as student


clinicians that is sometimes described as a teachercentered style.14
In the clinical teacher/student relationship, an
aspect of dental clinical teaching that the focus group
participants frequently mentioned was clinical demonstration. During a clinical demonstration, which
occurs in the clinic during a patient clinical care session, a clinical teacher provides patient care whilst a
student (or students) observes the procedure. Students
in the focus group said this was one of the best forms
of clinical teaching as it allowed students to see how
things are done so that you can understand them. Students value seeing the expert completing the task
that they will be expected to complete over time and
with practice. In direct reference to a clinical demonstration by a clinical supervisor, an illustrative comment in the student focus groups was: It is very help-

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Table 4. Comparison of teacher and student perceptions in the theme of skills important in dental clinical practice
Questionnaire Statement

Teachers
Median Mean S.D.

Students
Median Mean S.D.

Significance

Whilst many skills are important for dental


clinical practice, the most important part of
dental clinical practice is:
a. Decision making

1.6

0.3

1.6

0.4

NS

b. Fine-motor

2.0

0.4

2.1

0.5

NS

c. Communication

1.6

0.4

1.5

0.3

NS

d. Broad knowledge base

2.0

0.5

2.2

0.5

NS

e. Critical appreciation of EBP

2.2

0.2

3.0

0.2

SP<0.0013

f. Self-assessment

1.9

0.5

2.5

0.6

NS

g. Self-confidence

2.2

0.4

2.1

0.2

NS

Rating scale: 1=always agree, 2=agree, 5=disagree, 6=strongly disagree.

ful to see theory work applied or demonstrated as this


adds depth and reinforces the theory. Another student called this interactive teaching, saying there
is a need for more interactive learning environments
and demonstrations to reinforce clinical and theory.
There is an appreciation for these but a demand for
more. Questionnaire data supported the view that this
style of teaching was perceived as a valuable teaching
style by both teachers and students.
Another aspect in the theme of the clinical
teacher/student relationship highlighted by the focus
group discussions was the nature and level of interaction between clinical teacher and student during patient care. This complex aspect refers to a balance
between student self-confidence in providing patient
care independently and teacher interactivity (or assistance) in that care when required. This balance can
represent a strong tension in the dental teaching clinic
at times and is a likely motivator in the progression of
clinical skill acquisition by the student clinician. This
balance illustrates an example of a motivator described
in the Dreyfus model of skill acquisition.14 This model
describes progression from novice (reliance on rules,
no discretionary judgment, and little situational perception) to expert (no reliance on rules, analytical approach only in novel and problematic times, intuitive
approach based on deep understanding). These motivatorsself-confidence and perception of competencehave been considered by Stewart et al.15 in
medical students. These authors used a modified
Delphi technique with a qualitative analysis to clarify
house officers perceptions of these two important
motivators, with an ultimate goal of designing a selfevaluation instrument. In view of the association with

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quality of patient care and development of professional


attributes in clinicians, a clearer understanding of the
relationship between self-confidence and motivation
and how these factors influence students progression
from novice to expert is an important avenue for future study.
The second theme explored in our study was
that of the application of aspects of educational theory
to dental clinical teaching. In the context of this study,
this theme included clinical simulation, collaborative small group teaching, the use of log books to
track student work, authentic student evaluation, and
student-teacher debriefing after active teaching sessions as aspects of teaching styles adapted for use in
dentistry from other educational fields. In our study,
both student and teacher groups demonstrated an
awareness of teaching styles reflecting educational
theory. For example, a majority of respondents in
both student and teacher groups strongly agreed that
preclinical instruction was essential for student preparation for independent clinical practice. A smaller
majority of respondents in both student and teacher
groups agreed that small group teaching, grading of
students during patient care sessions, and debriefing
sessions with students and their clinical teachers were
valuable in preparing students for independent clinical practice. A relative ambivalence by the majority
of respondents on the value of PBL supports the findings of Colliver, although neither students nor faculty reported extensive current or past experience
with this modality.16 The link between theory and
practice is a central one in education, but in this study,
more students than teachers perceived that the link
was apparent in the program. The very central issue

Journal of Dental Education Volume 69, Number 12

of evaluation of students in teaching and learning


was also broached in our study, presented here in the
issue of grading. Both teacher and student groups
saw an important purpose in evaluation of student
competence in clinical sessions, but neither group
clearly agreed nor disagreed with the use of grade
descriptors such as pass and fail.
Teacher and student perceptions about the most
important professional skills for dental clinical practice was the final theme considered in the study.
Again, a level of similar strength and direction of
view was seen in the two participant groups, with
almost coincident high support for communication,
decision making, and fine-motor skills. The study
supports the observations of Werb and Matear17 in a
recent review reporting the challenges in implementing evidence-based practice in dental education. That
study notably reported the superior performance in
national board examinations of dental students from
PBL-based programs that emphasize evidence-based
practice, but also proposed a comprehensive model
for implementation.
It is likely that well-planned and innovative
teaching adapted to the realities of the dental clinic
would have a positive influence on student preparation for independent practice. PBL has been reported
to have only modest effects on development of clinical skills, but it has been associated with student satisfaction with teaching and development of appropriate learning skills.18,19 A well-structured student
record of clinical accomplishment, such as a log
book, enables provision for self-reflection in addition to an achievement in clinical services and has
been favorably evaluated by medical students.20 Enhancing the clinical learning environment in strategic ways has also been considered in the medical
context and provides good advice for the dental clinical learning environment as well.21 The current study
demonstrates that students and teachers value the
clinical teaching styles they have experienced and
also believe that prevailing teaching strategies serve
to adequately prepare students for independent clinical practice in dentistry.
Many clinical teaching guidelines from the literature are relevant to clinical education in dental
schools. Tiberius et al. suggested the following: reflection on assumptions underlying teaching; establishment of an early alliance with students by setting
goals; building of trust and recognition; and addressing transference.4 To this, Gordon et al. have added
understanding of the purpose and process of learning in a clinical environment and encouragement of

December 2005

Journal of Dental Education

students to develop survival skills given the range


of climates in clinical settings.21 The current study
has, in addition, shown that teachers and students
valued the following characteristics of dental clinical teaching: empathic guidance, provision of objectives for the clinical session, discussion of alternative clinical treatments, clinical demonstrations, and
continuous clinical feedback by the supervisor.
Guidelines for program directors responsible
for organizing dental clinical programs are another
valuable aspect. Tiberius et al. suggested assigning
students to clinical teams that will unite individuals
who interact well; revision of policy on factors that
maintain power differentials between students and
supervisors when these differentials serve no valuable purpose; and use of faculty development programs to enhance faculty skills pertinent to clinical
teaching and mentorship.4 The current study points
to the value of providing time and resources for clinical demonstrations, faculty development in empathic
skills, and the restructuring of clinical sessions to
include time for discussion of clinical objectives,
clinical alternatives, adequate feedback, and clinical
demonstrations. Providing faculty development related to evidence-based teaching and motivators for
clinical learning may further illuminate the clinical
learning environment for clinical students, clinical
teachers, and classroom educators alike.

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