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Students' and Patients' Perspectives of Clinical Teaching at a Dental School

Permanent Link: http://ufdc.ufl.edu/UFE0021562/00001

Material Information

Title: Students' and Patients' Perspectives of Clinical Teaching at a Dental School
Physical Description: 1 online resource (124 p.)
Language: english
Creator: Grimaudo, Nicholas J
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2007

Subjects

Subjects / Keywords: clinical, curriculum, dental, education, patients, students
Educational Administration and Policy -- Dissertations, Academic -- UF
Genre: Curriculum and Instruction (EDL) thesis, Ph.D.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract: In dental education, the clinic is the learning environment that requires students to transfer knowledge from the basic sciences and utilize it to render safe and efficient patient care. The effectiveness of teaching and learning in the clinical learning environment and how it prepares dental students to independently provide patient care is a central concern for dental education. The underlying theory in this study was to describe how teacher effectiveness influences students in the clinical learning environment and impacts patient care. There is growing awareness that students? responses to and views of their educational experiences are important to shaping and modifying the educational process. The primary purpose of this study was to describe the instructional practices among clinical dental educators as they pertain to student and patient involvement. The secondary purpose was to describe the interactions between the teacher, student, and patient during clinical teaching. The study examined the students? and patients? perspectives of the dental clinical teaching environment. Utilizing participant observation, this study focused on the oral health care educator?patient?student triad and the learning experience in comprehensive oral health care. Methods of data collection included unobtrusive observations of interactions between oral health care educators, patients, and students, and patient and student interviews. This study is grounded in a constructivist framework, whereby the researcher considered individuals? perceptions and communications, as well as the setting, as essential for developing insight into the observable relationships and interactions. The participants were comprehensive care patients at the U of Wallace College of Dentistry, faculty members of the College of Dentistry, and student dentists in the classes of 2006 and 2007. Data were collected from three primary sources: patient interviews, student interviews, and participant observation of the patient?faculty?student interaction for a total of 330 student/patient/faculty observation/interviews completed. The results indicate that there are particular student attributes, characteristics of teaching/learning, and characteristics of clinical teachers that are essential to clinical learning. Students reported a preference for a learning environment that emphasizes the student-patient-education relationship while promoting good rapport and respect. Attributes ascribed to the effective clinical educator are professional, competent and consistency with treatment planning and evaluation and use of teaching techniques such as demonstration and the provision of accurate, comprehensive feedback delivered in a positive emotional manner. Four major styles of communication interactions emerged: faculty- centered, student-directed, student?faculty collaboration, and patient-driven, although students reported that the student?faculty collaboration was the most positive. Although patient experiences were positive overall, these particular findings did not contribute any new information that might be used to improve or modify current clinical teaching. The findings from this study were compared with the key concepts of studies on teaching and learning in health care environments. Finally, a theoretical model that emerged from the observations and interviews was presented and explained.
General Note: In the series University of Florida Digital Collections.
General Note: Includes vita.
Bibliography: Includes bibliographical references.
Source of Description: Description based on online resource; title from PDF title page.
Source of Description: This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility: by Nicholas J Grimaudo.
Thesis: Thesis (Ph.D.)--University of Florida, 2007.
Local: Adviser: Behar-Horenstein, Linda S.

Record Information

Source Institution: UFRGP
Rights Management: Applicable rights reserved.
Classification: lcc - LD1780 2007
System ID: UFE0021562:00001

Permanent Link: http://ufdc.ufl.edu/UFE0021562/00001

Material Information

Title: Students' and Patients' Perspectives of Clinical Teaching at a Dental School
Physical Description: 1 online resource (124 p.)
Language: english
Creator: Grimaudo, Nicholas J
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2007

Subjects

Subjects / Keywords: clinical, curriculum, dental, education, patients, students
Educational Administration and Policy -- Dissertations, Academic -- UF
Genre: Curriculum and Instruction (EDL) thesis, Ph.D.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract: In dental education, the clinic is the learning environment that requires students to transfer knowledge from the basic sciences and utilize it to render safe and efficient patient care. The effectiveness of teaching and learning in the clinical learning environment and how it prepares dental students to independently provide patient care is a central concern for dental education. The underlying theory in this study was to describe how teacher effectiveness influences students in the clinical learning environment and impacts patient care. There is growing awareness that students? responses to and views of their educational experiences are important to shaping and modifying the educational process. The primary purpose of this study was to describe the instructional practices among clinical dental educators as they pertain to student and patient involvement. The secondary purpose was to describe the interactions between the teacher, student, and patient during clinical teaching. The study examined the students? and patients? perspectives of the dental clinical teaching environment. Utilizing participant observation, this study focused on the oral health care educator?patient?student triad and the learning experience in comprehensive oral health care. Methods of data collection included unobtrusive observations of interactions between oral health care educators, patients, and students, and patient and student interviews. This study is grounded in a constructivist framework, whereby the researcher considered individuals? perceptions and communications, as well as the setting, as essential for developing insight into the observable relationships and interactions. The participants were comprehensive care patients at the U of Wallace College of Dentistry, faculty members of the College of Dentistry, and student dentists in the classes of 2006 and 2007. Data were collected from three primary sources: patient interviews, student interviews, and participant observation of the patient?faculty?student interaction for a total of 330 student/patient/faculty observation/interviews completed. The results indicate that there are particular student attributes, characteristics of teaching/learning, and characteristics of clinical teachers that are essential to clinical learning. Students reported a preference for a learning environment that emphasizes the student-patient-education relationship while promoting good rapport and respect. Attributes ascribed to the effective clinical educator are professional, competent and consistency with treatment planning and evaluation and use of teaching techniques such as demonstration and the provision of accurate, comprehensive feedback delivered in a positive emotional manner. Four major styles of communication interactions emerged: faculty- centered, student-directed, student?faculty collaboration, and patient-driven, although students reported that the student?faculty collaboration was the most positive. Although patient experiences were positive overall, these particular findings did not contribute any new information that might be used to improve or modify current clinical teaching. The findings from this study were compared with the key concepts of studies on teaching and learning in health care environments. Finally, a theoretical model that emerged from the observations and interviews was presented and explained.
General Note: In the series University of Florida Digital Collections.
General Note: Includes vita.
Bibliography: Includes bibliographical references.
Source of Description: Description based on online resource; title from PDF title page.
Source of Description: This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility: by Nicholas J Grimaudo.
Thesis: Thesis (Ph.D.)--University of Florida, 2007.
Local: Adviser: Behar-Horenstein, Linda S.

Record Information

Source Institution: UFRGP
Rights Management: Applicable rights reserved.
Classification: lcc - LD1780 2007
System ID: UFE0021562:00001


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STUDENTS' AND PATIENTS' PERSPECTIVES OF CLINICAL TEACHING AT A
DENTAL SCHOOL




















By

NICHOLAS J. GRIMAUDO


A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY

UNIVERSITY OF FLORIDA

2007

































2007 Nicholas J. Grimaudo

































To my family, especially my mother, Carmela Grimaudo, who passed away in 2003. Her
encouragement was and will always be my inspiration in life. I miss her, but I know that she is
proud of my accomplishments.









ACKNOWLEDGMENTS

My study could not have been completed without the support of the students, patients,

and faculty who volunteered their time. I am thankful to all of them. I could not have completed

this dissertation without the assistance of the members of my doctoral committee: Dr. Kenneth

Anusavice, Dr. James Doud, and Dr. Linda Serra Hagedorn. I would like to especially thank Dr.

Linda Behar-Horenstein, my committee chair. She provided guidance and assistance and has

been a role model, friend, and colleague.

Most importantly, I would like to thank my family. I thank my dad, Joe. I owe all that I

am and everything that I have accomplished. What else can I say?

I thank my sons, Joe and Nick, for their understanding, support, sacrifices, and patience.

We have all been students together for several years but I think dad wins with the most degrees.

They really know the meaning of "lifelong learner."

Most of all I thank my wife, Jeanne, for her encouragement, understanding, support,

sacrifices, and love. She has always been there and pushed me when I needed it. I could not

have completed this dissertation, my degrees, or everything else without her.









TABLE OF CONTENTS

page

A CK N O W LED G M EN T S ................................................................. ........... ............. .....

LIST OF TA BLES .............. ......... .......................................................... 8

LIST OF FIGURES .................................. .. ..... ..... ................. .9

CHAPTER

1 INTRODUCTION ............... ................. ........... .............................. 12

P u rp o se of Stu dy ...................................... .............................................. 16
R research Questions ......................................... ........... ...... ......... 16
Definition of Terms ................. .... .............................. 16
Significance of Study ................................. ............... .. ............17
L im ita tio n s ................................................................................................................. 1 8

2 L IT E R A T U R E R E V IE W ............................................................................ ..................... 19


Theory of Teacher Effectiveness ........................................................................... 19
Oral Health Care Educator-Student Relationship ...................................... ............... 22
The R ole of the Teacher .................................................... ................. 23
The Role of the Learner .............................. ...................... ......... .............. ... 25
The Interaction Between Clinical Teacher and Student...............................................32
Communication Skills ..................................... ......................... 32
C clinical E education ............................................................................37
Individual and Team Learning ............................................ ............................... 39
Findings Relevant to Studies on Clinical Education .......................................................40
Purpose or goal of clinical teaching ........................................ ...... ............... 40
L earning context .................................... ............. ..........................4 1
Requirements and demands from the learning setting. .........................................41
Professional role m odeling......................................................... .............. 42
Concept of service .......................... ...... .......................... ....... ............ 43
Advantages/Disadvantages of Clinical Education.........................................................44
Problem solving opportunities ........................................ ........................... 44
Expectations and feedback ............................................. ..... ....................... 45
C clinical Teaching ......................................................... ................. 46
D definition of C clinical T teaching .......................................................................... ...... 46
R ole of Clinical Instructors ................................. .......... ............ ...............46
Contributions of Clinical Teaching to Dental Practitioners ........................................49
Challenges associated with clinical teaching ................................. ............... 50

3 M A TER IA L S A N D M ETH O D S ........................................ .............................................53









Theoretical Framework for Data Collection and Analysis....................................................53
M methodology .................................. ................... .................................53
Researcher Qualifications and Bias ......................................................... ............... 55
P artic ip an ts .........................................................................5 7
Instrum entation ......... ..................................... ...........................58
D ata C o lle ctio n ................................................................................................................. 5 8
D ata A analysis ................................................... 59
T ru stw orth in ess of D ata .................................................................................................... 59
C red ib ility ............................................................................... 6 0
Transferability .........................................61
Dependability and confirmability ................................. ........................... ....62

4 R E S U L T S .........................................................................6 3

Research Question 1. What are the Characteristics of Oral Health Care Educators-
Patients-Students Interactions in the Clinical Learning Environment? .............................63
F aculty-C entered ....................................................... 63
Stu dent-D riv en ................................................................6 5
Student-Faculty Collaborative ......................................................... 66
P atien t-D riv en .............................................. .............................................................. 6 7
Research Question 2. How are Oral Health Care Educators-Patients-Students
Interactions Perceived by the Student? .............................................................. 68
Research Question 3. How are Oral Health Care Educators-Patients-Students
Interactions Perceived by the Patient? ................................. .. ...... ........ ......... ... 77
Research Question 4. How do the Student and Patient Perspectives of the Oral Health
Educators-Students-Patients Interaction Compare? ...............................................78
Com prison of Observations and Interview s ...................... ......................................79
Research Question 5. How does the Clinical Specialty Influence the Type of Interaction
between the Oral Health Educators-Students-Patients? .......... ...............79
Research Question 6. From the Student's Perspective, What are the Elements of an
"Ideal" Clinical Teaching/Learning Experience? .......................................................80
Student A attributes ......... .......... .................................... ....................................80
Need for support...................................... ........ 81
Student autonomy and student self-assessment. .......................................... 81
Characteristics of Teaching/Learning ................................................................82
Com munication/discussion .................................. ......................................82
F eedb ack .......................... ................................. ..................... 82
Demonstration ......................................................83
Integration of knowledge and skill................ ..... ........... .. .................... 84
Understanding the limits of student knowledge ............................ .............85
Respecting the student/patient relationship............................. .....................86
D desirable Characteristics of the Clinical Teacher ..........................................................86
A approachable personality ................................. ....................................87
Punctuality ....................................................... ............ ....... ..... 87
A v ailab ility .................................................................. ...............................8 7
C o n sisten cy ..................................................................................................8 8



6









5 CON CLU SION .......... ....................................................... ...... ............ ... 92

Characterization of Healthcare Educator-Patient-Student Communication..........................92
F acu lty -C entered ....................................................... ................ 92
Student-Directed ................................................................... ... ......... ........ 92
Student-F aculty C ollaborations ........................................................... .....................93
Patient-Driven .................. ......................... 93
Student Perspective of Triad Relationship ........................................ ........................ 93
Patient Perspective of Triad Relationship.......................................... 94
Influence of Clinical Specialty on Interaction ................ ........ .......... ....................94
Student Perspective of an "Ideal" Clinical Teaching/Learning Experience.........................96
Theoretical implications of this study ........... ............................... ............... 98
Sum m ary of Findings ................................... .. ....... .... ... .. ............98
F u tu re R e search .......................................................................... 10 1

APPENDIX

A INFORM ED CON SENT ......... .. ....... ....... .............. ......... ............................... 107

B PATIENT INTERVIEW PROTOCOL ........................................ .......................... 109

C STUDENT INTERVIEW PROTOCOL .................................... ............................ ......... 110

D CLINIC OBSERVATION SCHEDULE GRID ........................................... .................111

L IST O F R E F E R E N C E S .................................................................................. ..................... 112

B IO G R A PH IC A L SK E T C H ......................................................................... .. ...................... 124









LIST OF TABLES

Table page

4-1 Student and patient dem graphics .......................................................... .. ............... 89

4-2 Student interview responses ......................................................................... ....................90

4-3 P patient interview responses .......................................................................... ....................9 1

5-1 Findings of study based on theoretical framework/perspective ....................................... 104











































8









LIST OF FIGURES


Figure

2-1 Conceptual model for physician-patient relationship continuum .....................52

5-1 Descriptive model of clinical teaching based on student preference..............104










Abstract of Dissertation Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Doctor of Philosophy

STUDENTS' AND PATIENTS' PERSPECTIVES OF CLINICAL TEACHING AT A
DENTAL SCHOOL

By

Nicholas J. Grimaudo

December 2007

Chair: Linda Behar-Horenstein
Major: Curriculum and Instruction


In dental education, the clinic is the learning environment that requires students to

transfer knowledge from the basic sciences and utilize it to render safe and efficient patient care.

The effectiveness of teaching and learning in the clinical learning environment and how it

prepares dental students to independently provide patient care is a central concern for dental

education. The underlying theory in this study was to describe how teacher effectiveness

influences students in the clinical learning environment and impacts patient care. There is

growing awareness that students' responses to and views of their educational experiences are

important to shaping and modifying the educational process.

The primary purpose of this study was to describe the instructional practices among

clinical dental educators as they pertain to student and patient involvement. The secondary

purpose was to describe the interactions between the teacher, student, and patient during clinical

teaching. The study examined the students' and patients' perspectives of the dental clinical

teaching environment. Utilizing participant observation, this study focused on the oral health care

educator-patient-student triad and the learning experience in comprehensive oral health care.

Methods of data collection included unobtrusive observations of interactions between oral health









care educators, patients, and students, and patient and student interviews. This study is grounded

in a constructivist framework, whereby the researcher considered individuals' perceptions and

communications, as well as the setting, as essential for developing insight into the observable

relationships and interactions.

The participants were comprehensive care patients at the U of Wallace College of

Dentistry, faculty members of the College of Dentistry, and student dentists in the classes of

2006 and 2007. Data were collected from three primary sources: patient interviews, student

interviews, and participant observation of the patient-faculty-student interaction for a total of

330 student/patient/faculty observation/interviews completed. The results indicate that there are

particular student attributes, characteristics of teaching/learning, and characteristics of clinical

teachers that are essential to clinical learning. Students reported a preference for a learning

environment that emphasizes the student-patient-education relationship while promoting good

rapport and respect. Attributes ascribed to the effective clinical educator are professional,

competent and consistency with treatment planning and evaluation and use of teaching

techniques such as demonstration and the provision of accurate, comprehensive feedback

delivered in a positive emotional manner. Four major styles of communication interactions

emerged: faculty- centered, student-directed, student-faculty collaboration, and patient-driven,

although students reported that the student-faculty collaboration was the most positive.

Although patient experiences were positive overall, these particular findings did not contribute

any new information that might be used to improve or modify current clinical teaching.

The findings from this study were compared with the key concepts of studies on teaching

and learning in health care environments. Finally, a theoretical model that emerged from the

observations and interviews was presented and explained.










CHAPTER 1
INTRODUCTION

Dental education researchers have suggested that "the clinic is the learning environment

to which all our students aspire" (Mullins, Wetherall, & Robbe, 2003, p. 58) because it requires

the "transfer of knowledge from the basic sciences by tuning and restructuring of knowledge"

(Gordon, Hazlett, ten Cate, Mann, Kilminster, & Prince, 2000, p. 844). The effectiveness of

teaching and learning in the clinical learning environment and how it prepares dental students to

independently provide patient care is a central concern among dental educators and clinical

supervisors.

Although more is now known about medical/professional education, adult learners, and

the development of expertise than ever before, standards and criteria for effective U.S. teaching

are less well developed in medical and health profession programs than in K-12 settings. Many

faculty lack current teaching skills and also lack emerging knowledge concerning how adults

learn and gain expertise (Mennin, 1999), even though teaching medical/dental and health

professional students is central to the mission of these schools.

All medical and health profession programs have clinical and experiential course work

that permits students to practice in the field, under the tutelage of credentialed professionals

(James, Kreiter, Shipengrover, Crosson, Heaton, & Kernan, 2001). These experiences allow

students to put the principles and concepts learned in the classrooms into practice. Clinical or

experiential courses occur throughout the students' course of study, or it can be the last stage of

professional training before the students receive degrees, certificates, or licensure. Guided or

one-on-one learning is used extensively in medical/dental and the health professions schools. To

ensure that proficiently trained graduates enter the profession, teachers must continue to study

and improve their own instructional practices (Cunningham, Stevens, Blatt, & Fuller, 1999).









The clinical learning environment is challenging for teachers and students (Gordon, et al.,

2000). In this setting, the student is a trainee clinician responsible for patient care, while the

clinic is both a patient care facility and a learning environment (Ferenchick, Simpson, Blackman,

DaRosa, & Dunningham, 1997). In the clinic, students are expected to demonstrate diverse

competencies simultaneously such as a broad knowledge base, professionalism, empathy, and

ethical behavior. Recent research suggests that it is important to introduce students early to the

clinical environment, because of the demonstrated value of contextual learning. The clinic is the

central location where basic science knowledge is typically integrated with patient care, and

teaching occurs with an experienced clinician (Mullins, et. al, 2003). Clinical supervision

provides "...monitoring, guidance, and feedback on matters of personal, professional, and

educational development in the context of patient care" (Kilminister, Jolly, & van der Vleuten,

2002, p. 387). Researchers have suggested that the student-clinical teacher relationship is an

educational alliance that mirrors the therapeutic alliance between the patient and physician

(Tiberius, Sinai, & Flak, 2002).

Effective supervision of learners requires that students and instructors together engage in

problem-solving activities and while instructors provide requisite feedback, reassurance, and

theory-practice linking (Hirons & Velleman, 1993). There is some evidence that effective

clinical teaching in medicine has a positive impact on patient outcomes. For example, Albanese

(2000) found that patient outcomes improved when direct supervision of the student clinician

was combined with focused feedback and reflection.

In a dental education context, clinical teaching has been less extensively examined

(Bertolami, 2001). Effective clinical instruction in dentistry requires that educators provide

clinical care while they demonstrate technical competence to their students (Fugill, 2005). Their









abilities to motivate students, explain difficult concepts, display interest in the subject, show

compassion and caring, and to be proactive were also rated as very important by students in a

study reported by Chambers, Geissberger, and Lekinus (2004). A range of educational

modalities supports clinical teaching and patient care such as large group lectures, small group

tutorials, problem-based and case-based activities, interactive interactions, role-play, simulation,

and computer-assisted modalities. These modalities support clinical teaching by using teaching

resources efficiently, by objectifying clinical sessions, by facilitating the development of

professional attributes, sharing common clinical concerns, and affording individual student

interaction (Chambers, et al., 2004). One of the criteria that differentiates clinical from didactic

learning is that clinical learning opportunities are typically unique. Often they cannot be

repeated, anticipated, or planned (Werb & Matear, 2004). In this setting the mastery of clinical

teaching is demonstrated. Instructors must recognize the moment, utilize it, and engage students

so that learning occurs.

Teaching in the clinical learning environment is characterized by the separation of the

teacher in time and distance from other colleagues making it difficult to collaborate with other

teaching professionals. Documentation and analysis are lacking, so the pedagogical literature is

bare (Shulman, 1999). To advance the scholarship of teaching and to transmit clinical teacher's

knowledge, observation and studies are needed.

Some researchers question the need to study clinical teaching. However, when one

considers that it is the core of professional development in medicine and dentistry (Gordon, et

al,, 2000) and that the quality of patient care is dependent on clinical teaching (Fugill, 2005), the

need for documenting its effectiveness becomes clear.









The educational process of the pre-doctoral dental curriculum is designed to help students

learn how to collect patient information data, interpret and synthesize findings, evaluate the

effects of actions taken, perform procedures skillfully, and relate to patients in an ethical and

caring manner (Bertolami, 2001). Taking novice dental practitioners and transforming them into

competent practitioners is one challenge in dental education (Henzi, Davis, Jasinevicious, &

Hendricson, 2006). The aim of clinical education is to produce students who are capable of

practicing both the art and the science of dentistry.

Clinical teaching is a formidable task for faculty. Often faculty are required to teach

individuals simultaneously who are at various levels of training. Patient cases that are presented

are often unpredictable and avert an opportunity for faculty to prepare for teaching. Attending

faculty are responsible for teaching and ensuring high quality patient care. Despite these

challenges, many attending faculty are excellent clinical teachers who exemplify the best values

and behaviors of practicing dentists, provide effective clinical supervision, and are enthusiastic

teachers (Henzi, et al., 2006).

The clinical environment has unique advantages. For example, it is focused on authentic

problems that may occur in the context of professional practice (Li, 1997). Students are typically

motivated by specific demands, active participation, and the professionalism that teachers model

(Levinson, 1999). Finally, this is the only setting in which taking a medical/dental history,

conducting an examination, using clinical reasoning, decision-making, empathy, and

professionalism can be taught and learned as an integrated whole. Despite these strengths,

clinical teaching is often criticized for its variability, lack of intellectual components, electoral

challenge, and haphazard nature. In other words, while clinical teaching is an educationally

sound approach, it is frequently undermined by problems of implementation (Albanese, 2000).









Hutchins and Shulman (1999) pointed out that faculty in most fields do not have the

training for, or the habit of, framing questions about their teaching and students' learning.

Concurring with their opinion, Behar-Horenstein, Dolan, Courts, and Mitchell (2000) suggested

that dental educators are usually considered subject matter experts. However, they usually

provide didactic instruction whereby the students remain in passive roles.

Purpose of Study

The primary purpose of this study was to describe the instructional practices among

clinical dental educators from the students' and patients' perspective. The secondary purpose of

this study was to describe the interactions between the teacher, student, and patient during

clinical teaching.

Research Questions

1) What are the characteristics of the oral health care educators-patients-students interactions in
the clinical learning environment?

2) How are oral health care educators-patients-students interactions perceived by students'?

3) How are oral health care educators-patients-students interactions perceived by patients'?

4) How do the students' and patients' perspectives of the oral health educators-students-patients
interaction compare?

5) How does the clinical specialty influence the type of interaction between the oral health care
educators, patients, and students?

6) What do students consider to be the elements of an "ideal" clinical teaching/learning
experience?

Definition of Terms

Attending faculty are dentists who a hold state license and board credentials and work as

educators at a particular dental school.

Clinical teaching is a process of teaching and learning in a health care setting that usually

directly involves diagnosis and treatment of patients.









Communication is any act by which one person gives to or receives from person information

about that person's needs, desires, perceptions, knowledge, or affective states. Communication

may be intentional or unintentional, involve conventional or unconventional signals, and may

occur through spoken or other modes.

Dental student is an individual who is currently enrolled in a professional program of study that

upon matriculation will ultimately result in receipt of the degree of doctor of medical dentistry

(DMD).

Non-verbal communication is information transmitted between sender and receiver via eye

contact, gesture, body language, and distance.

Constructivism is a philosophy of learning founded on the premise that, by reflecting on our

experiences, we create our own understanding and make meaning of the world we live in.

Oral health refers to the oral cavity, the mouth, and the collective known as the craniofacial

complex that is an integral indicator and component of overall wellbeing.

Patient is the person receiving oral health care from a specified provider in the clinical setting

Significance of Study

The findings from this study will (a) contribute to an understanding of what constitutes

effective clinical teaching, and (b) render suggestions for improving clinical teaching and

professional education. This study provides information to the literature that is lacking in

qualitative studies of clinical teaching within doctoral level experiential education at a school of

dentistry, by offering a scholarly study that is "public" in that its "vision, design, enactment,

outcomes, and analysis" open to critical review by the health and medical education community,

as well as the larger education community.









Limitations

This study was designed to investigate oral health care educators'-patients'-students'

interactions and clinical teaching in a comprehensive oral health care teaching facility,

emphasizing the students' and patients' perspectives. The applicability of the results is limited to

similar learning environment such as teaching institutions in the United States. In addition, the

results of this study may differ from previous research findings involving oral health care

educator-student-patient interactions, as this study emphasizes students' perspectives.

The participants in this study were limited by the patients, specific clinics, student

assignments, and faculty coverage available during observations. The four clinics represented in

this study may not be representative of all the clinics within the dental school. Furthermore, the

results of this study may have been influenced by the setting, as well by the participants.










CHAPTER 2
LITERATURE REVIEW

Theory of Teacher Effectiveness

Theoretical perspectives of teacher effectiveness vary. Teacher effectiveness has been

purported to be a teacher trait perspective, a teacher behavior perspective, a process-product

perspective, and a process-psychological mediators-sociological mediators-process research

perspective (Behar-Horenstein and Morgan, 1995). However, most educators agree that students

grow and learn the most from effective teachers. Teacher effectiveness is a major issue in current

movements of education reform and improvement. It is generally agreed that the teacher is the

key element for the success of education (Omstein & Lasley, 2004). Traditional studies on

teacher effectiveness focus largely on the performance of individual teachers in classrooms. In

recent decades, the topic of teacher effectiveness has continued to attract the attention of

researchers, educators, and professional organizations. Ornstein and Lasley (2004) point out that

the literature on teaching effectiveness, or teacher effectiveness, is a morass of ill-defined and

changing concepts. To different people, the definition of teacher effectiveness could be very

different. Some researchers focus on teacher personalities, traits, behaviors, attitudes, values,

abilities, competencies, and many other personal characteristics. Other researchers are more

concerned with the teaching process (including factors such as teaching styles, teacher-student

interactions, and classroom climate) or the teaching outcomes (including factors such as

students' academic achievements, personal development, and learning experiences). Despite

thousands of studies conducted in the last 50 years, it is difficult to arrive at generally accepted

conclusions. Few generalizations concerning teacher effectiveness have been established

(Borich, 1996). Some scholars have criticized the underlying philosophy, methodologies, and

findings in teacher effectiveness studies. They suggested that the existing perspectives of teacher









effectiveness, such as the teacher trait perspective, the teacher behavior perspective, and the

process-product of teaching perspective cannot be successful in explaining or analyzing the

complexity of teacher effectiveness (Fullan, 1999).

Borich (1996) suggested that effective teachers achieve the goals they set for themselves

or the goals set for them by others such as school principles, education administrators and

parents. According to Ornstein and Lasley (2004), effective teachers must have a body of

knowledge essential for teaching and know how to apply it. By integrating these two concepts,

effective teachers may be assumed to be those who possess the relevant competence (including

necessary professional knowledge, skills, and attitudes) and use the competence appropriately to

achieve their set goals.

From this line of thinking, the understanding of teacher effectiveness must be based on

the linkage between teacher competence, teacher performance, and set goals or expected

educational outcomes. Medley's (1996) structure of teacher effectiveness is a comprehensive

framework which integrates the teacher trait perspective, the teacher behavior perspective, and

the process-product of teaching perspective to explain the relationships between teacher

competence, teacher performance, student learning experience, and educational outcomes. He

explained that "teacher effectiveness" refers to the teacher results or to the amount of progress

the students make towards specified goals of education. One implication of this definition is that

teacher effectiveness must be defined and can only be assessed in terms of behaviors of students,

not behaviors of teachers. For this reason, and because the amount that students learn is strongly

affected by factors not under teachers' control, teacher effectiveness should be regarded not as a

stable characteristic of the teacher as an individual but as a product of the interaction between

certain teacher characteristics and other factors that vary according to the situation in which the









teacher works. According to Medley (1996) the structure of teacher effectiveness should include

components such as: teacher characteristics, competence, performance, learning experience,

learning outcomes, training, teaching context, and student characteristics. Cheng (1999) further

developed Medley's structure by the inclusion of two more components, teacher evaluation and

professional development.

Teacher effectiveness is a complex issue. Evaluation of teaching effectiveness is

problematic. The ability of bright people to learn what they need to know despite any curriculum

cannot be discounted and high-aptitude students tend to succeed regardless of the instructional

strategy used (Woodward, 1996). One of the daunting aspects of evaluating professional

education is that academics in the medical and dental field, who have been trained in the

scientific methods, which are mandatory for evaluating treatment modalities, try to utilize similar

methods for evaluating educational outcomes (Van der Vleuten, Dolmans & Scherpbier, 2000).

Such attempts, while efficient because of the numerical data they supply, are ultimately

unreliable. The rigid quantitative scientific method of controlled experimentation cannot be

considered valid in an environment where the variables of the sample are almost as great or

greater than the sample itself, the student sample in any one year of a dental or medical school

being statistically minute (Lechner, 2005).

Another difficulty is in delineating a clear definition of outcomes. Wilkes and Bligh

(1999) grouped several types of evaluation into student-oriented, program-oriented, institution-

oriented, and stakeholder-oriented. The indicators cover a wide area, ranging from attendance at

class, through patient satisfaction, questionnaires, test results and peer evaluation. Several studies

have attempted evaluation using examination (Login, Ransil, & Meyer, 1997, Bachman, Lua &

Clay, 1998, Lindquist, Clancy, & Johnson, 1997) the number of student inquiries regarding the









levels of knowledge required for examinations (Roberts, Clancy, & Roberts, 1997), follow-up

surveys (Bachman, et al., 1998), and self-evaluation by the students (Lary, Lavigne, & Muma,

1997).

The simplest measurement of outcome is by examination. Examination results can be

shown numerically and analyzed statistically. However, they cannot be relied on to give a whole

evaluative picture (Lechner, 2005). Currently, the most pragmatic approach in educational

evaluation is to focus on students' perceptions of their experiences in a learning program. This

approach has been used in several studies (Peters, 2000, Schuhbeck, 1999, Manogue, 1999,

Wenzel & Gotfredsen, 1997). Enjoyment and success engender a winning cycle in the learning

environment. If teaching resources can involve students and lead them to be successful in their

endeavors, they are more likely enjoy their tasks and want to become even more involved.

(Manogue, 1999)

In this study, students' perceptions will be explored to gain an understanding of rather

than measuring teacher effectiveness.

Oral Health Care Educator-Student Relationship

Communication between instructors and students is the most important consideration in

teaching (Marsh & Dunkin, 1997). Although knowledge is transferred by various means in

dental education, teacher-student interactions remains foremost (Losh, Mauksch, & Arnold,

2005). A successful classroom or clinic session not only transmits the desired information, but

also motivates students to learn more. In fact, the most important outcome of the experience

may not be acquisition of clinical or scientific data, but behavioral and attitudinal changes that

contribute to future development (Branch, Kern, Haidet, Weissmann, Gracey, Micthell, & Inui,

2001).

Communication includes much more than verbal exchange; it encompasses the entire









teaching-learning environment. Instructors' verbal skills, "stage presence," audio-visual aids,

and attitudes toward the students and the topic also influence factors in communication. Interest

in the topic, the curriculum, the students and their success, and the desire to do the best job

possible go a long way toward improving communication (Lizzio, Wilson, & Simons, 2002).

An adage in education states that the best classroom is one in which both the students and

the instructor are learning. Teachers try to communicate information to students that will expand

their knowledge base and promote acquisition of skills as they progress towards degree

completion but teachers in higher education also have career goals: promotion, tenure, expanded

opportunities, and recognition (Fraser, 1998). Open, two-way communication between students

and teachers is one of the most effective ways to determine how well these aims are being met.

Dental education, like all postsecondary education, has the advantage of dealing with

adult students. Often instructors' teaching styles are mismatched with adults' learning needs.

However an effective communicator will seek and promote dialogue with the students so that

both profit from the experience (Beasley, 1997).

Accepting the principle that effective communication is bilateral, instructors strive to

create a democratic, humane atmosphere in both classrooms and clinics (Branch, et al., 2001).

An environment that encourages communication between instructors and students, and-even

more importantly-among the students themselves, especially outside the learning situation, will

provide the most successful learning experience (Emerson & Groth, 1996).

The Role of the Teacher

Many medical and dental educators think that the only role of the teacher is to be a

reservoir of knowledge and skills that occasionally, and unpredictably, spills over its dam, letting

information flow randomly down a canyon of learning (Benor & Levy, 1997). However, as

McKeachie (2002) emphasized, expertise in a particular discipline is not sufficient to ensure









good teaching.

Clinical teachers assume multiple roles in their interactions with their students. In a

review of 20 of the most significant studies of perceptions of excellent clinical teaching

Stockhausen (1998) found that the behaviors and characteristics of excellent clinical teachers fall

into four roles: Physician/Provider, Teacher, Supervisor, and Person.

The Physician/Provider is considered to be the expert and the source of all knowledge.

There is considerable discrepancy between the Physician/Provider's level of experience and

wisdom and that of the students. This discrepancy is the reason the medical/dental teacher and

students are together. The physician is also responsible to school administrators, specialty

boards, and hospital credentials committees for evaluating and certifying the competency of

students. The physician upholds professional standards and is a socializing agent of the

professional discipline.

As Teacher, the medical/dental educator is acutely aware of the needs and aspirations of

students, but does not automatically assume it will be possible to provide them everything they

need. The Teacher can listen, question, paraphrase, encourage, or doubt students, but cannot

always provide for them.

As a Supervisor, the medical/dental educator demonstrates procedures, provides practice,

observes and assesses performance, and provides feedback.

Finally, as a Person, the educator develops an atmosphere of sufficient trust so that the

students are comfortable sharing ideas, feelings, and thoughts. The physician/dentist-educator

does not necessarily have to like the students, but does need to accept their learning needs and

imperfections. The Person may provide significant personal help and support outside the formal

teaching setting.









The Role of the Learner

Research on student learning in higher education has shown that students adopt

qualitatively different approaches to their studies, depending upon their prior learning

experiences and the particular context in which they find themselves (Prosser & Trigwell, 1999).

Because of the varied experiences students have had, they are likely to have qualitatively

different learning outcomes. These experiences can be characterized as surface and deep

learning. Surface approaches, in which students focus on reproducing the content and processes

they are studying, are associated with high workload and assessment demands that are expected

to be met by reproductive learning. Deep approaches are associated with good teaching

experiences whereby goals and standards are clear, and students have some freedom and choice

in how and what they learn. Deep approaches to study are in turn associated with an

understanding subject matter, which can be broadly described as relational, while in surface

approaches, the understanding can be described as multi-structural (Biggs, 1999). That is,

students can understand the outcomes of their courses and programs and what their courses and

programs are about in terms of a coherent (relational) or of an unrelated (multi-structural) set of

ideas and procedures. The way institutions structure the teaching and learning contexts of

students has a substantial impact on what and how students learn (Gendrop & Eisenhauer, 1996).

Students' perceptions of teaching and learning contexts are a function of both their prior

experiences of teaching and learning and the present context (Anderson & Speck, 1998; Brown

& Gillis, 1999). Through prior learning experiences, students develop perceptions that guide the

ways that they approach future studies. To improve students' learning outcomes, university

teachers need to be concerned with the context, students, and their own perceptions of that

context (Fenderson & Damjanov, 1997).









Conditions for Effective Learning

Since medical/dental students are adult learners, professional education should follow the

principles of adult learning (Irby, 1983; Klineberg, et al., 2002). Unfortunately, this does not

always happen. Medical/dental learners are certainly adults chronologically, and they are

pursuing a field of study that requires discipline and maturity. Medical/dental education is, or

should be, an adult learning process (Lyon, 2004). There are several principles that enhance

adult learning (Spencer & Jordan, 1999).

Malcolm Knowles was the first to theorize about how adults learn. As a pioneer in the

field of adult learning, he described adult learning as a process of self-directed inquiry. Six

characteristics of adult learners were identified by Knowles (1970), they are: autonomous and

self-directed, accumulated a foundation of experiences and knowledge, goal oriented,

relevancy oriented, practical and need to be respected. He advocated creating a climate of

mutual trust and clarification of mutual expectations with the learner. In other words, a

cooperative learning climate is fostered.

The reasons most adults enter any learning experience is to create change. This could

encompass a change in (a) their skills, (b) behavior, (c) knowledge level, or (d) even their

attitudes about things (Adult Education Centre, 2005). Compared to school-age children, the

major differences in adult learners are in the degree of motivation, the amount of previous

experience, the level of engagement in the learning process, and how the learning is applied.

Each adult brings to the learning experience preconceived thoughts and feelings that will be

influenced by each of these factors. Faculty are well advised to assess the level of these traits and

the readiness to learn should be included each time a teaching experience is being planned.

Adults learn best when they are convinced of the need for knowing the information.









Often a life experience or situation stimulates the motivation to learn (O'Brien, 2004).

Meaningful learning can be intrinsically motivating. The key to using adults' "natural"

motivation to learn is tapping into their most teachable moments (Zemke & Zemke, 1995).

Adults have greater depth, breadth, and variation in the quality of previous life

experiences than younger people (O'Brien, 2004). Past educational or work experiences may

color or bias the students' perceived ideas about how education will occur. If successfully guided

by the health care provider, former experiences can assist the adult to connect the current

learning experience to something learned in the past. This may also facilitate making the learning

experience more meaningful. However, past experiences may actually make the task harder if the

teacher does not recognize these biases.

Adults learn and process information in different ways. There are different ways to

classify learning styles. Learning styles can be classified into general categories: perceptual

modality, information processing, and personality patterns. The categories represent ways to

focus on the learner.

Perceptual modalities define biologically based reactions to the physical environment and

represent the way people most efficiently adopt data. It is advantageous for learners and

educators to know perception style so that information can be given in the format that the learner

can process most efficiently. Educators should pay attention to modalities to ensure programs

incorporate all physiologic levels (Dunn & DeBello, 1999).

Information processing distinguishes between the way people sense, think, solve

problems, and remember information. Each learner has a preferred, consistent, distinct way of

perceiving, organizing, and retaining information. Personality patterns focus on attention,









emotion, and values. Studying these differences allows educators and researchers to predict ways

learners will react and feel about different situations (Dunn & DeBello, 1999).

Most adult learners develop a preference for learning that is based on childhood learning

patterns (Edmunds, Lowe, Murray, & Seymour, 1999). Several approaches to learning styles

have been proposed, one based on the senses that are involved in processing information. An

assessment of the students' learning style is a fundamental step prior to beginning any

educational activity. Determining the students' learning style will help identify the preferred

conditions under which instruction is likely to be most effective (Richardson, 2005). The most

frequently used method of delineating learning styles is identifying visual, auditory, and

kinesthetic learners.

Visual learners prefer seeing what they are learning. Pictures and images help them

understand ideas and information better than explanations (Jezierski, 2003). A phrase you may

hear these learners use is "The way I see it is." The teacher needs to create a mental image for the

visual learner as this will assist in processing the information. For a visual learner to master a

skill written instructions must be provided. Visual learners read and follow the directions as they

work and appreciate when diagrams are included.

Auditory learners prefer to hear the message or instruction given. These adults prefer to

have someone talk them through a process, rather than reading about it first. A phrase they may

use is "I hear what you are saying." Some of these learners may even talk themselves through a

task, and should be given the freedom to do so when possible. Adults with this learning style

remember verbal instructions well and prefer that someone else read the directions to them while

they engage in the physical work or task.









Kinesthetic learners want to sense the position and movement of the skill or task. These

learners generally do not like lecture or discussion classes; they prefer to "do something." These

adults do well learning a physical skill when materials are available for hands-on practice.

The adult learner has many responsibilities that must be balanced against the demands of

learning. Because of these responsibilities, adults may have barriers that mitigate their

participation. Melton, Calder, and McCollum (2005) discuss the barriers that adult learners face

such as time, confidence, convenience, and motivation. They propose alternative types of

education delivery such as distance and open learning to reduce the barriers. If the learner does

not see the need for the behavioral change or acquiring knowledge, then a barrier exits. Likewise,

if the learner cannot apply learning to his/her past experiential or educational situations, the

teacher will have barriers to overcome. A successful strategy includes showing the adult learner

the relationship between the knowledge/skill and the expected outcome.

Dental students are considered professional students and typically are 22 years of age or

more. Leaving aside the question of whether chronological age is an appropriate definition of

adulthood (Fraser, 1995), for the purpose of this study, the researcher makes the assumption that

dental students are adults. From there, it follows that we should ask how they learn and how

they should be taught. Does andragogy describe the way dental students learn? Doubts have

been expressed about the validity of the assumptions on which Knowles model is based. Stephen

Brookfield (1995 p.75) is among such critics:

"We are far from a universal understanding of adult learning... Theory development... is

weak and is hindered by the persistence of myths that are etched deeply into adult educators'

minds... Indeed, a strong case can be made that as we examine learning across the lifespan the









variables of culture, ethnicity, personality and political ethos assume far greater significance in

explaining how learning occurs and is experienced, than does the variable of chronological age."

Typically, adults want to apply what they learn soon after they have learned it. This rule is

broken somewhat less in clinical teaching than in other areas of medical/dental education. Even

so, clinical teachers should feel compelled to justify any clinical teaching that cannot be shown

to have relevance or be applicable to a patient problem or clinical situation.

Adults are interested in learning concepts and principles; they like to solve problems

rather than just learn facts. Medical/dental education suffers terribly under the weight of

unrelated, and often relatively useless, facts. As medical/dental knowledge expands, so does the

density of the medical/dental education process, often to the detriment of the problem-solving

and clinical reasoning skills of future professionals. By the emphasizing use of facts, rather than

their mere retention, clinical educators will not contribute to what is already recognized as a

major problem by national authorities. Behar-Horenstein, Mitchell, and Dolan (2005) used a

case study to illustrate how an evaluation strategy was used to assess classroom instructional

practices following a multi-year institutional curriculum revision process in the first and second

year basic science courses. Observations revealed that seventeen of the twenty classes observed

were teacher-centered, passive, and lacked observable efforts to help students understand the

relationship of the lecture content to the oral health problems. The findings of their study

illustrated the importance of using formative evaluation as a mechanism to assess change efforts.

In addition this study showed how evidence-based study can support initiatives directed toward

assessing active student learning and problem solving. Behar-Horenstein, et al., (2005) also

reported that raising faculty awareness about the importance of acquiring evidence-based

educational skills, aligning instruction with course goals and objectives, formatively assessing









teaching, and providing practice-based learning experiences are essential to ensuring that

demonstration of active learning and critical thinking are demonstrated in the curriculum.

Adults like to participate actively in the learning process by helping to set appropriate

learning objectives, yet can students realistically know what they need to know? The teacher

possesses considerable knowledge and experience that learners do not.

Adults also like to know how well they are doing, thus, providing timely formative

feedback helps them evaluate their own progress. Medical and dental education offers numerous

opportunities for making decisions about competence, promotion, or advancement using

summative evaluation (Bardes, 1995). Clinical teachers play a critical role by providing

feedback and critiques, particularly negative ones, which can help shape students' professional

behaviors, decision-making, and skill performance. Personal, well-intentioned feedback is the

critical element for cementing a teacher-student relationship and bringing closure to the learning

process (Gillespie, 2002).

Although it is each individual's responsibility to learn, a teacher can help or hinder a

student's attempt to learn; by facilitating learning and helping the students, a teacher can exert a

positive influence (Gerzina, 2003). Good teachers of adults are people-centered, more interested

in people than things, more interested in individuality than conformity, and more interested in

finding solutions than following rules (Hekelman, 1996). The teacher must be understanding,

flexible, patient, humorous, practical, creative, and prepared (Ziv, 1998).

Students are individuals, with individual experiences and individual abilities. Thus,

knowing the strengths and weaknesses, rather than the age of the student may be more important

in teaching.









The Interaction Between Clinical Teacher and Student

The physician-patient relationship has been characterized as a continuum with two

complementary control scales along which physicians and patients move at equal rates and in the

same directions. The conceptual model for this is shown in Figure 2.1.

As the physician moves from left to right and uses interviewing and communication

behaviors that are increasingly less assertive or controlling, the patient moves from left to right,

with the opposite results. An example of a situation to the far right of the scales would be a

traditional psychoanalytic relationship in which the patient takes almost total responsibility for

the outcome of the interaction and receives little or no feedback or comment from the

psychiatrist (Pasquale & Pugnaire, 2002). The interactions between teacher and student can be

characterized in a similar manner. A high degree of control and activity on the part of a teacher

calls for a relatively passive role for the learner, and vice versa.

Communication Skills

The clinical teacher draws upon a broad range of communication skills and behaviors and

chooses the specific technique that is appropriate to the particular situation (Benor & Levy,

1997). The necessary repertoire of communication skills ranges from a group that might be

labeled "attentive silence" whereby the teacher is passive, to a group labeled "cooperative

negotiation" when teacher and learner take a fairly equal stance, to a group labeled "persuasive

confrontation" when the teacher takes an active and controlling stance in the relationship.

Attentive silence is a group of skills that communicates that the teacher is paying attention

and gives the learner time to think. One of these skills is observation, whereby the teacher

gathers behavioral and nonverbal data about the student. The clinical teacher may also use

purposeful eye contact to engage learners who require special attention and tracking to indicate









understanding and general approval (Manague, Brown, & Foster, 2001). Open-ended

encouragement and advocacy is used to provide a supportive learning environment. Although it

is not a completely anxiety-free, learning environment, surface paraphrasing, and exploration

helps the clinical teacher gain additional general information from the learner. The self-

disclosure approach is used to strengthen the teacher's image and credibility by revealing

personal experiences and "war stories" (difficult cases and mistakes) and active listening, when

the clinical teacher probes the student's thinking for purposes of clarification, expansion,

justification, and correlation about patients' presenting problems and potential treatment

planning. Intense paraphrasing allows the teacher to more aggressively question the learner for

specific information or for specific responses. Open-ended questioning is used to expand the

discussion and to probe the student about treatment options. Giving positive and negative

feedback allows the teacher to give negative information in a way that the learner can improve

future performance, whereas summarizing and interpreting enables the clinical teacher to take

control of a discussion and add appropriate emphasis, clarity, and emotional punctuation. The

clinical teacher transmits expert knowledge directly to the learner by information giving and

prescribing (Mark, Saayler, & Geddes, 1997). Critiquing, correcting, and closed questioning is a

technique that provides the student with summative evaluations and examines the student's

knowledge in a focused and convergent style. Persuasion, challenge, and confrontation allows

the teacher, in the most active and assertive way possible, to challenge old knowledge and

attitudes in an effort to persuade the student to adopt new knowledge and attitudes (Cameron,

1996; Elnicki, et al., 2003; Engel, 1996; Irby, 1987; James, 1998).

Interpersonal skills involve such care-related areas as communication, provision of a safe

and comfortable environment, privacy and confidentiality, respect, and courtesy, all of which are









vital to the effective performance of skilled providers (DaRosa, Dunningham, Stearns &

Fernchick, 1997).

Effective role modeling is also essential to teaching interpersonal skills (Elnicki, Kolarik &

Bardella, 2003). Whether working with a model or a patient, demonstrating a skill, or coaching a

student who is developing a skill, the teacher must incorporate effective interpersonal skills. For

example, the teacher must communicate with the anatomic model while performing a procedure.

The teacher must be careful to drape the model and be aware of the need for privacy and respect

as if the model were a patient. When assessing the student's care of the patient, the teacher must

give as much attention to interpersonal skills as to psychomotor skills. Post-clinical conferences

should bring up issues and practices around communication and interpersonal skills as well as

those pertaining to the more technical aspects of care (Schaefer & Zygmont, 2003).

Effective verbal communication is a key factor in interpersonal skills, whether in

interactions with patients, families and communities, administrators, supervisors, and other

healthcare workers. Interpersonal communication is a person-to-person, verbal or nonverbal

exchange of opinions, feelings, and information (Spiegel, 1995). Effective communication is a

two-way process. To be effective, counseling, for example, must be a two-way communication

process. Good communication skills are as important as good clinical skills in providing high

quality healthcare (Emerson & Groth, 1996).

Communication skills are fundamental to medical and dental practice (Epstein & Hundart,

2002). These skills are critical for information gathering, diagnosis, treatment, patient education,

and health team interactions. Patients' benefits resulting from effective communications with

health care providers include increased satisfaction, greater symptom resolution, lower referral

rates, improved functional status, and enhanced health outcomes. Health Care Providers' benefits









from effective communications include increased satisfaction, efficacy, and reduced malpractice

claims (Hickson, Federspiel, Pichert, Miller, Gauld-Jaeger, & Bost, 2002). Recognizing the

importance of communication skills in medical and dental encounters, the Association of

American Medical Colleges and the American Dental Education Association have called for

medical and dental educators to carefully define, teach, and evaluate communication skills for

physicians and dentists in training (Stewart, Brown, Boon, Galajda, Meredith, & Sangster, 1999).

Patients' expectations regarding health communications have also shifted as more patients take

active roles in information gathering and decision-making. Many medical and dental schools

have established programs to respond to these new expectations (Little, Everitt, & Williamson,

2001).

Students develop communication skills by observing others and then practice these skills

in settings where they can receive feedback. Communication skills are usually introduced in the

preclinical years, but these skills have been less frequently reinforced and evaluated during the

clinical years when students are actively practicing communication in clinical settings. Although

fast-paced clinical teaching environments present challenges for systematic teaching of

communication skills, attention to communication during clinical encounters can bring these

skills to life and allow students and faculty to see their relevance (Haq, Steele, Marchand,

Seibert, & Brody, 2004).

Patients are more likely to seek timely care, cooperate with necessary procedures, follow

through on recommendations, and return for follow-up care when they have trust and confidence

in their providers. Developing a relationship of trust and confidence requires the ability to

communicate well. Effective communication skills are therefore powerful and essential tools for

all providers. Verbal communication is more than the words themselves-it also involves the









tone and volume of words. Tone can communicate compassion, hostility, anger, or indifference

(Irby, 1978). Nonverbal communication can be as powerful as, or even more powerful than,

verbal communication. Therefore, providers must be especially alert to the nonverbal messages

they convey. Besides the position and stance of the body, nonverbal messages can be

communicated through hand shaking, laughing, gently patting, handholding, eye contact (in

some cultures), and facial expressions (e.g., frowning, furrowing the brow, and smiling)

(Ferenchick, et al., 1997).

Negative verbal or nonverbal communication can be a barrier to healthcare. Not only

should providers be careful about the messages they are communicating through verbal and

nonverbal means, but they must also pay close attention to the verbal cues and nonverbal

behavior of other people.

The learning environment is also an influential factor in effective interpersonal

communication. The provider should try to create an environment that is culturally appropriate,

emotionally safe, and comfortable. Examples of factors that should be considered in the cultural

environment are gender preference in providing healthcare, the language and culture of the

provider (if different from that of the patient), traditional food customs, beliefs about blood

transfusions, and values and ideals related to modesty (Ellis & Llewellyn, 1997). Lack of regard

and respect for cultural values can become an obstacle to receiving care. The negative attitudes

of providers can frighten patients away. Therefore, providers should respect patients' culture,

values, and beliefs, even when they are unfamiliar with them (Gillespie, 2002).

Just as interpersonal skills are part of every patient-provider interaction, these skills are

woven throughout the learning resource process. Case studies can be used to acquaint students

with the sociocultural environment of the patient and teach them how to communicate so that









they can effectively gather data and manage complications (James, 1998). During training,

attention must be given to development of the students' attitudes and interpersonal skills, as well

their psychomotor and clinical decision making skills (Knight, et al., 1997). Patients require

attention to emotional and psychosocial needs as well as to physical needs. Effective teachers

are constantly attentive to the students' need to develop interpersonal skills throughout the

learning experience (Kernan, et al., 2000).

Clinical Education

Clinical education is a problem-centered approach in the context of professional practice,

an experience-based learning model, and a combination of individual and team learning (Bligh,

Lloyd-Jones, & Smith, 2000).

The focus of clinical education is on the patient. Patient problems provide teaching

opportunities for the faculty and learning opportunities for the student (James, et al., 2001). The

richness of that learning experience depends in large measure upon the faculty member's

instructional skills and the patient mix available. Since clinical instruction takes place in the

context of professional practice, students' questions about the relevance of what is to be learned

are minimal and motivation is high. Students actively strive to emulate faculty and resident role

models (Colliver, 2000).

In clinical education, the process of learning is principally by doing. This form of

experiential learning differs from most classroom settings, where the symbolic medium is used to

transmit information. In experiential learning, information is generated through the sequence of

steps (O'Malley 1999) whereby the student: (a) acts in response to a particular situation and

experiences the consequences, (b) infers the effects of action in the particular case, (c)

generalizes understanding over a wider range of circumstances, and (d) acts in a new

circumstance anticipating the consequences.









Experiential learning is time consuming and requires repeated actions in enough

circumstances to allow for the development of a generalization from experience. When the

consequence of action is separated in time and space, the learning process is not effective

(Karuhije, 1997)

A "typical" observation of those who have learned something through this process is that

"they cannot verbalize it, but they can do it." The weakest link in experiential learning is in

generalizing from the particular experiences to a general principle applicable in other

circumstances. Thus, post-experience discussion is critical to the learning process so that

students can infer general principles from the experience (Li, 1997). The strengths of this

learning process include intrinsic motivation. Recall is often stronger from experiential learning

than during learning through information processing. Clinical education relies heavily on

experiential learning, but also uses information processing for knowledge acquisition.

Bligh, Lloyd-Jones, and Smith (2000) proposed an instructional model for clinical

settings that postulates a developmental sequence for educational activities. Learning begins

with the attending physician providing an orientation to the service and to the work at hand. This

is followed by the acquisition and application of knowledge and skills in the context of practice

and finally, the termination of the instructional/work sequence. This model is tied directly to the

tasks of the work group and relies heavily upon the instructional leadership role of the faculty.

The term clinical practice appears to suggest that learning occurs through student practice.

But how is this experience converted into learning? There seems to be a belief, inherent in

dental school curricula, that student learning in the clinic occurs through practice. Until recently,

most dental schools used a "quota" or requirement system, whereby students were required to

achieve at least a minimum number of different operative procedures. Though the quota system









has been changed with the introduction of competence-based curricula, the changes so far appear

to relate principally to student assessment rather than to teaching (Chambers, 1998; Walsh,

2000). The assumption remains that students can learn operative procedures through multiple

repetitions.

The processes of learning in the classroom and learning to carry out clinical activity do not

appear to be the same. Much has been written about experiential learning (i.e., the idea that we

learn by doing things), and there are many definitions of what is meant by the process (Kolb,

1984; Clark, et al., 2001). This idea has become a popular educational ideology, so much so,

that there now appears to be a divergence of opinion and lack of clarity about the process.

The development of experiential learning as a concept is attributed particularly to Kolb.

The Kolb learning cycle describes experiential learning as involving "four stages which follow

each other in a cycle" (Gibbs, 1988), viz, concrete experience, reflective observation, abstract

conceptualization, and active experimentation. Some researchers believe that Kolb's learning

cycle describes the way that adults learn (Best & Rose, 1996; Fraser, 1995). This may or may

not be completely true, but ideas expressed in the Kolb learning cycle have directed curriculum

development for adults and various aspects of students' clinical practice (Stockhausen, 1998).

From Kolb's observation learning is cyclical-that repetitions do allow the student to

make changes based on past experience-but as discussed above, the basic tenet of Kolb's work

was that "it is not sufficient simply to have an experience in order to learn" (Gibbs, 1988). Yet

there have been few studies in dentistry that have examined how students learn in clinical

practice.

Individual and Team Learning

Strength of clinical education is the combination of individual and team learning. While

students are responsible as individuals for their learning during a clinical clerkship, this learning









occurs in the context of the work team (Barfield, 2000). Instructional time and effort are

allocated in the context of teamwork and team function. In a field study of instruction by

attending physicians in an internal medicine department, Branch and Paranjape (2002) observed

that learning by individual team members appeared tied to overall team development. As

individual team members learn, they appear able to contribute and use the contributions of others

to their teams, and as teams develop their abilities to work together. They also appear to

promote additional learning among their individual members.

Clinical education is a challenging experience for most students because it allows them to

participate actively in the health care team, seek solutions to real problems, and learn by doing,

all while caring for patients.

Findings Relevant to Studies on Clinical Education

The review of the health care education literature that differentiates clinical and didactic

teaching sharpens the definition of "clinical" teaching for this study. Some researchers have

identified basic components or dimensions of health care teaching that claim to be exclusive to

clinical teaching but, in fact, are applicable to both didactic and clinical practices. Several

studies in medical or health care education make clear distinctions of clinical teaching in

comparison to didactic teaching.

These distinctions have been categorized as: (a) Purpose or goal of teaching, (b) Learning

context, (c) Requirements and demands from the learning setting (d) Role modeling and (e)

Concept of service.

Purpose or goal of clinical teaching

Clinical teaching in dentistry is primarily centered on the provision of patient care.

(Fugill, 2005) While providing patient care, the clinical teacher and student interact on a one-to-

one basis. In the clinical environment, students interact with patients to learn how to care for









them in the most skillful manner possible. This is distinctively different from didactic teaching

where cognitive learning prevails and experiences are based on course-specific objectives that

are less frequently correlated to clinical experience (Karuhije, 1997).

Learning context

Clinical teaching in medicine occurs "at the bedside," which refers to an acute care

hospital setting, a client/patient interaction in an examining room at an ambulatory setting, or an

out-patient clinic with walk-in clients. Irby (1994) states that clinical education occurs at the

bedside.

In dentistry, the operator is the realm for clinical teaching. The teacher and student

form a relationship that has traditionally been perceived as a key element in clinical teaching

(Fugill, 2005). The clinical learning environment also includes the patient, who adds complexity

to the learning process. For the student, clinical practice involves irreversible procedures, which

must be completed without harm to the patient. The clinical teacher must ensure that patients'

treatment is acceptable and s/he has a duty to prevent harm to the patient while providing a

learning experience for the student. (Henzi, et al., 2007)

Didactic teaching most often occurs in a classroom environment, away from the vicinity

of patients (Perry, 1997). Didactic teaching may emphasize theoretical concepts, whereas

clinical teaching utilizes psychomotor skills involving patient care (Sharp & Spence, 1999).

Requirements and demands from the learning setting

The key distinctions between clinical teaching and didactic teaching are the requirements

and demands that arise in the learning setting. According to James and Shipengrover (2001),

these include the element of risk for safety and wellbeing of the patients with whom the students

are interacting. There is limited control over outside factors that occur in the clinical setting,

such as interactions with unanticipated personnel, patient treatment procedures, or a change in









the status of the patient. Thus, learning experienced in a clinical environment may be unique and

cannot be repeated (James & Osborne, 1999). Diversity of facilities is a factor in the distinction

of clinical teaching (Talwar & Weilin, 2005). Within the teaching time frame of the day, many

rooms, units, or bedsides become the location for teaching within the institution, unit, or facility.

Thus, the clinical teacher must be able to function within various settings as learning

opportunities arise and as the needs of the patient change.

In contrast, didactic teaching utilizes lecturing primarily to transmit new knowledge and

reinforce previous knowledge that is often infrequently correlated to clinical experience. Behar

Horenstein, Mitchell and Dolan (2005) utilized a case study in first and second year dental basic

science courses to assess classroom instructional practices. Observations revealed that most of

classes observed were teacher-centered, passive, and lacked observable effort to help students

understand the relationship of the lecture content to the oral health problems.

The didactic teacher has full authority over a classroom environment. Learning

experiences are planned for a full term or a semester (Karuhije, 1997), whereas in clinical

teaching, experiences planned for a day can be changed by others and are dictated by case loads

and patient conditions. In clinical teaching, the clinical instructor must address the patient's

concerns and identify the student's goals (Spencer & Jordan, 1999). This emphasizes the dual

role of the clinical instructor, a need to assess concomitantly the patient's oral health needs and

the student's learning needs. The didactic teaching encounter is focused solely on the student's

learning needs.

Professional role modeling

The clinical teacher's job is complex and the teacher's main responsibility is to provide

opportunities for practical experience, discuss and review patients, respond to questions, provide

explanations and be supportive (Parsell & Bligh, 2001). The clinical teacher acts as a role model









for the profession (Bergman & Gaitskill, 1990; Chapnick & Chapnick, 1999; Irby, 1978). Biddle

(1996) demonstrated that both faculty and students ranked being a good role model of the

profession as the highest-rated characteristic of the best instructors and the lowest-rated

characteristic for the worst clinical instructors.

Clinical teaching takes place within the context of the professional environment. Since

teaching takes place "at the bedside," or operator, the clinical instructor is in his or her roles

both as instructor and medical, dental or health care professional. During clinical teaching,

students participate in a teaching/learning process while observing the clinical teacher as a role

model for the profession. Sharp and Spence (1999) found that students ranked the professional

role of their instructor higher than person or teacher role characteristics. Irby (1978) also

identified the modeling professional behaviors as one of the factors that is unique to clinical

teaching. The didactic teacher is primarily concerned with transmitting knowledge and is not

necessarily acting in the professional role of his or her discipline while teaching. The didactic

teacher does need professional knowledge of his or her field but is not actively engaged in such

actions during classroom teaching.

For clinical teachers to be role models, they must teach the psychosocial aspects of

medicine and dentistry, demonstrate the importance of building positive doctor-patient

relationships, and have a comprehensive approach to patient care (Branch, et al., 2001). This

example set is the most powerful way for learners to acquire the values, attitudes, and behavior

needed for professional and ethical practice (Parsell & Bligh, 2001)

Concept of service

In the clinical learning environment, the clinical instructor provides education to the

learner and also delivers a service to patients (Stemmler, 1988). In other words, the instructor

has an obligation for providing competent, thorough, and up-to-date instruction to students, and









good patient care within the same encounter. Several authors (Biddle, 1996; Branch, et.al., 2001;

DaRosa, et al., 1997; Elnicki, et al., 2003) have pointed out that medical clinical instructors are

members of two service professions as they are clinicians whose goal it is to help patients as well

as teachers whose goal it is to help students. In this service role, the clinical teacher not only

assesses the needs of the patient, but must also assess the student's needs. The didactic instructor

provides educational learning experiences only to the student with no other immediate service

obligations to patients or others.

Advantages/Disadvantages of Clinical Education

Clinical education is a conceptually sound learning model, which, unfortunately, is

flawed by problems of implementation. Some of the more glaring problems of clinical teaching

include: (a) limited emphasis on problem-solving, (b) lack of clear expectations for student

performance, and (c) inadequate feedback to students.

Problem solving opportunities

One of the persistent complaints about clinical education is the overwhelming work

demands placed upon students, leaving them little time for thinking and reflecting, but primarily

memorizing facts. The clinical years perpetuate non-thinking; because an inordinate amount of

time is spent in mechanical "doing." Operating-room work, repetitive wards, rounds, and nights

and weekends lead to fatigue, which dulls thought. Most bedside teaching is mini-lecturing,

noneducational chores, and the reflexive ordering of test after test. Students rarely have an

opportunity to reflect on their learning, make connections to basic science information,

restructure the knowledge that they already have, and engage in real problem-solving about

patients under their care.

In order for students to learn problem-solving skills, they must actively participate in the

learning process. Gordan, et al. (2000) stressed the importance of engaging students as active









learners at an early stage, so that they can acquire knowledge and skills that are relevant,

organized, accessible and functional. There is some evidence to suggest that students are not

active participants in their clinical education. Brown and Gillis (1999) concurred when they

stated that students should "...be active, independent learners and problem solvers, rather than

passive recipients of information."

The simplistic approach of "see one, do one, teach one", prevalent in clinical teaching for

years, is no longer acceptable, although the statement does imply a strong relationship between

practical learning, skill acquisition and teaching (Parsell & Bligh, 2001). Students must

recognize their own thinking and learning strategies in order to develop and organize a

knowledge base for problem solving (Gordan, et al., 2000).

Expectations and feedback

Another problem with clinical teaching is the lack of clear expectations for student

performance. Few clerkships have clearly defined objectives and descriptions of work

responsibilities. As a result, students encounter differing and sometimes conflicting

expectations. As a consequence, each student tends to have a different educational experience

with respect to the information learned and the proficiency of skills developed (Beasley, 1997;

James, et al., 2002). Students frequently complain about the lack of feedback on their learning

and performance. Although feedback on their skills and abilities is essential for efficient and

effective learning, students often experience clinical clerkships in a feedback vacuum. Feedback

from written evaluations of their performances is as inadequate as oral feedback, due to the lack

of specificity by faculty members in identifying their student's strengths and weaknesses.









Clinical Teaching


Definition of Clinical Teaching

In regard to dental education, it has been suggested, "the clinic is the learning

environment to which all our students aspire," (Mullins, et al., 2003 p.35), requiring the "transfer

of knowledge from the basic sciences to the clinic by tuning and restructuring of knowledge."

How learning and teaching best occur in this environment for the preparation of dental students

to advance to independently provide patient clinical care is important and a central business of

dental educators and clinical supervisors alike.

The learning environment of the clinic or hospital is challenging 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, a 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 because of the demonstrated value of contextual learning and the facilitation of

integration of knowledge from basic to clinical sciences (Mullins, et al., 2003).

Role of Clinical Instructors

Clinical teaching typically involves the supervision of a trainee clinician by an

experienced clinician, and as a consequence, 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"

(Kilminister, et al., 2002). The student/clinical teacher relationship has also been compared to

the therapeutic alliance that exists between patient and physician because it represents an

educational alliance (Tiberius, et al., 2002).









Clinical teaching in medical education has been extensively examined (Irby, 1995).

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 (Kilminister, et al., 2002). Effective

supervision of learners involves problem solving by students and instructors together, along with

feedback, reassurance, and theory-practice linking (Hirons & Velleman, 1993). There is

preliminary evidence that effective clinical teaching in medicine may have a positive impact on

patient outcomes. For example, Fallon, et al. (1993) found that patient outcomes improved when

direct supervision of the student clinician is combined with focused feedback.

Davis, Thomson, Oxman, and Haynes (1995) have conducted rigorous reviews of the

research literature related to what educational methods are most likely to produce desirable

changes in physicians' patient care strategies. These publications were the catalyst for similar

reviews in health profession education that addressed a variety of questions: What constitutes

"effective clinical instruction"? Do effective clinical teachers have unique attributes that less

effective instructors do not possess? Are there components of the educational process that are

more effective than others in the clinical setting? These questions have been the subject of

several comprehensive reviews (Irby, 1995; Heidenrich, et al., 2000), numerous observational

studies and surveys (Ende, Operant, & Erickson, 1995; Epstein, et al., 1997; Frank, et al., 1997;

Goertzen, Stewart, & Weston, 1995; Hekelman, et al., 1996; Irby, 1994; O'Malley, 1999; Pinsky

& Irby, 1997), and countless anecdotal "teaching tips," guidelines (Da Rosa, et al., 1997; Biddle,

1996; Cunningham, et al., 1999; McGee & Irby, 1997)-primarily in the medical education

literature but also, to a lesser extent, in dental education. Irby's (1995) massive summary of the









literature for best practices in ambulatory teaching in medicine remains the most comprehensive

and most frequently cited review of clinical teaching practices.

Irby identified four key factors that distinguish the "excellent" clinical teacher from other

instructors. He/she 1) serves as a positive role model of a competent and compassionate health

care provider, 2) provides effective supervision and mentoring for learners, 3) employs a varied

and dynamic approach to teaching, and 4) is a supportive person. Teaching strategies consistent

with effective supervision and mentoring include communicating clear expectations for students'

behavior and performance, providing practical and helpful "just-in-time" teaching (commonly

known as prompting), explaining concepts and techniques clearly at the students' level and then

confirming their understanding, providing "how-to" feedback in a non-belittling manner

understanding students' learning needs at different levels of training and adjusting teaching

accordingly.

In 2000, Heidenreich and colleagues reported the results of a comprehensive review of

more than 600 articles on clinical teaching strategies in medical education to identify empirical

evidence supporting frequently recommended teaching strategies. Hekelman, et al. (2003)

identified forty-one papers that reported either quantitative or qualitative data related to eleven

clinical teaching methods, but concluded that there was inadequate evidence to support the

effectiveness of any of these techniques in spite of widespread student and faculty belief in the

desirability of these methods. In contrast to Heidenreich, et al. (2000) and Hekelman, et al. 2003,

reviews conducted by Davis, et al. (1995) identified a group of learning strategies that are

strongly associated with modifying providers' clinical behaviors. These strategies include

persistent feedback on performance in relation to standards, comparison of performance to other

practitioners, emotionally intense activities such as role-play, observed performance and peer









feedback, participation in live-action simulations that require decision making, personal

reflection on performance, and notably, an absence of lecture-based instruction (O'Brien, et al.,

2003).

Many investigators have studied clinical teaching effectiveness and the clinical learning

environment in dental school. Chambers, et al. (2004), Manague, et al. (2001), and McGrath, et

al. (2005) reached essentially the same conclusions as Irby, Heidenreich, and other medical

school investigators about "what effective clinical teachers do." Teacher attributes associated

with effective clinical teaching in dental school include providing specific feedback about

performance, demonstrating an interest in teaching, making an effort to motivate students,

knowing how to translate didactic information into patient care situations, explaining difficult

concepts clearly, showing compassion, and approaching treatment in a proactive manner

(Chambers, et al., 2004). Dental students also reported that the most effective instructors took

their teaching responsibilities seriously, behaved in a professional manner during interactions

with students and patients, and were technically competent.

Contributions of Clinical Teaching to Dental Practitioners

Research conducted in the 1980s and 1990s demonstrated the importance of orienting

learners prior to task performance, providing frequent "formative" (progress) feedback to

students, guiding students with questions, and helping students understand the desired outcome

for a technical procedure (Berk, et al., 1998; Croft, White, Wiskin, & Allen, 2005; DaRosa, et al.,

1997). In a dental school environment, Behar-Horenstein, et al. (2000), and in medical education

(family medicine residency programs), Taylor, et al. (1998), both found that instructors in their

respective settings were aware of teaching best practices such as asking students open-ended

questions to stimulate critical thinking but rarely used these techniques when working with

students. McGrath, et al. (2005), recently pilot-tested an instrument known as the Effective









Clinical Dental Teaching Inventory (ECDT) to gauge student views of clinical instruction. This

instructional environment survey elicits students' opinions about an instructor's skill in creating a

positive learning climate, controlling the clinic, communicating goals, promoting understanding

and retention, evaluating performance, providing feedback, and promoting self-directed learning.

Authors of the ECDT suggested that the inventory can be used to collect data for assessment of

instructors' clinical teaching effectiveness.

One difference in the literature on effective clinical teaching in medical and dental schools

is that dental students place more emphasis on evaluation skills in their reports of teachers' best

practices (Chambers, et al., 2004). This may occur because dental students are graded/rated far

more frequently and in greater detail than medical students. From a student's point of view,

faculty members who are able to provide helpful and prompt feedback and accurate ("fair")

evaluations are viewed as the most effective instructors. Chambers, et al. reported that certain

faculty members who saw themselves as experts were likely to be seen as poor evaluators by

students because they were out of touch with students' actual capabilities and thus unrealistically

expected "expert" level performance from the students. In this situation, students reported that

they were graded down for performing at an appropriate level of competence for a student in

training.

Challenges Associated with Clinical Teaching

To identify best practices for evaluation of dental students, Manague and colleagues.

(2001) surveyed dental faculty to identify their perceptions of the most effective evaluative

techniques. Faculty members viewed self- and peer-assessment, portfolio-based learning, the

provision of consistent feedback to students, and the use of objective criteria as crucial to student

evaluation. However, when asked how often these evaluation techniques were implemented,

faculty indicated that these methods were used infrequently. Manague, et al. (2001) found that









the most prevalent assessment tools in dental school were day-to-day observations and the

number of competency exams (competency patients) completed. Although observations and

completing competency exams were the primary forms of assessing student learning, the faculty

perceived that these assessment methods were not particularly valuable to student development

(Chambers, et al., 2004).

In summary, the literature related to the question of what constitutes effective clinical

teaching in dentistry and medicine is extensive but has been comprised primarily of observational

studies, opinion surveys, and anecdotal "teaching tip" guidelines. There is limited evidence to

support the actual influence of these techniques on student learning, although Davis, et al. have

associated a number of instructional strategies with positive learning outcomes in the arena of

continuing education (Davis, et al., 1995; O'Brien, et al., 2003). Key elements of "effective

clinical teaching" are quite similar in both disciplines.

However, there are four limitations to these data that constrain generalizability. First, most

of the observational studies and opinion surveys that form the basis for this literature were

limited to one set of students in a single academic program or health care facility. Second, in

many of these studies, the numbers of survey respondents or teaching observations were quite

small. Third, in studies where researchers collected student impressions of clinical teaching by

surveys and interviews or implemented protocols to observe teaching, they used a wide variety of

data collection instruments-many of which were created by the investigators and not subjected

to pilot-testing to verify validity and reliability. And fourth, much of the data that still provides

the basis for assumptions about student perceptions of their clinical education that were collected

in the 1980s and 1990s.
















High Control


Physician









Patient


Low Control


High Control


Figure 2-1 Conceptual model for physician-patient relationship continuum


Low Control


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CHAPTER 3
MATERIALS AND METHODS

Theoretical Framework for Data Collection and Analysis

The theoretical framework for this study is interpretivism. Proponents of interpretivism

seek to "understand human action" by understanding the meaning of that action (Schwandt,

2005). "The interpreter objectifies (i.e., stands over and against) that which is to be objectified.

In that sense, the interpreter remains unaffected by and external to the interpretive process. (p.

191)" This method of participant observation allows the researcher to objectively understand

someone's intent by studying his or her actions in the context of the situation. The

epistemological framework for interpretivism is understanding. Schwandt (2005) states that

understanding is "an intellectual process whereby a knower (the inquirer as subject) gains

knowledge about an object (the meaning of human action)" (pp. 193-194). For this study, the

researcher will analyze interaction between the student, teacher, and patient to interpret the

student's perspective of the clinical teaching/learning that takes place during student, faculty, and

patient interaction.

Methodology

The methodology used in this research was participant observation and interviews.

Participant observation is a process whereby the researcher immerses himself or herself in the

subject being studied to gain understanding, perhaps more deeply than could be obtained, for

example, from participants' responses to survey items.

Observations between patients, students and faculty were used to acquire insight about

interactions that are characteristic of each group as well as the relationship between the three









groups. As a result, an understanding of the attributes that are common to the relationships were

developed. Observations in the clinic over a seven-month period were used to collect data for the

assessment of the characteristics of the educators-students-patients interactions.

A qualitative interview research design was chosen to obtain data relevant to the educator-

student-patient relationship and clinical teaching/education. According to Taylor and Bogdan

(2005), "qualitative methodologies refer to research procedures which produce descriptive data:

people's own written or spoken works and observable behavior" (p.128). Glesne (1999) noted

that qualitative research is better understood by the characteristics of its methods than by a

definition.

According to DeWalt and DeWalt (2002), qualitative researchers want study participants

to be heard and to actively provide their perspectives. Therefore, qualitative research is an

interactive process in which the persons studied teach the researcher about their lived

experiences. Qualitative researchers attend to the experience as a whole, not as separate

variables. Thus, the aim of qualitative research is to understand experience as unified. One

qualitative research method that lends itself to this study is the interview.

Kvale (1996) noted that an interview is "a purposeful conversation usually between two

people (but sometimes involving more) that is directed by one in order to get information"

(p.151). He also stated that the major purpose of an interview is to learn to see the world from

the eyes of the person being interviewed. The researcher learns from the interviewees and seeks

to discover how they organize their behavior. The interview should be approached as one in

which "the researcher asks those who are studied to become the teachers and to instruct her or

him in the ways of life they find meaningful" (p. 163).









Researcher Qualifications and Bias

In studies where extensive qualitative fieldwork is conducted, the researcher is the

"primary research instrument" because all data are collected through observations, and

interviews and are filtered through the lived experiences-past and present-of the researcher.

The level of contact that occurs during the observation and interview places the research under

the microscope and requires persistent self-monitoring to ensure that data are documented and

reported objectively. The researcher should describe his limitations as the primary research

instrument. A personal biography and a description of data collection methods are essential to

describe the researchers' limitations (Fischer, 2005).

As a practicing dentist and dental educator, I have worked in private practice and the dental

college for the past twenty-five years. Consequently, I have insight into the daily operations and

culture of dental practice and dental education. Since 1996, I have been an associate professor in

the Department of Operative Dentistry at the college where this study was conducted. As a

result, I have to acknowledge any biases resulting from this experience to prevent them from

influencing my analysis and discussion of the data.

As a qualitative researcher, I received formal training in participant observation as a program

evaluator and experience in using qualitative research methods. Subsequently, I co-authored and

published a research article delineating the findings of a nursing study (Tasso, Behar-Horenstein,

Aumiller, Gamble, Grimaudo, Guin, Mandell, & Ramey, 2002). The publication resulted from a

study that involved participant observation of health care providers, and patient interviews about

their satisfaction. I have published several other qualitative studies dealing with patients'

attitudes, beliefs and opinions concerning dental care. The purpose of one of these studies,

Qualitative Description ofDental Patients Perceived Rights by Grimaudo, Behar-Horenstein and

Yantorni (2003) was to describe and characterize how dental patients perceive their rights and to









identify which specific rights patients remember after reading and asking questions pertaining to

the form. There appeared to be some correlation to ethnic minority and beliefs/perceptions. The

findings of this study suggest that patients perceive the form more as a legal or protective

document for the school rather than an informative tool and suggest that many patients were

unaware and unsure of their rights as patients.

Another study by Stewart, Grimaudo, Behar-Horenstein and Rawal entitled, Description of

Patient Perception of Quality Dental Care (2003) reported that a major issue in clinical dentistry

is providing quality dental care. Luborsky's thematic analysis was used to analyze structured

interview and it was shown that the perceptions provided by the patients emphasized that

providing quality dental care has more to do with interpersonal skills, empathy, care, concern,

and provider relationship with the patients than the actual technical dental care provided.

Grimaudo and Piedra (2004) reported patients' perceptions of the "ideal" dentist using a survey

that included topics such as: cleanliness, openness of discussion, recommendation of relatives,

primary language and ethnic origin, gentleness, and time spent. The data from this study indicate

that there are differences in the way that ethnic minorities choose an oral healthcare provider.

These differences were between the minority and majority as a whole and between the specific

minority groups.

And finally, Grimaudo, Bhaktha, and Potter (2007) compared patient knowledge of HIPAA

from 2003 to 2006 and through surveys showed that patient knowledge and understanding of

HIPAA has significantly declined over time. Patients involved with health care knew more about

HIPAA, but even after patients were given information, they did not know what HIPAA was.

This 2007 was a follow-up study concerning HIPAA completed by Grimaudo and Potter (2004)

that showed about 60% of patients were aware of HIPAA because they had recently heard about









it from media advertising and the dental students. HIPAA was enacted to protect patient

information and patients are not fully aware of the law.

From these experiences, I developed a deep understanding of the factors that influence

patient and dental provider interactions. The progression from these studies was to study the

faculty-student-patient triad relationship and clinical teaching/education. Consequently, from

my experiences as a researcher and patient care provider, I feel I am qualified to conduct this

study. While bias cannot be ignored, it can be kept on the side. My role as researcher has been

to listen and allow the participants to speak openly about their experiences. My hope is that the

findings in this study will contribute to developing a better understanding of faculty-student-

patient interaction and improve clinical teaching/education.

Participants

Because I am a faculty member at the University of Wallace (a pseudonym), College of

Dentistry, gaining access to the clinics was non-problematic. Institutional IRB approval was

obtained for faculty-student-patient observations and interviews. (Appendix A contains a copy

of IRB 2006-U-0433.) The participants in this study were comprehensive care patients at the

College of Dentistry, faculty members of the College of Dentistry, and student dentists in the

classes of 2006 and 2007. The four clinics used for observations and interviews were operative

(opr), oral health maintenance (ohm), prosthodontics (pros), and periodontics (per). Eighty (80)

students were in the Class of 2006 and 81 in the Class of 2007. A total of 168

interviews/observations were conducted among the class of 2006, of which n=84 (50%) were

female and n=84 (50%) were male. The males were aged 24 to 34 and the females were aged 24

to 32. The class of 2007 completed 162 interviews with approximately n=65 (40%) female and

n=97 (60%) male. The males were aged 23 to 35 and the females were aged 24 to 29.









Overall there were 330 patient observation /interviews in all. The patients ranged in age

from 19 to 84 years including n=166 (50%) male and n=164 (50%) female, n=198 (60%)

Caucasian, n=56 (17%) African-American, n=50 (15%) Hispanic, n=17 (5%) Asian, and n=9

(3%) unknown.

Instrumentation

The researcher-constructed interview protocols were based on literature research. The

protocol used in this study was comprised of open-ended questions (See Appendices B and C).

The semi-structured format allowed for the participants to elaborate on their viewpoints.

Data Collection

Data were collected from three primary sources: patient interviews, student interviews,

and participant observations of the faculty-student-patient interaction. Triangulation of the data

contributes to the credibility of the results (Creswell, 2002). The observations and interviews

were conducted on regular clinic days during regular hours. The observations and interviews

took place over a seven-month period. Each clinic was observed one half-day per week on an

alternating basis. This strategy was adopted because different faculty members were assigned to

each clinic on a given day and the process allowed access to more faculty rather than observing

the same faculty repeatedly (See Appendix D).

An interaction consisted of the dialogue between the student and faculty member, student

and patient, and a student and faculty member during the treatment appointment. Student and

patient interviews were completed at the end of the appointment and lasted fifteen to twenty

minutes. All interviews were conducted by the researcher. Running notes were used to

document the interactions and nonverbal cues were also recorded. The written notes were

entered into a word processing program for analysis.









Data Analysis

There are two major purposes for analyzing data in qualitative studies: interpretation and

translation into concepts. In this study the latter process was used. Identifying concepts help to

explain the relationship between the data. Data from the student interviews were compiled and

analyzed to determine if there were common patterns among the students regarding what they

learned, how the faculty fostered their learning, and what they perceived to be important about

clinical teaching. Data from the patient interviews were compiled to see how patients felt the

faculty and student interacted with them and each other, if they knew what dental treatment they

were receiving, and their main reasons for coming to the dental school. Data gathered during

patient interviews was compiled and analyzed to see if there were common trends and patterns

among the patient's responses. The constant comparative method (Denzin & Lincoln, 2005) was

used in this study to analyze and determine common attributes among the student, faculty, and

patient interviews. Student and patient interview responses were compared to assess common

patterns and themes in relation to each question. Responses from student and patient interviews

are also used to compare the perspective of the patient and student to the same interaction.

Data from the faculty-student-patient interactions was coded. The data were classified

and categorized to allow for development of common themes, patterns, and concepts. The

researcher used memo writing during the code, which enabled him to express personal

reflections from the data analysis.

Trustworthiness of Data

The basic question regarding trustworthiness in naturalistic inquiry is: "How can an

inquirer persuade his or her audiences that the findings of an inquiry are worth paying attention

to, worth taking account of?" (Denzin & Lincoln, 2005). Criteria for trustworthiness include

credibility, transferability, dependability, and confirmability (Denzin & Lincoln, 2005).









In qualitative research, the trustworthiness of data is equated with validity in quantitative

research (Glesne, 1999). Trustworthiness is achieved through prolonged engagement in the field

that allows for persistent observation and the opportunity to acquire sufficient data to support the

study. The data collection process for the present study took place over a seven-month period.

The observations consisted of more than one-hundred hours spent in the field. Student and

patient interviews were an additional 150 hours. Approximately 350 hours were spent analyzing

the data from interviews and observations. Another contribution to the trustworthiness of the

study is triangulation of the data. Member checks are also used to establish trustworthiness of

data (Glesne, 1999). Member checking is a process through which respondents verify data and

the interpretations thereof (Denzin & Lincoln, 2005). To ensure the accuracy of the data, a

summary was reviewed with the data source in order to understand the perspective of the

participant. In this study, during interviews, verbal information was restated to the patient or

student as a means of member checking.

Credibility

Denzin and Lincoln (2005) recommend a variety of strategies for improving the

likelihood that findings and interpretations produced through naturalistic inquiry methods will be

credible. Two of these strategies are peer debriefing and member checking. Denzin and Lincoln

(2005) define peer debriefing as "a process of exposing oneself to a disinterested peer in a

manner paralleling an analytic session and for the purpose of exploring aspects of the inquiry

that might otherwise remain only implicit within the inquirer's mind." (p. 122). The peer

debriefer for this study was Dr. Sandi Anusavice who analyzed ten percent of the data. Her

interpretation of the data agrees with the findings of this study.









Transferability

The emergent theory of naturalistic inquiry is dependent on a specific context and

interactive dynamics, necessarily lowering the possibility and desirability of a focus on external

validity, as compared with positivistic inquiry (Denzin & Lincoln, 2005). Qualitative

observational research describes and classifies various cultural, racial and/or sociological groups

by employing interpretive and naturalistic approaches (Fischer, 2005). It is both observational

and narrative in nature and relies less on the experimental elements normally associated with

scientific research (reliability, validity, and generalizability). Qualitative observational research

is a systematic inquiry into the nature or qualities of observable group behaviors in order to learn

what it means to be a member of that group. The researcher's job, rather than to describe a stable

entity, is to give continually updated accounts of observations on multiple levels of group

interactions that occur on both a temporal and continuous basis simultaneously (Patton, 2002).

Qualitative study lends itself to thick narrative description, and it may be intensive given

the complexity of group interactions. It takes place on site, in the group's natural environment,

and attempts to be non-manipulative of group behaviors. The purpose is to aim for objectivity,

while it must take into account the views of the participants (DeWalt & DeWalt, 2002).

Qualitative observational research is naturalistic because it studies a group in its natural

setting. Patton (2002) explains, "Naturalistic inquiry is thus contrasted to experimental research

where the investigator attempts to completely control the condition of the study" (p. 42).

In order to enable others to make an informed decision about whether to apply the findings of

this study to their own research, extensive description of the experiences and identity

development of the participants, as well as the definitive exposition of the researcher, are

provided.









Dependability and confirmability

Denzin and Lincoln (2005), both dependability and confirmability can be determined

through one "properly managed" audit. To establish dependability, the auditor examines the

process by which the various stages of the study, including analytic techniques, were conducted.

The auditor determines whether this process was applicable to the research undertaken and

whether it was applied consistently (Denzin and Lincoln, 2005). To illustrate confirmability, a

record of the inquiry process, as well as copies of all taped interviews and discussions, notes

from interviews and discussions, and hard copies of all transcriptions have been maintained.









CHAPTER 4
RESULTS

The results obtained from student interviews, observation of student-patient-faculty

interactions, patient interviews, and descriptions that typify these relationships in the dental

school setting are described in this chapter. These results will be described in the context of the

six research questions.

Research Question 1. What are the Characteristics of Oral Health Care Educators-
Patients-Students Interactions in the Clinical Learning Environment?

Clinical observations were made during regularly scheduled clinic appointments.

Across all observations, the faculty interacted with a student at the beginning and the end of the

procedure. However other types of interactions ensued as described below. At times, students

called upon the faculty if assistance was needed during the procedure. At other times, faculty

were observed walking around the clinic and asking students how they were doing during the

clinic period. Some faculty waited for the student to come to them after the student had finished

the treatment. Student and patient demographics are described in Table 4-1.

Four styles of interaction emerged from these observations: 1) faculty-centered, 2)

student-directed, 3) student-faculty collaborations, and 4) patient-driven. The frequency of each

is as follows: faculty-centered (n=192, 58%), student-driven (n= 76, 23%), student-faculty

collaborative (n=53, 16%), and patient-driven (n=9, 3%). In the following section each style will

be defined and observations that typified each are presented.

Faculty-Centered

Faculty-centered interactions were those where the faculty member told the student what

to do and the student completed the procedure without much input. These interactions usually

involved patients who already had their treatment plans completed and were scheduled for

restorative procedures. During the interactions, the faculty member would look at the treatment









plan and radiographs and tell the student which procedure to complete. The faculty member

would answer questions concerning the procedure as needed providing input as an expert in the

field.

During these interactions, faculty were usually sought out by the student. After

approaching faculty for help, the faculty member treated the patient without giving much

feedback to the student during the process. An example of this occurred in prosthodontics,

where a student was completing a crown preparation on a tooth and he asked the faculty member

to check to see if the margins were okay. The faculty member sat down and modified the

preparation. When he was finished, he told the student to go ahead and make the impression

since the procedure was now complete. The faculty member did not tell the student what or why

the modifications were being done. Thus, this teachable moment was not utilized.

Another example occurred in operative when a student had trouble anesthetizing a lower

molar. The student called over the faculty member and told him the problem. The faculty

member told the student to get a specific type of anesthesia and then proceeded to inject the

patient. The student was not told why a different anesthetic was used or if this was a different

procedure being employed.

In another faculty-centered interaction, a junior student treated a patient in the operative

clinic. The patient was seated and the faculty member approached and greeted the student. The

faculty member looked at the patient's treatment plan and said to the student and patient that they

should complete a silver filling on tooth number 19. The faculty member signed the necessary

forms for the patient and student to begin; the student began the procedure and called the faculty

when the procedure was completed. The faculty member signed the chart notes and the patient

was dismissed. The interaction with the student and patient was minimal and cordial. Faculty









input was only in response to the procedure completed. Minimal teaching was performed by the

faculty.

In the clinic the teacher must supervise because s/he has responsibility for patient safety

as well as treatment. However, the teacher is also expected to address the learning needs of the

student simultaneously. Teaching takes more time than supervision.

Student-Driven

Student-driven interactions were those whereby the student would tell the faculty

member what s/he was going to do in that clinic. The faculty member would verify that this

procedure was needed per the treatment plan, check the patient, and then tell the student to

proceed with the procedure. In these interactions, students took the initiative in providing patient

care and the faculty member still checked his/her work at the completion of treatment. In these

interactions, the faculty members allowed the students to make decisions about the given

treatment.

Other interactions included in this category occurred when the students initiated the

faculty interaction. In one example, a student asked a faculty member to evaluate a bridge

preparation; the faculty member told the student that it looked okay. The student then asked the

faculty member to discuss what could be done to make the preparation better.

In a similar example the student prepared the tooth for a large filling and asked the

faculty member to evaluate it. The faculty member said it was good, but the student wanted to

know what could be done to make it better.

In the operative clinic, a senior student had a patient who needed composite restorations

on teeth 8, 9, and 10. The patient was seated and the student brought the faculty members over

and told them that s/he planned to place restorations on all three teeth during the same visit. The

faculty member checked the plan and told the student to complete those procedures. After the









procedure, the student told the faculty member that the work was ready to be checked.

Afterward, the faculty member checked the procedures and said that they were acceptable. The

student asked the faculty member, "What could be done to make the aesthetics better?" This led

to a discussion concerning the faculty's experience and expertise. The student reported a

positive experience and said that s/he learned advanced aesthetics techniques that day.

During these observations, the faculty member would usually remain in one area of the

clinic. To attain the faculty member's attention, the student would contact the faculty member

when s/he needed assistance, or the student would follow the faculty member from operator to

operator until s/he was next in line to be seen.

Clinical teaching is directed toward increasing autonomy to prepare the student for

practice. As seen in the aforementioned examples, autonomous learning included: goal setting

by students, use of teachers as guides rather than instructors, and students using self-assessment

and reflection. Clinical teaching is designed to promote students taking an active role in their

professional education over the course of two years.

Student-Faculty Collaborative

Student-faculty collaborative interactions occurred when students and faculty members

examined the treatment plan together and decided which procedure would be completed that day.

The procedures completed were clinic dependent. Collaborative interactions occurred mostly in

the operative clinic, where there are several procedures listed on a patient's treatment plan. In

periodontics and prosthodontics, the treatment options were limited by the specific nature of the

specialty involved. For example, scaling and root planing occurs in periodontics; there is not

much choice as to what else can be done. In these interactions, the faculty and student had a

dialogue concerning the day's treatment.









These observations also included ongoing discussions between faculty and students

during the treatment process. In one example, the student had a large restoration. The faculty

and student discussed what material should be used to fill the tooth. During this discussion, the

faculty member asked the student many questions about how and why different materials could

be used.

In another example, a student was having trouble anesthetizing a patient. The faculty

member and the student discussed reasons why this may have been happening. Then the faculty

member demonstrated an alternative technique to anesthetize the patient. The professors asked

students questions about the treatment plan and alternative treatment. During one interaction in

the periodontics clinic, students reported: "The faculty member fostered learning by listening to

me, because he knows that I see the patient clinically more often than he does and we worked

together to come up with a treatment plan that was best for the patient." The student reported

that the most important thing about clinical teaching was for "the faculty member to be thorough,

not talk down to me, and make sure that I have all of my questions answered."

Another interaction was described by the student as incorporating "social caring and good

conversation." The student learned from the faculty member's ideas and experiences. The

faculty member helped during the procedure and discussed potential problems. During these

observations, the faculty member actively moved around the clinic and went from operator to

operator to check students' progress. Interactions were conversational and reciprocal.

Patient-Driven

During the patient-driven interactions the student and faculty member asked the patient

what s/he wanted to complete that day. The patient had input and could select from a list of

necessary procedures on the treatment plan. What distinguished these interactions from others

was the patient's involvement in the dialogue. In some of the dental clinics, the patient's wishes









and concerns were taken into consideration when developing a personalized sequenced treatment

plan for the patient. However, this category of observation is limited because the faculty member

could not deviate from accepted treatment protocols and guidelines.

A good example of this type of interaction follows. A junior student in the operative

clinic had a patient who had lost a filling in a front tooth. The patient told the student that s/he

wanted to have that tooth filled that day. The student told the faculty member about the patient's

request and was allowed to complete the procedure for that day. While the patient had other

restoration needs, this tooth was filled first per the patient's request.

Research Question 2. How are Oral Health Care Educators-Patients-Students Interactions
Perceived by the Student?

Students were interviewed about the faculty's interaction with their patients (Table 4-2).

The interactions were classified into four major categories based on the students' descriptions

and described by terms used by the students. These four categories consisted of none, minimal,

good, and excessive. About 3% (n=10) of the students stated that the faculty did not interact

with their patient and described interaction as nonexistent, or without communication entirely.

About 10% (n=33) reported that the faculty did not interact well with the patient and describes

the interaction as "minimal or very cursory," "did not talk much," and "could have been more

friendly and professional." Approximately 8% (n=27) of the students reported that the faculty

interacted with the patient. They described faculty members' actions in these interactions as

"very talkative, too much conversation, left patient confused, and spent too much time talking

about extraneous material." The majority of the students 79% (n=261) reported that the

interaction was good. Representative descriptions of good interactions included: "explained

step-by-step to the patient..."; "paid attention to the patient and the patient's feelings..." and

"was friendly and courteous with the patient..."









Students reported that faculty interaction with their patients were positive; however, they

also stated that a certain amount of interaction that is acceptable. For example, students indicated

that they wanted the faculty to explain to the patient when a procedure was complex. Students

reported that the faculty should be cordial to the patient, explain what is necessary, and help as

needed depending on the students' level of expertise. Tangential and too much conversation

were viewed as counter productive because the amount of available clinical time is limited.

Students also reported that they perceived aloofness or quick interactions as unfriendly and

unprofessional.

Students were asked to describe the type of faculty interactions with them. The

interactions were categorized into two main as described by the students: good or poor. The

majority of the student 85% (n=281) described the faculty interaction as good. Representative

examples of these interactions included: "...the faculty was kind and generous...; and "...they

handled problems appropriately..." In addition, 15% (n=49) of the students described

interactions as poor when faculty: "...did not spend enough time with me...; "they were

aloof...", "...they were too busy...", "...not much interaction...;" and "...could have been more

patient with me and less demeaning..."

Students explained that they wanted the faculty to interact with them concerning patient

treatment and that when they did interactions were easy. Faculty members that did not spend

much time with a particular student may have been due to the number of patients in the clinic

and the complexity of procedures on a given day, causing the amount of time available for

supervision to fluctuate. Different procedures among faculty members on the same clinic caused

difficulties for students.









Students reported that inconsistent feedback was a common occurrence in the dental

school clinics. They described situations in which two instructors would look at the same work

performed by the students and each would give different feedback. The following three

examples depict students' frustrations with lack of instructor calibration:

"A big problem is inconsistent feedback and instructions."

"Inconsistency of instructors. One will start a case with you and suggest their

philosophy, then another teacher changes the way you do things; a waste of time."

"Different instructors tell me to do different things even though the treatment has already

been approved by another licensed and practicing dentist."

Students also wrote about their appreciation for faculty members who they perceived to

be knowledgeable and eager to help. They frequently described how fortunate they felt to work

with faculty who had a firm understanding of clinical skills and the ability to communicate these

skills at the students' level of understanding. The following written responses are representative:

"Instructors encouraged me to try new procedures, become more independent, and

expand my abilities."

"Faculty bring their clinical experience, share the different ways of restoring a lesion,

allow you to ask multiple questions as to the pros and cons."

"Instructors give positive feedback and never belittle me. They share clinical advice and

patient management."

"The faculty are very committed to educating us."

In addition students reported situations where instructors communicated respect to

students and worked in a collegial manner, such that students felt confident that the instructor

"was there supporting you." Approachability, openness to questions, and willingness to give









guidance and feedback were characteristics of faculty that students considered to be important.

Instructors who displayed these characteristics were able to motivate students. Enthusiasm for

the subject matter, patience, and a sense of humor were personal qualities displayed by

instructors in positive learning incidents. Perceived instructor commitment was also reported as

important.

Students were asked what they learned during their clinical session. The responses were

varied and ranged from "nothing"-"I've done this procedure many times," to "I learned a new

technique today." Their response seemed to correspond with the student's year and the clinic

assignment. For example, senior students described treatment in the periodontal and operative

clinics as routine procedures that they had already done, whereas juniors reported that they were

learning new things in these clinics. Senior students reported learning new techniques in

prosthodontics. Students did not comment on requirements or competencies. Many students

considered a clinical session as a poor learning experience if they did not get a requirement or

competency completed. Where the dental clinics strive to provide comprehensive patient care,

the education requirement fosters students that must meet various competence for graduation.

Thus, there is a tension between the goals of patient care and students' educational need.

When asked how faculty fostered their learning, students reported that during routine

procedures faculty fostered learning about 65% (n=215) of the time, however 35% (n=l 16)

reported that faculty did not foster learning. Senior students reported than faculty fostered their

learning (40%, n=67) of the time, while junior students (80%, n=130) reported that faculty

fostered their learning twice as much of the time.

Descriptions of how faculty fostered (facilitated) learning included responses such as

"telling (me) what to do...;" "giving verbal expressions;" "...helping to build my confidence...;"









"... giving me different perspectives and opinions concerning the treatment...;" "teaching me a

new method;" "...demonstrating and reinforcing what was given in lectures...;" and "...giving

real world experience and allowing me to do the procedure myself and coming back and making

suggestions for improvements..."

Instructors, who engaged the students, were eager to help, and were actively involved

with the students, were seen as faculty who facilitated student learning. Instructors who

facilitated learning in the clinic frequently shared with students "tips" and "tricks" from their

own clinical experience. Students perceived their sharing of knowledge to be valuable because

it was written and available in textbooks and often helped them understand a concept more

deeply or learn how to complete a procedure successfully.

Students' written comments included more frequent descriptions of exceptional learning

experiences than negative ones. Overall students reported that their learning experiences were

positive, 90% (n=297), while 10% (n=33) reported that particular faculty's teaching skills and

traits inhibited their learning. Representative examples of students' comments follow.

"It all depends on your faculty coverage. Some people make you feel comfortable; some

make you feel very uncomfortable and then it becomes more difficult to perform to a high level."

"Certain instructors are great, extremely helpful and provide positive feedback."

"My clinical experiences are predictable based on which instructor will be in the clinic."

Negative learning experiences were often characterized by a lack of communication

between the instructor and students and/or problems with the organization or presentation of

the material. For example, communication problems occurred when the instructor was

perceived as unapproachable, uninterested in the students' learning, or discouraged questions. At

times, instructors failed to determine students' prior level of knowledge about a topic, and









used terminology that was unfamiliar and confusing to the students. Unclear directions about

tasks to be completed and lack of timely and/or constructive feedback were also problems

reported by students.

Students viewed their interactions with knowledgeable faculty members as a highlight of

their education, but a high percentage described situations in which they felt their progress in the

clinic was hindered either because too few faculty were assigned to clinic or because faculty

"wandered off' and could not be located when they were needed to supervise patient care,

evaluate work, or sign off on paperwork. One of the most frequently written comments made by

students was that lack of clinical faculty made it difficult for them to attend to patients in a timely

manner. Students who wanted the best possible care for their patients and to meet the

educational expectations of the various clinical departments were frustrated by this occurrence.

The following four examples illustrate student's experiences with the lack of faculty coverage:

"There was not enough faculty coverage on the floor at all times."

"Prolonged waiting for instruction and assistance... This is the most recurrent and

frustrating aspect of my dental education in clinic."

"Some (not all) faculty fail to be efficient as clinical instructors-talking on their cell, and

so forth. Is this the proper way to spend clinic time? That time should be dedicated to teaching

and helping students."

"Instructors are not available in a timely manner. I feel this is a HUGE problem in my

clinical education."

When students reported positive learning experiences, they described the educators' focus

and efficiency. In these instances, students reported that information and instruction were

presented in a clear, concise, and easily understood format. Goals for the session were made









clear, and instructors were organized. Instructors focused on the topic at hand and avoided what

the students termed "tangents." In these experiences, instructors acted as guides for students, led

them through a large quantity of information, pointed out the most important details, and helped

students to grasp essential concepts. Positive learning experiences were also high in relevance,

that is, instructors communicated and students could clearly see how what they were learning re-

lated to specific patient treatment needs as well as to problems the students would encounter in

the future.

Some of the students' clinical learning experiences involved learning from peers. Many

students reported that opportunities to observe and assist senior students in the clinic were

valuable and eased the transition from lab to clinic.

Students also reported that prompt, informative, and sometimes critical feedback was

necessary for development of their clinical skills. However, many students described situations in

which feedback messages were delivered in a manner that was abrupt and rude, embarrassing,

and condescending, especially when criticisms were communicated in open areas of the clinic

where other students, patients, and faculty members could hear the conversation. Three

representative examples follow:

"The faculty were downright rude to me and extremely critical."

"At times I feel unsure about asking questions for fear of being ridiculed. I wish I could

be more open about not knowing something without being scared of insulting comments."

"Instructors try to make us students feel stupid in front of our patients."

Students were asked to identify the most important thing about clinical teaching. Their

responses emerged as four categories: faculty characteristics (65%, n=215), student

characteristics (15%, n=50), patient interaction (12%, n=40), and characteristic of the learning









experience (8%, n=26). The majority of their responses reflected how faculty characteristics

impacted their learning experience, whereby the faculty took the onus for teaching...

Representative examples follow. "...patient friendly faculty who are not condescending...;"

"...faculty giving helpful and practical hints and tips...;" "...faculty should not just tell you what

to do...;" "...faculty should be supportive and faculty has to respect the students and patients..."

Students taking the onus for their learning reflected how they thought about their education

include, "...want constructive criticism to better myself...;" want real world and practical advice;

want to understand better to make my skills better; "...want to progress through the curriculum,

educate my patients, and provide quality care for them..."; "...being able to speak with the

faculty one-on-one about the patient and to get constructive criticism after a procedure is

completed...;" "...getting help at having freedom to make decisions; and students should be

prepared for clinic and provide quality care to their patient..."

Students also reported that the most important thing about clinical teaching was having

positive experiences and opportunities to work with patients. Interactions with patients helped

dental students increase their confidence when performing new skills. The following quotes

illustrate this theme:

"One positive experience was being able to give comprehensive care to my patients and

being involved in every step of the way-from treatment planning to carrying out treatment."

"I have a well-rounded patient pool with diverse needs and responsibilities."

"I enjoy working with my patients and formulating a treatment plan suitable for each

individual."









Students offered characteristics of their learning experiences. They described intentions as

"...hands-on learning...;" "...explaining, showing, and letting the students do the work...;"

"...learning experience and skill in a compassionate clear manner..."

A last theme that evolved from the student interviews concerned the large amount of

"legwork" that they were required to perform while working in the clinic. This work involved

tracking down patients, completing paperwork, scheduling appointments, and performing other

clinic tasks that students felt should be accomplished by support staff. These issues take away

from providing patient care and required concentration on administrative activities that interfere

with students' chair time with patients and accomplishment of educational tasks required by the

clinical departments. The following written responses are representative of the students'

experiences with administrative activities:

"Too many hoops and hurdles. New things thrown at us constantly. Bombarded with

paperwork."

"Considerably more time spent 'jumping through hoops' than actually practicing

dentistry."

"The paperwork, calling patients and often harassing them to come in, and the amount of

lab work. I know that some of this is needed, but it takes away from time that could be utilized

working on patients, trying to meet requirements."

Students reported that the paperwork and administrative issues concerning patient care

were sometimes overwhelming. Administrative issues, such as scheduling patients and calling

them to confirm appointments, are an important part of patient care education. Although

students might dislike doing these tasks they are developing essential patient management skills

for use in dental practice.









Research Question 3. How are Oral Health Care Educators-Patients-Students Interactions
Perceived by the Patient?

An overwhelming majority of the patients 99% (n=327) described the faculty interaction

with them as positive and used descriptors such as "great, exceeded expectations, fantastic,

excellent, beautiful, professional, and nice." Three patients described the faculty patient

interaction as poor. One patient said: "The interaction was "poor, as the first doctor told the

student the wrong thing to do and the second doctor corrected him." Another patient stated the

interaction was "... poor and I felt that the faculty member did not really speak to me." Patients'

descriptions of student interaction were unanimously favorable (Table 4-3).

Patient description of the faculty student interaction fell into two major categories: good

and "could be better." The majority of patients 97% (n=320) described the interaction between

the student and faculty as good, using terms such as: "... Good communication, professional,

they were nice to each other...," "top-of-the-line work together," "...faculty questions student

and answered students' questions and communicated greatly;" "this faculty member was better

than the last time." Ten patients (3%) described the interaction between the faculty and student

as "could be better" as depicted by the following statements. "...there really was not much

interaction; the work was checked at the end..." More patients described the faculty-student

interaction in a negative light than the faculty-patient interaction. Two of the patients reported a

negative response to both interactions.

Patients were asked to identify who explained the treatment plans to them. Their responses

fell into three categories: the student, student/faculty, and faculty. Most of the patients (92%,

n=304) stated that the student described the necessary treatment, 6 % (n=20) stated that the

student and faculty explained their necessary treatment, and 2 % (n=7) reported that the faculty

member explained the treatment to the patient and student. In the last instance, the faculty









member explained the treatment to the student and patient in situations that required a specialty

consult because plans are typically too complex for the attending student.

Patients stated that the main reason that they came to the dental clinic was financial (85%,

n=281), because of a recommendation (7%, n=23), they had a problem or bad experience with a

private dentist (4%, n=13), they wanted to receive expert advice (2%, n=7), or to improve dental

health (2%, n=6). When asked what could be done to make their treatment better, the vast

majority of patients (95%, n=314) said that the treatment was fine and nothing was needed to

make it better. The remaining patients who gave recommendations for improvement asked: for

evening hours; appointments that were efficient and flexible; lower fees; and less time between

visits. Some patients commented that the students shouldn't be in charge of scheduling and

collecting fees.

Patient's perceptions were predominately positive, and provided no findings that could be

used to revise or enhance clinical education. Patients seemed satisfied if they are treated fairly,

felt no discomfort, were charged a reasonable fee, and had a good relationship with their student

dentist.

Research Question 4. How do the Student and Patient Perspectives of the Oral Health
Educators-Students-Patients Interaction Compare?

Responses to questions involving faculty interaction with the patient and faculty

interaction with the student were compared. Overall, patients' descriptions of their interactions

with the faculty were more positive than the students' responses. The student would typically

say that the interaction was okay while the patient described it as excellent. When the student

reported that the faculty member was very friendly and spent much time addressing the patient's

concerns, the patient's response was that the faculty member asked a lot of questions and it was

comfortable. One student reported that the interaction was professional, and the patient reported









that it was a "beautiful, professional, and nice experience" and that the interaction was very

comfortable.

Comparison of Observations and Interviews

Observations where students reported a negative interaction were mostly categorized into

the faculty-centered style. Students reported this kind of interaction as less favorable. The

student-directed- and patient-input-style encounters were reported as mostly positive by the

students. The student-faculty collaboration style received no negative reports by the students or

patients.

Student reports of condescending faculty input were not corroborated by the observations

in all cases. For example, 15% (n=49) of the students reported poor interactions with the faculty

and condescending behavior by the faculty. Eight interactions that students described as

"condescending" behavior by the faculty member were instances in which the student came to

clinic unprepared for the clinical procedure. As a result, the faculty member appeared to the

observer as annoyed with the student. While the situation could have been handled differently,

the researcher did not observe belittling of the student in front of the patient.

The other seven cases involve two non-American female faculty members. The students

perceived one faculty member's demeanor as condescending. The student reported the faculty

member's pointed critique was too harsh. At times, students reported particular faculty as

condescending when the observer perceived them as really stern.

Research Question 5. How does the Clinical Specialty Influence the Type of Interaction
between the Oral Health Educators-Students-Patients?

A comparison of interactions across different clinics provided insight into the procedures

involved in each clinic. The information from interview and observations were assessed to

describe the influence of the clinical specialty on the educators-students-patients interaction.









Interactions in the periodontal clinic were unanimously favorable. Students reported positive

experiences with the faculty and their learning experiences. The operative clinic interactions

were mostly positive. There were a few negative interactions that typically involved two specific

faculty members. The prosthodontics clinic interactions were also mostly positive, but several

negative interactions were reported. Senior dental students reported more negative interactions

with faculty. Patient interviews did not report that their interactions were different by the clinics

where they were treated.

Research Question 6. From the Student's Perspective, What are the Elements of an "Ideal"
Clinical Teaching/Learning Experience?

Data from the interviews and observations was compiled to provide the students'

perspectives of an "ideal" clinical teaching/learning experience. Dental students made a number

of significant comments concerning student attributes, characteristics of teaching/learning and

desirable characteristics of clinical teachers. These comments pertained solely to clinical

teaching. Nevertheless, themes common to other teaching environments, such as feedback,

demonstration, integration of theory with practice, and student autonomy, were described by the

dental students. The findings were categorized as student attributes, characteristics of

teaching/learning, and desirable characteristics of clinical teachers.

Student Attributes

Dental students reported that their level of confidence was important and that their

relationship with the clinical faculty affected their learning experience. Confidence in providing

oral health care for patients is considered important as an educational outcome (Talwar, et al.,

2005). Among medical students, increased confidence has been associated with increased

clinical competence, though the relationship between the two is not well understood (Barrows,

2003). Confidence cannot be directly measured, but self-reports of student perceived confidence









is commonplace (Frank, et al., 1997). Some students reported feelings of uncertainty when they

are treating patients; they were not completely confident with what they are doing. This was

reflected in some survey comments, such as "when you have messed up beyond belief..." and

"When I do procedures, I get quite scared of doing things wrong."

Need for support. Perhaps, because of uncertainty concerning patient treatment, these

students preferred to be supervised by a supportive teacher. Student comments included the

following: "Yes, I do a filling but I'm not always sure ... [that] I've removed all the caries. It's

nice to have someone when you're doing it saying 'okay' and maybe talk you through it step by

step..." and "...nice to be reassured instead of the faculty expecting you to fail..."

Student autonomy and student self-assessment. Because clinical faculty are legally

responsible for the patient's well-being, there is a tendency in dental student clinical practice

towards faculty-led clinical decision-making. All clinical teachers have had occasion to take

over students' work to protect the patient. Many students in this study experienced this

interaction as an infringement of their autonomy, and it appeared to cause some resentment. For

example:

"We're supposed to be diagnosticians as well, not just technicians. If they say 'do this, do

that' then we get into the habit of going 'okay,' rather than thinking carefully and thinking 'Why,

specifically am I using this material?'"

In this context it seems reasonable to suggest that student clinical activity needs to be

directed towards increasing autonomy in order to prepare the student for practice.

However, it also seems important to teach students how to assess their own clinical work.

Researchers have reported that self-assessment promotes learning and is at the heart of the









educational process within professional education (Croft, et al., 2005; McCunniff & Holmes,

1999).

Students also made a number of comments about their autonomy: "I think options are

important. I was doing a filling last week and I was going to line it, then one clinician explained

the options to me, gave me three options, and then asked me to choose. So I chose with my

limited knowledge and that's what I used, and he didn't mind which one I did. And that was

constructive because he gave me the options and left the decision to me, rather than deciding and

not giving me the reason why."

Characteristics of Teaching/Learning

Communication/discussion, feedback, demonstration and the integration of knowledge and

skills were characteristics of the teaching and learning process that students frequently described

as important.

Communication/discussion. Several times students discussed faculty and staff

communication with students, not student communication with patients. They placed an

emphasis on willingness to discuss rather than on ability to communicate, which the students

appear to take for granted. The following comments illustrate this point. "...briefing helps. Dr.

X is very good. He asks us about our treatment beforehand...;" and "...there are some that will

say it to you in such a tone, volume and in such a nasty way that you're not going to ask them

again."

Feedback. Students reported that the quality and the emotional tone of feedback were

important. Comments that indicate the powerful role that feedback plays and how important

feedback is coming from clinical teachers follow. As one student commented, "... even the

smallest word or the shortest sentence can make a difference."









The data indicate that most feedback consisted of faculty members reassuring students that

their work was "fine." Most of the feedback students received was positive. Feedback is

generally recognized as important to student learning, because it provides students with

understanding (Berk, Close, & Weyant, 1998). Feedback that is perceived to be negative or

unkind may affect self-efficacy and motivation (Lawrence, 2003). Mager (1997) provides a

useful way of understanding feedback in clinical teaching by identifying it as adequacy,

diagnostic, or corrective. Adequacy feedback provides information on the efficacy of the clinical

outcome; diagnostic feedback provides confirmation of the shortcomings in the clinical outcome,

while corrective feedback suggests action to be taken to ameliorate those shortcomings.

From these interviews, students viewed feedback as very powerful. "Encouragement

definitely reduces your anxiety." One student reported being motivated by an instructor's

feedback. When he said, 'You've got to improve on this.' [I] felt like going back to your patient

and doing it really well, and instead of 'He's really put me down; I just want you to go now and

book another appointment,' you really want to strive to do better."

Students seemed to appreciate feedback that was accurate, comprehensive, systematic, and

stated in a positive manner. Given the importance of feedback, perhaps dental clinical teachers

should be encouraged to offer feedback that is comprehensive, structured, and provides both

diagnostic and corrective information. Perhaps the use of a standardized feedback form would

provide dental teachers with a rubric for organizing their feedback.

Demonstration. Students described how demonstration aided their ability to learn procedures.

Demonstration is considered a significant factor in influencing learning psychomotor skills

(Clark, Oyen, & Feil, 2001), and ought to be a common feature of dental student clinical

practice. When clinical teachers make demonstration a regular practice, it helps students learn









new procedures, even though it does take significant time. Demonstration needs careful

managing. The knowledge underlying demonstration is often tacit and invisible to the student

(O'Shea & Parsons, 1999), and it needs to be clearly communicated during the demonstration.

Students were unanimous when they suggested that demonstration was a good teaching

method for dental procedures. They lamented the fact that faculty were generally unwilling to sit

down and demonstrate, but found it useful when they did. "Some [faculty] will actually do part

of the prep for you. That's when you actually gain, when you see what a 1.5 mm shoulder looks

like." None of the students suggested that faculty do their work for them. They just appeared to

want short demonstrations: "He gave a little two-second demonstration, [saying] 'that's what I'd

like..." Yet, students felt ambivalent about teachers taking over from them. "If you think you are

doing nicely then it's a bit upsetting..." If a faculty takes over a procedure, students typically

worry that such action will have a negative impact on their patent relationship.

Integration of knowledge and skill. During interviews, a number of students complained

that the theoretical teaching they received was non-contextual and that they received no help in

linking it with practice. As one student commented, "People tell us, 'get on with it, you studied

it two years ago, you should know this.'" Nevertheless, when the student does not have the

experiences that help them assimilate content information, they reported that faculty appeared to

be reluctant to help them see the theory to practice relationship.

While it is the responsibility of the clinical teacher to facilitate learning within clinical

activity, perhaps dental curriculum could be restructured so that there is integration between

knowledge, attitudes, and skills (Levinson, 1999) and that the clinical learning environment

becomes a 'convergence' of academic and practical understanding.









The difficulty of such integration has already been mentioned in the literature review, and

it was interesting to see it occupied a significant place in student opinion. Some students

pointing out the difficulty they had learning theory because theory had not been taught in a

contextual manner: "When they do it [teach] in a class room [it is] miles away from the patient.

There is nothing to reinforce it." Effective learning should involve opportunities not just to

hear or learn new information, but to apply that information immediately in a hands-on

situation. This aspect of instruction is lacking in dental education when the first two years are

spent in the classroom and the last two years are in the clinic. Topics taught out of context

might not be used in clinic for a year.

Students also regretted that they had not been given any assistance with integration.

"There seems to be this theory that if they lead us too much, we're not going to learn anything,

you should remember every facet of it." While integrating theory and practice into a learning

process, it should also be integrated into teaching orientation. There seemed to be some

reluctance among clinical teachers to engage in this area of teaching because they perceived it as

spoonfeedingg". Although learning is the student's responsibility, some students have not had the

experiences that allow them to link information to be able to link information with experience, or

they had not had the same clinical experiences.

Understanding the limits of student knowledge

Students appeared concerned that they did not have identical clinical experience. In a

learning environment driven by patient need it is difficult to ensure identical student experience.

Several students mentioned that faculty often assumed that they have had exactly the same

experience: "There should be a lack of assumption by clinicians that you're going to be good at

something simply because of the year you're in or because you're confident about other things."









Respecting the student/patient relationship. A number of comments reflected students'

anxiety about the triangular relationship between student, patient, and teacher: "It's a learning

environment but you don't want to be made to look like an idiot in front of your patients." The

teacher will often need to correct the student in some aspect of the procedure s/he is carrying out,

but students appear to see this as damaging: "[They] turn up in front of your patient and say

'you are doing it wrong.' Then the patient loses confidence in you," some students reported that

they prefer that corrective instruction take place away from the patient: "It's good if they take

you aside from the patient, otherwise the patient is sitting there with her mouth open wondering

what's going on." As supervisors, there are times when faculty need to intervene and take over

the procedure from the student; however, students regarded this with ambivalence because while

they considered it to be useful, they also saw it as potentially damaging. The way faculty act is

important here. "There are ways and means of doing things, rather than 'Get out of the way, you

are doing that wrong.' "...if the faculty takes over the task, the student needs to know why."

Desirable Characteristics of the Clinical Teacher

The students reported several characteristics that they felt were desirable for clinical

faculty. Students preferred faculty who were professional and competent in their field,

approachable, and possessed a love for teaching. They also considered punctuality important

because they wanted to use their time efficiently. Students also reported that the faculty member

should be available in the clinic when the patient and student needed their help and visible in the

clinic when questions arose concerning patient treatment. Students preferred to be evaluated

with consistency so that when criticism was given, it was consistent for each and every student.

Students preferred faculty members who understood the limits of their knowledge and did not

speak above their level of comprehension. The students reported that faculty should have respect

for the student-patient relationship, treat the patient and student professionally, and not









undermine this relationship.

Professional competence. The knowledge and clinical competence of the faculty

member is crucial to the quality of teaching in all clinical teaching settings. Students reported

that although they were taught by specialists in dental fields, some of the faculty did not have an

appropriate level of general competence to provide support or foresight to provide

comprehensive patient care. These comments run counter to the basic philosophy of the dental

school. The school is based on a specialist model which means that each specialty is taught in a

specific clinic. Another model of dental education is the generalist approach where the clinical

teaching is supervised and taught by general dentists with general practice experience. The

following professional competencies emerged from analysis of data in this study.

Approachable personality. Some students seemed fearful of particular faculty and

reported how their teaching styles impacted their learning unfavorably; for example, "If you are

scared, you are less likely to ask, and are not going to learn." One student reported that he

preferred to ask a colleague rather than go to certain faculty because then s/he "[didn't] feel

stupid asking questions."

Punctuality. Students liked to discuss patient treatment matters with their faculty before

patients arrived. They reported feeling displeased when faculty do not arrive in time for this:

"Clinicians should be in clinic at a reasonable time for the 8:30 session so they've actually got

time to spend with students to go through what they're planning on doing."

Availability. Students appreciated the close presence of their teacher for two reasons.

First students did not want to take time looking for the faculty. As one student stated, "There's

nothing worse than putting a matrix band in place, getting moisture control and then you've got

to go and find a clinician." Another reason was the psychological reassurance of seeing the









faculty nearby. Another student reported that, "What is really beneficial as well, I've noticed that

Dr. X doesn't disappear like some clinicians like to do." Students' comments indicated that at

times they feel there was an insufficient number of faculty in the clinic. Absence or

unavailability of faculty contributed to losing chairside time and an insufficient amount of time

spent with each student that interfered with learning. As one student stated, "The trouble with

this is, sometimes in clinic, there might be 2-3 clinicians on if we're lucky and the amount of

time that the clinician has to spend with you, even though he might only have 6 students, I just

don't think they have time; they might have time to do this if you're lucky."

Consistency. Students also reported the difficulties that arise when faculty disagreed over

treatment plans. "I have had a treatment plan that has changed every single time I have brought

my patient in clinic. We don't get much further, it is all that continued debate about what we're

going to do." Students also reported feeling without support when faculty criticized each other.

One student reported, "It is quite hard for us when some clinicians frown on other clinicians'

opinions and we're left thinking well now what."









Table 4-1. Student and patient demographics


Group
Class of
2006*


Class of
2007**


Patients***


N Gender
168 50% Male (n=84)
50% Female (n=84)


162 60% Male(n=97)
40% Female (n=65)


330 50% Male(n=166)
50% Female(n=164)


Ethnicity
70% Caucasian (n= 118)
18% Hispanic (n=30)
8% Asian (n=13)
4% African American (n=7)
72% Caucasian (n=117)
14% Hispanic (n=23)
11% Asian (n=18)
3% African American (n=5)
60% Caucasian(n=198)
17% African American (n=56)
15% Hispanic (n=50)
5% Asian (n=17)
3% unknown (n=9)


Age *Male- 24 to 34 yo, Female-24-32 yo **Male-23 to 35 yo, Female-24 to 29 yo
***Male-19-82 yo, Female-20-84 yo









Table 4-2. Student interview responses


Interview Topic
Faculty interaction with patient



Faculty interaction with student

What you learned

How faculty fostered learning



Make learning experience better


Importance of clinical teaching


Response
3% (n=10) No interact with patient
10% (n=33) Did not interact well
8% (n=27) Excessive interaction
79% (n=261) Very good interaction
85% (n=281) Positive interaction
15% (n=49) Negative interaction
Varied from "Nothing, I've done this procedure many
times" to "I learned a new technique today."
Class of 2006
40% (n=67) Reported that faculty fostered learning
Class of 2007.
80% (n=130) Reported that faculty fostered learning
(90%, n=297), Positive reports of learning experience
10% (n=33) Negative reports of faculty teaching skills
and traits
65% (n=215) Faculty characteristics
15% (n=50) Student characteristics
12% (n=40) Patient interaction
8% (n=26) Characteristic of the learning experience









Table 4-3. Patient interview responses


Interview Topic


Faculty interaction with patient

Student interaction
Faculty-Student Interaction

Who explained treatment


Main reason for coming to college





Make care better


99% (n=327) Positive
1% (n=3) Negative manner
Unanimously favorable
97% (n=320) Good communication
3% (n=10) Could be better
92% (n=304) Student
6% (n=20) Student and faculty
2% (n=6) Faculty explained
85 % (n=281) Financial
7% (n=23) Recommendation
4% (n=13) Problem or bad experience
with a private dentist
2% (n=7) Expert advice
2% (n=6) Improve my dental health
95% (n=314) Treatment was fine nothing
needed to make it better
5% (n=16) Evening hours, appointments
efficient and flexible, lowering time
between visits, students shouldn't be in
charge of scheduling and collecting fees


Response









CHAPTER 5
CONCLUSION

Characterization of Healthcare Educator-Patient-Student Communication

Four major styles of communication interactions emerged from the observation/interview

data: faculty centered, student directed, student-faculty collaboration, and patient-driven.

Faculty-centered

Faculty-centered interactions resulted when faculty instructed students what to complete

at the appointment, when telling students where modifications were needed in the treatment, or

when faculty completed a procedure without involving the student. These interactions are based

on the expert model. When the faculty told the student what to do or made modifications, the

student reported both kinds of interactions as negative because they did not feel involved in the

learning process. Students reported that they would rather be shown what to do and then do it

than have the faculty member do it for them.

Student-directed

During student-directed interactions either students told the faculty member what

procedure they were doing or students sought out the faculty member when they needed

assistance. In these instances, faculty usually allowed the student to perform the treatment with

supervision. For the most part, the students reported these learning experiences as positive. The

observations showed that these opportunities were limited and student-patient interaction was

minimal.

In this interaction the student's learning process was primary. The faculty member would

usually stay in one place during the clinical procedure. The faculty member interacted with the

student and patient but at the initiative of the student.









Student-Faculty Collaborations

In student-faculty collaboration, the student and faculty decided together what would be

done at that appointment. During these types of interactions, the faculty member approached the

student at different phases of the treatment and offered suggestions and pointers. The faculty

member looked for teachable moments and interacted with the student and patient during the

treatment. The students and patients reported this style of interaction was positive. Faculty-

student collaborations promoted an open, collegial atmosphere; students reported that these types

of interactions fostered their learning.

Patient-driven

During patient-driven interactions, the patient decided what procedure would be done that

day. Typically, the student explained to the faculty member what the patient desired for that

particular day. A faculty member interacted with the student and patient during treatment to

insure that the treatment was necessary and correct, but the patient had more input as to what was

done.

Student Perspective of Triad Relationship

Student responses indicating what was most important about clinical teaching were

classified into three major categories: faculty characteristics, student characteristics, and

characteristics of the learning experience. The majority of the responses were the faculty

characteristics and their impact on the learning experience. The faculty characteristics were

characterized by traits of the faculty and placed the onus for learning on the faculty.

The majority of the students placed the importance of clinical teaching on the faculty

members. The observations showed that students preferred faculty-student collaboration in

clinical teaching. The students preferred faculty members who were more interactive and









involved in the learning and treatment process. They expressed a dislike for faculty members

who were dominating and completed the treatment for them.

Students also reported that student characteristics were important to clinical teaching.

They stated that they wanted to learn to become better clinical dentists and wanted constructive

criticism. Students also reported a preference for a hands-on (demonstrative), active approach to

learning.

Patient Perspective of Triad Relationship

Patients are essential to clinical teaching. The majority of patient responses were

positive. The patients wanted faculty to have oversight of their care and they did not feel

negatively when the faculty took over a procedure instead of a student.

As described in a study by Grimaudo and Behar-Horenstein (2004) it was evident that

patients related quality dental care to many different factors and that the age, gender, or ethnicity

of the patient influenced their impressions. General themes that were apparent were that the

perceived technical skill of the student was less important than the empathy students showed

towards patients. Overall, the information gathered in this study from patient interviews and

observation provided little new information or suggestions to change clinical teaching.

Influence of Clinical Specialty on Interaction

Students and patients did not report major differences in faculty/patient interactions within

the Operative, Oral Health Maintenance, Periodontics, and Prosthodontics clinics. The

procedures in Periodontics such as root planning and scaling were reported as routine by

students. The students had only favorable remarks about this clinic. Students commented

favorably about Oral Health Maintenance and reported some concerns with specific faculty in

Operative. Most of the unfavorable remarks concerning faculty were reported in the

Prosthodontics clinic, where the students perform the most complex and time-consuming









procedures. Faculty members spend large amounts of time with some students, while other

students must wait. This is out of necessity since the faculty must ensure that the procedures are

done correctly and of a high quality. Most of the procedures are completed at the end of the

clinical curriculum when students are scrambling to graduate. It is at this specific time, when

most senior students reported that they felt junior students were unprepared and took away from

their clinical time with faculty.

Students described a number of characteristics of the clinical teacher that were both

desirable and undesirable. Students generally expressed a desire for their teachers to use teaching

behavior such as demonstration, feedback, and a willingness to talk about treatment. As noted

above, the adequacy of such teaching is generally disputed by the students.

Students also reported that it is important to have a faculty member constantly available in

the clinic. This need is influenced by time constraints such as fixed-length appointment times

and need for reassurance. The need for teacher availability also prompted comments about

teacher-student ratios. Students also expressed a desire for increased autonomy. While this may

be a desirable outcome of clinical practice, it is possible that faculty may see this as an

impediment with ensuring patient safety. Also, experiences suggests that increasing student

autonomy takes time, which may not be available in a busy clinical session with current faculty

to student ratios.

Students also described the importance of teacher competence. Certainly, knowledge

allows the clinical teacher to explain concepts to the student, and competent demonstration may

lead to better student performance, but students appeared to link competence more with

psychological support. Students gained confidence from knowing that whoever is backing them

up has the knowledge.









Of all the teacher characteristics described, it is apparent that students view a positive

relationship with the teacher as most important to them. In interviews, words such as

approachable, friendly, understanding, and helpful were used. But students also used words

such as domineering, authoritarian, condescending, sarcastic, and patronizing. Student

comments elaborated that point: "There are some that will say it to you in such a tone, volume,

and in such a nasty way that you're not going to ask them again," or "If you are scared, you are

less likely to ask, and are not going to learn."

Student Perspective of an "Ideal" Clinical Teaching/Learning Experience

Based on the findings of this study, a descriptive model of clinical teaching based on

student preference is proposed. The student-teacher- patient triad is at the center of the model,

and the overall environment is the clinic. The student brings to the environment his/her basic

preclinical knowledge and level of confidence. The student feels a level of confidence which can

be affected by faculty interaction. The student relationship with the clinical teacher is important

and the student will learn more efficiently if this relationship is viewed as positive by the student.

Good rapport and respect between the three members of the triad is essential. The student wants

the faculty member to have respect for the student-patient relationship, as this relationship is the

basis for clinical care.

Desirable characteristics of the clinical teacher are professional competence, punctuality

(so that the student is able to use the allotted clinical time), availability during clinic and after for

questions and concerns, consistency with treatment and evaluation, and practicality concerning

clinical matters.

The teaching and learning technique preferred by the student is demonstration. As the

student brings background knowledge, the faculty member shows them how to do the procedure,

and then the faculty member lets the student do it. The students view feedback as very









important. Students appreciate feedback which is accurate, comprehensive, and systematic, and

which is provided in a positive emotional environment. In clinical learning, the faculty should

help students integrate knowledge and skill by combining theory into practice. The triad and

interactions should lead to quality care for the patient.

Other factors that are important are student autonomy and student self-assessment. These

two factors help the student to become a better practitioner. The outcome of the triad teaching-

learning interactions that lead to quality patient care should be clinical competence. This model

is only valid under the circumstances presented and within the context of this study.

Several key characteristics of positive learning experiences were identified by students in

this study. Instructor personal qualities such as approachability, enthusiasm, commitment, and

willingness to give guidance and feedback contributed to effective learning experiences and the

specific instructor skills. Particular characteristics of the learning process also contribute to

effective learning experiences. These included a focus on the big picture, modeling and

demonstrations, opportunities to apply new knowledge, availability of high-quality feedback,

learning opportunities that were focused, specific, and relevant, and the opportunity for learning

with and from peers.

These results are consistent with principles of adult learning. For example, adult

learners want their learning to be relevant to their learning goals, which parallels our "focus

on the big picture" and "relevance" themes. Adults learn best in a supportive environment in

which they can experiment with new behaviors and skills, which parallels our "instructor

characteristics," "opportunity to apply new knowledge," and "culture of the learning environ-

ment" themes. Finally, adult learners need and want feedback, which parallels our "high-

quality feed-back" theme.









These results are also consistent with experiential learning theory as described by Kolb

(1984), in which both active experimentation, which parallels an "opportunity to apply new

knowledge" theme, and reflective observation, which parallels our "modeling and

demonstrations" theme, are integral components of the learning cycle. Learning style

assessments of incoming students should be performed to determine the variety of learning

styles represented within the student body. Some students favor active experimentation, the

"hands-on" opportunity to try things out for themselves, while others favor reflective

observation, the opportunity to observe a faculty member or senior student demonstrate a

behavior, skill, or procedure. Instructors may want to provide a variety of modes of learning in

order to meet the needs of learners with varied learning preferences.

Theoretical Implications of this Study
Summary of Findings

Clinical experiences in dental school encompass a wide variety of learning opportunities.

Findings from this study demonstrate that students viewed their clinical education as a positive

experience with some exceptions.

Clinical instructors did not rely heavily on questioning strategies to guide or stimulate

student thinking, rarely asked students to reflect on performance or to self-assess, and often

employed less-than-ideal strategies for providing feedback. In particular, the results suggested

that many clinical instructors could enhance their technique for providing feedback with

emphasis on improving delivery of the message based on the traditional communication heuristic:

"It's not what you say, but how you say it."

Dental students did not perceive that they gained as much from the overall clinical setting

as they did from the interactions with individual clinical instructors. Many dental students saw









the clinical environment as being inefficient and characterized by non-productive down time that

was devoted to noneducational tasks in order to "make the system work."

Students described the impact of faculty shortages on the quality of the educational

program, either "real" coverage shortages (not enough faculty on staff) or "availability"

shortages (faculty could not be found when needed). Students preferred more opportunity to

work in a variety of patient care settings, not just the dental school clinic, and preferred to work

more consistently with a core of instructors rather than interacting with different faculty every

day.

Many of the ideas discussed above, such as demonstration, feedback, and positive

affirmation are fundamental to role modeling. The idea of the dental clinical teacher as a role

model was discussed by Chapnick and Chapnick (1999). Mentoring and role modeling are an

accepted part of medical educational literature, but the idea seems to be relatively neglected in

dental education. Appropriate role modeling could help dental students learn the knowledge,

skills, and attitudes appropriate to independent clinical practice.

The characteristics of positive learning experiences presented here may provide insights

for instructors who wish to increase the effectiveness of their teaching and their students'

learning. For example, instructors may be able to quickly and relatively easily implement

changes in how they give feedback to students, or in the extent to which their classroom sessions

are interactive in nature, and the frequency with which they "check-in" with the class.

Instructors within the same institution may not be aware of effective and/or innovative teaching

strategies used by their colleagues. One easy approach to faculty development may be to provide a

forum for faculty to share their "best practices" for teaching.









Many effective learning experiences happen outside the formal curriculum. For

example, studying with peers and working with senior students in the clinic are not necessarily

formal curricular activities, yet they were valuable for the students. Curriculum planners

should consider how to best capitalize on these effective modes of learning.

Findings from this study were compared with the key concepts of studies on teaching and

learning in health care environments (Table 5-1). There are characteristics of the clinical teachers

that students perceive as favorable when determining teacher effectiveness. According to

Chambers, Geissberger and Lekinus (2004), characteristics identified by the students were:

expert, enthusiastic, judicial, and good soldier. These characteristics were not confirmed by the

present study. This study agreed with the findings ofFugill (2005) where characteristics of

effective clinical teachers identified by students were: competent, approachable, practical and

consistent.

Effective clinical teachers provide accurate comprehensive feedback to students in a

positive environment (Berk et al 1998, Mager 1997). The present study confirms this concept

and agrees with Croft, et al. (2005) and McCuniff and Holmes (1999) that effective clinical

teachers allow students to have autonomy depending on their clinical level and encourage self

assessment and evaluation

Chapnick and Chapnick (1999) stated that effective clinical teachers are role models to

students and the students in this study reported that they look up to clinical faculty and view

them as role models. Levinson (1999) and Manague, et al., (2001) concluded that effective

clinical teachers integrate knowledge and skill by incorporating the basic sciences into the

clinical process and contextualizing dental education. The students in the present study confirm

this concept









Clark, et al. (2001) and O'Shea and Parsons (1999) reported effective clinical learning

includes demonstration. This study confirms this concept and students reported that they prefer

to see and then do. The students also prefer faculty that are flexible in clinic and allow the

student to complete the assigned tasks. This is not in agreement with Biddle (1996),

Cunningham, et al. (1999), Ende, et al. (1995) and Hirons and Velleman (1993). In those

studies, students preferred faculty that provided strict clinical supervision and completed tasks

for the student.

This study agrees with Fugill (2005), Kilminster, et al. (2002), and James, et al. (2001) as

students prefer faculty that act as facilitators. This study also confirms Chambers (1998) and

McGrath (2005) which reports that students prefer faculty that respect the student/patient

relationship and do not undermine the student in the presence of the patient. Students in this

study preferred open discussion and communication with faculty and preferred an active role in

the learning process which confirms findings by Chambers (1998), Fugill (2005) and Henzi, et

al. (2006). The students in this study did not report that they treated patients based on

requirements which was reported by Chambers (1998) and McGath (2005) but stated that they

want to provide comprehensive care and do what is best for their patients regardless of

requirements which confirms reports by Manague, et al. (2001) and Henzi, et al. (2007).

Future Research

Future research should investigate clinical teaching from the faculty member's perspective.

The model that emerged from such a study could be proposed and compared to the model from

this study. The model from this study could be used to develop a curriculum in a specific

clinical discipline and determine the effectiveness of this curriculum in clinical teaching. The

same could be done for the faculty perspective model, and comparisons could be made in order









to develop a curriculum for clinical teaching based on the data from several different

perspectives.

Although this study is limited in scope and scale, it raises important issues that require

further study and perhaps changes in teaching practices in dental schools. One recommendation

would be to examine dental student clinical practice from the clinical teachers' perspective,

perhaps using a semi-structured interview technique.

Teaching and learning interactions between student and clinical teacher are also worth

further study to document more precisely some of the issues surrounding communication,

demonstration, feedback, and integration. Such a study could be carried out using structured

observation and/or videotaping but would need to be designed carefully because of patient

confidentiality issues and concerns about the intrusiveness of videotaping. A study of this type

may also provide further understanding of the patient-student-teacher triangular relationship.

Other possible avenues for study include similar descriptive studies in other clinics or other

dental schools that could be conducted for the purposes of comparison and generalization.

The findings from this study showed that many of the clinical teachers are appreciated by

students. Nevertheless, there is room for improvement in clinical teaching. A more student-

centered approach to the balance between teaching and supervision should be encouraged and

better use made of both demonstration and feedback.

Finally, clinical teachers should be aware of their power, that their "smallest word or ...

shortest sentence can make a difference." Walsh (2000 p. 21) pointed out that:

The evident desire of students to be treated more like peers...conflicts with the
reality that [teachers] know more about the subject at hand[,]...bear the burden of
evaluating students[,]... and generally manifest far greater commitment to the learning
process.









The importance of cultivating a positive relationship between student and teacher has been

evident throughout this study, is recognized as important to student learning, and needs greater

attention. Perhaps a way to further mutual understanding could be through the concept of

building an "alliance" between student and teacher (Tiberius, et al., 2002). The key features of

this alliance are mutual respect, shared responsibility for learning, effective communication and

feedback, cooperation, willingness to negotiate conflict, and a sense of security.
















r


Oral Health Patient


Dental Student a

I

* Knowledge
* Level of
Confidence
* Self-Assessment
SAutonomy


Respect & Rapport


-Feedback
-Respecl
,Prolessionalism
rRespecl for Ihe
sludenl-palienl
relallonship


Clinical Teacher

I

Competent
Punctual
Available
Consistent
Practical
Professional


Figure 5-1: Descriptive model of clinical teaching based on student preference


1' I j IJ- _) II II EllI T


MJMMc


-


"-"--Wmww I









Table 5-1. Findings of study based on theoretical framework/perspective


Key Points of Theory


Findings


Theory confirmed or
refuted


Characteristics of Effective Clinical Teachers
There are characteristics that Chambers, Geissberger, and Lekinus, 2004
students perceive as The characteristics identified by students
favorable when determining were: expert, enthusiastic, judicial and good
teacher effectiveness soldier.
Fugill, 2005
The characteristics identified by students
were: competent, approachable, practical and
consistent
Providing feedback Berk, et al., 1998, Mager, 1997
Effective clinical teachers provide accurate
comprehensive feedback to students in a
positive environment
Role modeling Chapnick & Chapnick, 1999
Effective Clinical teachers are role models to
students


Refuted



Confirmed



Confirmed



Confirmed


Learning Environment
Demonstration



Integration of knowledge and
skill



Supervisor




Student/patient relationship


Clark, et al., 2001; O'Shea & Parsons, 1999
Effective Clinical learning includes
demonstration. Students like to see and then
do.
Levinson, 1999; Manague, et al., 2001
Effective Clinical teachers integrate
knowledge and skill. They incorporate the
basic sciences into the clinical process and
contextualize dental education
Biddle, 1996; Cunnigham, et al., 1999; Ende,
et al., 1999; Hirons & Velleman, 1993
Students prefer faculty that provide strict
clinical supervision and complete tasks for
the student
Fugill, 2005; Kilminster, et al., 2002; James,
et al., 2001
Students prefer that the faculty act as
facilitators and allow them to complete
patient procedures
Chambers, 1998; McGrath, 2005
Student prefer faculty that respect the
student/patient relationship and do not
undermine the student in the presence of the
patient


Confirmed



Confirmed




Refuted




Confirmed




Confirmed









Table 5-1--Continued

Key Points of Theory

Student autonomy and self
assessment



Communication/discussion




Requirements


Findings

Croft, et al., 2005; McCuniff & Holmes, 1999
Effective clinical teachers allow student
autonomy depending on their clinical level
and encourage self assessment and
evaluation
Chambers, 1998; Fugill, 2005; Henzi, et al.,
2006
Students prefer open discussion and
communication with faculty. They want an
active role in the process
Chambers, 1998; McGrath, 2005
Students claim that requirements drive their
clinical experience.
Manague, et al., 2001; Henzi, et al., 2007
Students want to provide comprehensive care
and do what is best for their patients
regardless of requirements


Theory confirmed or
refuted
Confirmed




Confirmed




Refuted


Confirmed









APPENDIX A


INFORMED CONSENT

Protocol Title: Qualitative description of Clinical Dental Teaching

Please read this consent document carefully before you decide to participate in this study.

Purpose of the research study: The purpose of this study is to identify and describe the
faculty-student-patient interactions that characterize communications in the dental education
clinic setting.

What you will be asked to do in the study: You will not be asked to do anything specific.
Your interactions/conversations with the dental student and faculty member will be observed.
You and the student will be asked a few questions about your treatment at the end of the
appointment.

Time required: 1-1.5 hour. This will be during a regularly scheduled dental appointment and
will not affect the length of the appointment.

Risks and benefits: There are no risks or benefits. The results will help us to better educate
future dental students.

Compensation: You will not be paid for participation.

Confidentiality: Your identity will be kept confidential to the extent provided by law. Your
information will be assigned a code number. Your name and chart number will not be recorded
on any of the observation information. Your name will not be used in any reports.

Voluntary participation: Your participation in this study is completely voluntary. There is no
penalty for not participating. This will have no effect on your status as a dental patient or your
treatment.

Right to withdraw from the study: You have the right to withdraw from the study at any time
without consequence.

Whom to contact if you have questions about the study:

Dr Nicholas J. Grimaudo, Associate Professor, University of Florida, College of Dentistry, 352-
392-0348, grimaudo@dental.ufl.edu.

Whom to contact about your rights as a research participant in the study:

UFIRB Office, Box 112250, University of Florida, Gainesville, FL 32611-2250; 352-392-0433.

Agreement:









I have read the procedure described above. I voluntarily agree to participate in the procedure and
I have received a copy of this description.

Participant (Patient): Date:

Participant(Student): Date:

Principal Investigator: Date:











APPENDIX B


PATIENT INTERVIEW PROTOCOL



1) What dental work was done today?
2) How did the faculty interact with you?
3) How did the student interact with you?
4) How did the faculty and student interact with each other?
5) Who explained the treatment to you?
6) What further dental treatment do you need?
7) What are your main reasons for coming to the dental college?
8) What could be done to make your care better?
9) Please include any additional feelings/responses concerning today's appointment?









APPENDIX C


STUDENT INTERVIEW PROTOCOL



1) What procedures) were you doing today?
2) How do you feel the faculty interacted with your patient?
3) How do you feel the faculty interacted with you?
4) What did you learn today?
5) Describe how the faculty fostered (facilitated) your learning?
6) What could the faculty have done to make your learning experience better?
7) What is most important to you about Clinical teaching?
8) Please include any additional feelings/responses concerning today's clinical interaction?









APPENDIX D


CLINIC OBSERVATION SCHEDULE GRID


Wednesday


Thursday Friday


Month 1
Operative
Periodontics
OHMC
Prosthodontics


OHMC
Operative
Prosthodontic
Periodontics


Prosothodontics
OHMC
Periodontics
Operative


Periodontics
Prosthodontics
Operative
OHMC


Month 2
Periodontics Prosthodontics OHMC Operative
Operative OHMC Prosthodontics Periodontics
OHMC Prosthodontics Operative Periodontics
Prosthodontics OHMC Periodontics Operative

Month 3
Operative OHMC Prosthodontics Periodontics
Periodontics Operative OHMC Prosthodontics
OHMC Prosthodontics Periodontics Operative
Prosthodontics Periodontics Operative OHMC

Month 4
Periodontics Prosthodontics OHMC Operative
Operative OHMC Prosthodontics Periodontics
OHMC Prosthodontics Operative Periodontics
Prosthodontics OHMC Periodontics Operative

Month 5
Operative OHMC Prosthodontics Periodontics
Periodontics Operative OHMC Prosthodontics
OHMC Prosthodontics Periodontics Operative
Prosthodontics Periodontics Operative OHMC

Month 6
Periodontics Prosthodontics OHMC Operative
Operative OHMC Prosthodontics Periodontics
OHMC Prosothodontics Operative Periodontics
Prosthodontics OHMC Periodontics Operative


Monday


Tuesday


I


I I I


I


i


'


I











LIST OF REFERENCES


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BIOGRAPHICAL SKETCH

Nicholas J. Grimaudo grew up in Oceanside, New York. He graduated in 1976 from

Adelphi University with a Bachelor of Science in biology and received his DMD from the

University of Florida, College of Dentistry in 1980. Nicholas was in private practice in

Inverness, Florida from 1980 to 1992. He returned to the University of Florida to earn a master's

degree in materials science and engineering in 1992 and a master's degree in oral biology from

the College of Medicine in 1995. Nicholas became an assistant professor in the Department of

Biomaterials at the College of Dentistry in 1995. He is currently an associate professor in the

Department of Operative Dentistry.





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STUDENTS AND PATIENTS PERSPECTIVES OF CLINICAL TEACHING AT A DENTAL SCHOOL By NICHOLAS J. GRIMAUDO A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLOR IDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY UNIVERSITY OF FLORIDA 2007 1

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2007 Nicholas J. Grimaudo 2

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To my family, especially my mother, Ca rmela Grimaudo, who passed away in 2003. Her encouragement was and will always be my inspirati on in life. I miss her, but I know that she is proud of my accomplishments. 3

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ACKNOWLEDGMENTS My study could not have been completed wit hout the support of the students, patients, and faculty who volunteered their ti me. I am thankful to all of them. I could not have completed this dissertation without the assistance of th e members of my doctoral committee: Dr. Kenneth Anusavice, Dr. James Doud, and Dr Linda Serra Hagedorn. I would like to especially thank Dr. Linda Behar-Horenstein, my committee chair. She provided guidance and assistance and has been a role model, friend, and colleague. Most importantly, I would like to thank my fa mily. I thank my dad, Joe. I owe all that I am and everything that I have accomplished. What else can I say? I thank my sons, Joe and Nick, for their understanding, support, sacrifices, and patience. We have all been students together for several years but I think dad wins with the most degrees. They really know the meaning of lifelong learner. Most of all I thank my wife, Jeanne, fo r her encouragement, understanding, support, sacrifices, and love. She has always been ther e and pushed me when I needed it. I could not have completed this dissertation, my de grees, or everything else without her. 4

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TABLE OF CONTENTS page ACKNOWLEDGMENTS...............................................................................................................4 LIST OF TABLES................................................................................................................. ..........8 LIST OF FIGURES.........................................................................................................................9 CHAPTER 1 INTRODUCTION..................................................................................................................12 Purpose of Study..............................................................................................................16 Research Questions.........................................................................................................16 Definition of Terms.........................................................................................................16 Significance of Study......................................................................................................17 Limitations.................................................................................................................... ...18 2 LITERATURE REVIEW.......................................................................................................19 Theory of Teacher Effectiveness............................................................................................19 Oral Health Care EducatorStudent Relationship..................................................................22 The Role of the Teacher..................................................................................................23 The Role of the Learner...................................................................................................25 The Interaction Between Clin ical Teacher and Student..................................................32 Communication Skills.....................................................................................................32 Clinical Education..................................................................................................................37 Individual and Team Learning.................................................................................39 Findings Relevant to Studie s on Clinical Education.......................................................40 Purpose or goal of clinical teaching.........................................................................40 Learning context.......................................................................................................41 Requirements and demands from the learning setting.............................................41 Professional role modeling.......................................................................................42 Concept of service....................................................................................................43 Advantages/Disadvantages of Clinical Education...........................................................44 Problem solving opportunities.................................................................................44 Expectations and feedback.......................................................................................45 Clinical Teaching....................................................................................................................46 Definition of Clinical Teaching.......................................................................................46 Role of Clinical Instructors.............................................................................................46 Contributions of Clinical Teach ing to Dental Practitioners............................................49 Challenges associated with clinical teaching...........................................................50 3 MATERIALS AND METHODS...........................................................................................53 5

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Theoretical Framework for Da ta Collection and Analysis.....................................................53 Methodology...........................................................................................................................53 Researcher Qualifications and Bias........................................................................................55 Participants.............................................................................................................................57 Instrumentation................................................................................................................ .......58 Data Collection.......................................................................................................................58 Data Analysis..........................................................................................................................59 Trustworthiness of Data..........................................................................................................59 Credibility.................................................................................................................... ....60 Transferability.................................................................................................................61 Dependability and confirmability....................................................................................62 4 RESULTS..................................................................................................................... .........63 Research Question 1. What are the Characte ristics of Oral Health Care Educators PatientsStudents Interactions in the Clinical Learning Environment?..............................63 Faculty-Centered.............................................................................................................63 Student-Driven................................................................................................................65 StudentFaculty Collaborative........................................................................................66 Patient-Driven..................................................................................................................67 Research Question 2. How are Oral Hea lth Care EducatorsPatientsStudents Interactions Perceived by the Student?...............................................................................68 Research Question 3. How are Oral Hea lth Care EducatorsPatientsStudents Interactions Perceived by the Patient?................................................................................77 Research Question 4. How do the Student and Pa tient Perspectives of the Oral Health Educators-Students-Patient s Interaction Compare?............................................................78 Comparison of Observations and Interviews..................................................................79 Research Question 5. How does the Clinical Sp ecialty Influence the Type of Interaction between the Oral Health E ducators-Students-Patients?......................................................79 Research Question 6. From the Students Perspective, What are the Elements of an Ideal Clinical Teachin g/Learning Experience?...............................................................80 Student Attributes............................................................................................................80 Need for support.......................................................................................................81 Student autonomy and student self-assessment.......................................................81 Characteristics of Teaching/Learning..............................................................................82 Communication/discussion......................................................................................82 Feedback...................................................................................................................82 Demonstration..........................................................................................................83 Integration of knowledge and skill...........................................................................84 Understanding the limits of student knowledge.......................................................85 Respecting the student/p atient relationship..............................................................86 Desirable Characteristics of the Clinical Teacher...........................................................86 Approachable personality.........................................................................................87 Punctuality................................................................................................................87 Availability...............................................................................................................87 Consistency..............................................................................................................88 6

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5 CONCLUSION.................................................................................................................. .....92 Characterization of Healthcare EducatorPatientStudent Communication..........................92 Faculty-Centered.............................................................................................................92 Student-Directed..............................................................................................................92 StudentFaculty Collaborations......................................................................................93 Patient-Driven..................................................................................................................93 Student Perspective of Triad Relationship.............................................................................93 Patient Perspective of Triad Relationship...............................................................................94 Influence of Clinical Specialty on Interaction........................................................................94 Student Perspective of an Ideal Cl inical Teaching/Learning Experience...........................96 Theoretical implications of this study......................................................................98 Summary of Findings............................................................................................................ .98 Future Research....................................................................................................................101 APPENDIX A INFORMED CONSENT......................................................................................................107 B PATIENT INTERVIEW PROTOCOL................................................................................109 C STUDENT INTERVIEW PROTOCOL...............................................................................110 D CLINIC OBSERVATION SCHEDULE GRID..................................................................111 LIST OF REFERENCES.............................................................................................................112 BIOGRAPHICAL SKETCH.......................................................................................................124 7

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LIST OF TABLES Table page 4-1 Student and patient demographics........................................................................................... 89 4-2 Student interview responses...................................................................................................90 4-3 Patient interview responses............................................................................................... .....91 5-1 Findings of study based on theo retical framework/perspective...........................................104 8

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LIST OF FIGURES Figure 2-1 Conceptual model for physicianpa tient relationship continuum.......................52 5-1 Descriptive model of clini cal teaching based on student preference................104 9

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Abstract of Dissertation Pres ented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy STUDENTS AND PATIENTS PERSPECTIVES OF CLINICAL TEACHING AT A DENTAL SCHOOL By Nicholas J. Grimaudo December 2007 Chair: Linda Behar-Horenstein Major: Curriculum and Instruction In dental education, the clin ic is the learning environmen t that requires students to transfer knowledge from the basic sciences and utilize it to render safe and efficient patient care. The effectiveness of teaching and learning in the clinical learning environment and how it prepares dental students to independently provid e patient care is a centr al concern for dental education. The underlying theory in this study was to describe how teacher effectiveness influences students in the clin ical learning environment and impacts patient care. There is growing awareness that students responses to and views of th eir educational experiences are important to shaping and modifying the educational process. The primary purpose of this study was to de scribe the instructional practices among clinical dental educators as they pertain to student and patient involvement. The secondary purpose was to describe the intera ctions between the teacher, stude nt, and patient during clinical teaching. The study examined the students and patients perspectives of the dental clinical teaching environment. Utilizing participant observation, this study focused on the oral health care educatorpatientstudent triad a nd the learning experien ce in comprehensive oral health care. Methods of data collection include d unobtrusive observations of inte ractions between oral health 10

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care educators, patients, and stude nts, and patient and student in terviews. This study is grounded in a constructivist framework, whereby the resear cher considered indivi duals perceptions and communications, as well as the setting, as essent ial for developing insight into the observable relationships and interactions. The participants were comprehensive care patients at the U of Wallace College of Dentistry, faculty members of the College of Den tistry, and student dentists in the classes of 2006 and 2007. Data were collected from three primary sources: patient interviews, student interviews, and participant observa tion of the patientfacultystude nt interaction for a total of 330 student/patient/faculty observation/interviews co mpleted. The results indicate that there are particular student attributes, ch aracteristics of teaching/learning, and characteristics of clinical teachers that are essential to clinical learning. Students repo rted a preference for a learning environment that emphasizes the student-patient-education relationship while promoting good rapport and respect. Attributes as cribed to the effec tive clinical educator are professional, competent and consistency with treatment planning and evaluation and use of teaching techniques such as demonstration and the pr ovision of accurate, comprehensive feedback delivered in a positive emotional manner. Four major styles of comm unication interactions emerged: facultycentered, student-directed, studentfaculty collaboratio n, and patient-driven, although students reported that the studentf aculty collaboration was the most positive. Although patient experiences were positive overall, these particular findi ngs did not contribute any new information that might be used to improve or modify current clinical teaching. The findings from this study were compared w ith the key concepts of studies on teaching and learning in health care environments. Fina lly, a theoretical model that emerged from the observations and interviews wa s presented and explained. 11

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CHAPTER 1 INTRODUCTION Dental education researchers ha ve suggested that the clinic is the learning environment to which all our students aspire (Mullins, We therall, & Robbe, 2003, p. 58) because it requires the "transfer of knowledge from the basic scie nces by tuning and restructuring of knowledge (Gordon, Hazlett, ten Cate, Mann, Kilminster, & Prince, 2000, p. 844). The effectiveness of teaching and learning in the clinical learning envi ronment and how it prepares dental students to independently provide patient care is a central concern among dental ed ucators and clinical supervisors. Although more is now known about medical/p rofessional education, adult learners, and the development of expertise than ever before, st andards and criteria for effective U.S. teaching are less well developed in medical and health profession programs than in K-12 settings. Many faculty lack current teaching skills and also lack emerging knowledge concerning how adults learn and gain expertise (Mennin, 1999), ev en though teaching medical/dental and health professional students is central to the mission of these schools. All medical and health profession programs have clinical and experiential course work that permits students to practi ce in the field, under th e tutelage of credentialed professionals (James, Kreiter, Shipengrover, Crosson, Heat on, & Kernan, 2001). These experiences allow students to put the principles and concepts learne d in the classrooms into practice. Clinical or experiential courses occur throughout the students' course of study, or it can be the last stage of professional training before the st udents receive degrees, certificates or licensure. Guided or one-on-one learning is used extensively in medical/dental a nd the health professions schools. To ensure that proficiently trained graduates ente r the profession, teachers must continue to study and improve their own instruc tional practices (Cunningham, Stev ens, Blatt, & Fuller, 1999). 12

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The clinical learning environment is chal lenging for teachers and students (Gordon, et al., 2000). In this setting, the student is a trainee clinician responsi ble for patient care, while the clinic is both a patient care facility and a learning environment (Ferenchick, Simpson, Blackman, DaRosa, & Dunningham, 1997). In the clinic, stude nts are expected to demonstrate diverse competencies simultaneously such as a broad knowledge base, professionalism, empathy, and ethical behavior. Recent research suggests that it is important to introduce students early to the clinical environment, because of the demonstrated value of contextual le arning. The clinic is the central location where basic scie nce knowledge is typically integr ated with patient care, and teaching occurs with an experienced clinician (Mullins, et. al, 2003). Clinical supervision provides "monitoring, guidance, and feedback on matters of personal, professional, and educational development in the context of patient care (Kilminister, Jolly, & van der Vleuten, 2002, p. 387). Researchers have suggested that th e studentclinical teache r relationship is an educational alliance that mirrors the therapeu tic alliance between th e patient and physician (Tiberius, Sinai, & Flak, 2002). Effective supervision of learners requires that students and instructor s together engage in problem-solving activities and while instructors provide requisite feedba ck, reassurance, and theory-practice linking (Hirons & Velleman, 1993). There is some evidence that effective clinical teaching in medicine has a positive imp act on patient outcomes. For example, Albanese (2000) found that patient outcomes improved when direct supervision of the student clinician was combined with focused feedback and reflection. In a dental education cont ext, clinical teaching has b een less extensively examined (Bertolami, 2001). Effective clin ical instruction in dentistry requires that educators provide clinical care while they demonstr ate technical competence to thei r students (Fugill, 2005). Their 13

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abilities to motivate students, explain difficult c oncepts, display interest in the subject, show compassion and caring, and to be proactive were also rated as very important by students in a study reported by Chambers, Gei ssberger, and Lekinus (2004) A range of educational modalities supports clinical teach ing and patient care such as large group lectures, small group tutorials, problem-based and case-based activities, interactive interactio ns, role-play, simulation, and computer-assisted modalities. These modalit ies support clinical teaching by using teaching resources efficiently, by objectif ying clinical sessi ons, by facilitating the development of professional attributes, sharing common clinical concerns, and affordi ng individual student interaction (Chambers, et al., 2004). One of the criteria that differentiates clinical from didactic learning is that clinical lear ning opportunities are typically unique. Often they cannot be repeated, anticipated, or planned (Werb & Matear, 2004). In this se tting the mastery of clinical teaching is demonstrated. Instructors must recognize the moment, utilize it, and engage students so that learning occurs. Teaching in the clinical lear ning environment is characteri zed by the separation of the teacher in time and distance from other collea gues making it difficult to collaborate with other teaching professionals. Documentation and analysis are lacking, so the pe dagogical literature is bare (Shulman, 1999). To advance the scholarship of teaching and to transmit clinical teachers knowledge, observation and studies are needed. Some researchers question the need to st udy clinical teaching. However, when one considers that it is the core of professional development in me dicine and dentistry (Gordon, et al,, 2000) and that the quality of patient care is dependent on clinical teaching (Fugill, 2005), the need for documenting its effectiveness becomes clear. 14

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The educational process of the pre-doctoral dental curriculum is designed to help students learn how to collect pa tient information data, interpret a nd synthesize findings, evaluate the effects of actions taken, perform pr ocedures skillfully, and relate to patients in an ethical and caring manner (Bertolami, 2001). Taking novice dental practitioners and transforming them into competent practitioners is one challenge in de ntal education (Henzi, Davis, Jasinevicious, & Hendricson, 2006). The aim of clinical education is to produce student s who are capable of practicing both the art and th e science of dentistry. Clinical teaching is a formidable task for faculty. Often faculty are required to teach individuals simultaneously who are at various levels of training. Patient cases that are presented are often unpredictable and avert an opportunity for faculty to prepare for teaching. Attending faculty are responsible for teaching and ensuri ng high quality patient care. Despite these challenges, many attending faculty are excellent c linical teachers who exemplify the best values and behaviors of practicing dentis ts, provide effective clinical s upervision, and are enthusiastic teachers (Henzi, et al., 2006). The clinical environment has unique advantages. For example, it is focused on authentic problems that may occur in the context of profe ssional practice (Li, 1997). Students are typically motivated by specific demands, active participati on, and the professionalism that teachers model (Levinson, 1999). Finally, this is the only setting in which taking a medical/dental history, conducting an examination, using clinical reasoning, decision-making, empathy, and professionalism can be taught and learned as an integrated whole. Despite these strengths, clinical teaching is often critici zed for its variability, lack of intellectual components, electoral challenge, and haphazard nature. In other words, while clinical teachi ng is an educationally sound approach, it is frequently undermined by problems of implementation (Albanese, 2000). 15

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Hutchins and Shulman (1999) pointed out that faculty in most fields do not have the training for, or the habit of, framing questions about their teaching and students learning. Concurring with their opinion, Behar-Horenstein Dolan, Courts, and Mitchell (2000) suggested that dental educators are usually considered subject matter experts. However, they usually provide didactic instruction whereby the students remain in passive roles. Purpose of Study The primary purpose of this study was to de scribe the instructional practices among clinical dental educators from the students and patients perspective. The secondary purpose of this study was to describe the interactions between the teacher, stude nt, and patient during clinical teaching. Research Questions 1) What are the characteristics of the oral health care educatorspatientsstudents interactions in the clinical learning environment? 2) How are oral health care educatorspatients students interactions perceived by students? 3) How are oral health care educatorspatients students interactions perceived by patients? 4) How do the students and patien ts perspectives of the oral h ealth educators-students-patients interaction compare? 5) How does the clinical specialty influence the t ype of interaction between the oral health care educators, patients, and students? 6) What do students consider to be the elements of an ideal clin ical teaching/learning experience? Definition of Terms Attending faculty are dentists who a hold state license and board credentials and work as educators at a partic ular dental school. Clinical teaching is a process of teaching and learning in a health care setting that usually directly involves diagnosis and treatment of patients. 16

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Communication is any act by which one person gives to or receives from person information about that persons needs, desires, perceptions knowledge, or affective states. Communication may be intentional or uninten tional, involve conventional or unconventional signals, and may occur through spoken or other modes. Dental student is an individual who is currently enrolled in a professional program of study that upon matriculation will ultimately result in receipt of the degree of doctor of medical dentistry (DMD). Non-verbal communication is information transmitted between sender and receiver via eye contact, gesture, body language, and distance. Constructivism is a philosophy of learning founded on th e premise that, by reflecting on our experiences, we create our own understanding an d make meaning of the world we live in. Oral health refers to the oral cavity, the mouth, a nd the collective known as the craniofacial complex that is an integral indicator and component of overall wellbeing. Patient is the person receiving oral health care from a specified provider in the clinical setting Significance of Study The findings from this study will (a) contribute to an understanding of what constitutes effective clinical teaching, and (b) render s uggestions for improving clinical teaching and professional education. This study provides information to the lite rature that is lacking in qualitative studies of clinical teaching within doc toral level experiential e ducation at a school of dentistry, by offering a scholarly study that is public in th at its vision, design, enactment, outcomes, and analysis open to critical review by the health and medical education community, as well as the larger education community. 17

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Limitations This study was designed to investigate oral health care e ducatorspatientsstudents interactions and clinical teaching in a compre hensive oral health care teaching facility, emphasizing the students and patien ts perspectives. The applicability of the results is limited to similar learning environment such as teaching ins titutions in the United States. In addition, the results of this study may differ from previous research findings involvi ng oral health care educatorstudentpatient interactions, as this study emphasizes stude nts perspectives. The participants in this study were limited by the patients, specific clinics, student assignments, and faculty coverage available during observations. Th e four clinics represented in this study may not be representati ve of all the clinics within th e dental school. Furthermore, the results of this study may have been influen ced by the setting, as well by the participants. 18

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CHAPTER 2 LITERATURE REVIEW Theory of Teacher Effectiveness Theoretical perspectives of teacher effectiv eness vary. Teacher effectiveness has been purported to be a teacher trait perspective, a teacher behavior perspective, a process-product perspective, and a process-psyc hological mediators-sociologica l mediators-process research perspective (Behar-Horenstein a nd Morgan, 1995). However, most educators agree that students grow and learn the most from effective teachers. Teacher effectiveness is a major issue in current movements of education reform and improvement. It is generally agreed that the teacher is the key element for the success of education (Orn stein & Lasley, 2004). Traditional studies on teacher effectiveness focus largely on the perfor mance of individual teachers in classrooms. In recent decades, the topic of teacher effectivenes s has continued to attr act the attention of researchers, educators, and prof essional organizations. Ornstein and Lasley (2004) point out that the literature on teaching effectiveness, or teac her effectiveness, is a morass of ill-defined and changing concepts. To different people, the defi nition of teacher effectiveness could be very different. Some researchers focus on teacher persona lities, traits, behavior s, attitudes, values, abilities, competencies, and many other personal characteristics. Other researchers are more concerned with the teaching process (including factors such as teaching styles, teacher-student interactions, and classroom climate) or the teaching outcomes (including factors such as students academic achievements, personal deve lopment, and learning experiences). Despite thousands of studies conducted in the last 50 year s, it is difficult to arri ve at generally accepted conclusions. Few generalizations concerning teacher effectiven ess have been established (Borich, 1996). Some scholars have criticized the underlying philos ophy, methodologies, and findings in teacher effectiveness studies. They suggested that the ex isting perspectives of teacher 19

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effectiveness, such as the teacher trait perspec tive, the teacher behavior perspective, and the process-product of teaching perspective cannot be successful in explaining or analyzing the complexity of teacher effectiveness (Fullan, 1999). Borich (1996) suggested that effective teachers achieve the goals they set for themselves or the goals set for them by others such as school principles, educat ion administrators and parents. According to Ornstein and Lasley (2004), effective teacher s must have a body of knowledge essential for teaching and know how to apply it. By integrating these two concepts, effective teachers may be assumed to be those who possess the relevant competence (including necessary professional knowledge, skills, and attitudes) and use the competence appropriately to achieve their set goals. From this line of thinking, the understanding of teacher effectiven ess must be based on the linkage between teacher competence, teacher performance, and set goals or expected educational outcomes. Medleys (1996) structure of teacher effectiveness is a comprehensive framework which integrates the te acher trait perspective, the teach er behavior perspective, and the process-product of teaching perspective to explain the re lationships between teacher competence, teacher performance, student learni ng experience, and educational outcomes. He explained that teacher effectiveness refers to the teacher results or to the amount of progress the students make towards specified goals of edu cation. One implication of this definition is that teacher effectiveness must be defined and can only be assessed in terms of behaviors of students, not behaviors of teachers. For this reason, and beca use the amount that students learn is strongly affected by factors not u nder teachers control, te acher effectiveness should be regarded not as a stable characteristic of the teacher as an indi vidual but as a product of the interaction between certain teacher characteristics and other factors th at vary according to the situation in which the 20

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teacher works. According to Medley (1996) the st ructure of teacher effectiveness should include components such as: teacher characteristics, co mpetence, performance, learning experience, learning outcomes, training, teachi ng context, and student charac teristics. Cheng (1999) further developed Medleys structure by the inclusion of two more com ponents, teacher evaluation and professional development. Teacher effectiveness is a complex issue. Evaluation of teaching effectiveness is problematic. The ability of bright people to learn what they need to know despite any curriculum cannot be discounted and high-aptitude students tend to succeed regardless of the instructional strategy used (Woodward, 1996). One of the da unting aspects of evaluating professional education is that academics in the medical a nd dental field, who have been trained in the scientific methods, which are mandatory for evalua ting treatment modalities, try to utilize similar methods for evaluating educational outcomes (Van der Vleuten, Dolmans & Scherpbier, 2000). Such attempts, while efficient because of th e numerical data they supply, are ultimately unreliable. The rigid quantitativ e scientific method of controlled experimentation cannot be considered valid in an environment where the va riables of the sample are almost as great or greater than the sample itself, th e student sample in any one year of a dental or medical school being statistically minute (Lechner, 2005). Another difficulty is in delin eating a clear definition of outcomes. Wilkes and Bligh (1999) grouped several types of evaluation into student-oriented, program-oriented, institutionoriented, and stakeholder-oriented. The indicators cover a wide area, ranging from attendance at class, through patient satisfacti on, questionnaires, test results and peer evaluation. Several studies have attempted evaluation using examination (Login, Ransil, & Meyer, 1997, Bachman, Lua & Clay, 1998, Lindquist, Clancy, & Johnson, 1997) the number of student inquiries regarding the 21

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levels of knowledge required for examinations (Roberts, Clancy, & Roberts, 1997), follow-up surveys (Bachman, et al., 1998), and self-evaluation by the students (Lary, Lavigne, & Muma, 1997). The simplest measurement of outcome is by examination. Examination results can be shown numerically and analyzed st atistically. However, they cannot be relied on to give a whole evaluative picture (Lechner, 2005). Currently, th e most pragmatic approach in educational evaluation is to focus on students' perceptions of their experiences in a learning program. This approach has been used in several studies (Peters, 2000, Schuhbeck, 1999, Manogue, 1999, Wenzel & Gotfredsen, 1997). Enjoyment and success engender a winning cycle in the learning environment. If teaching resource s can involve students and lead them to be successful in their endeavors, they are more likely enjoy their tasks and want to become even more involved. (Manogue, 1999) In this study, students perceptions will be e xplored to gain an understanding of rather than measuring teacher effectiveness. Oral Health Care EducatorStudent Relationship Communication between instructor s and students is the most important consideration in teaching (Marsh & Dunkin, 1997). Although knowle dge is transferred by various means in dental education, teacherstudent interacti ons remains foremost (Losh, Mauksch, & Arnold, 2005). A successful classroom or clinic session not only transmits the desired information, but also motivates students to learn more. In fact the most important outcome of the experience may not be acquisition of clinical or scientific data, but behavioral and attitudinal changes that contribute to future development (Branch, Ker n, Haidet, Weissmann, Gracey, Micthell, & Inui, 2001). Communication includes much mo re than verbal exchange; it encompasses the entire 22

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teachinglearning environment. Instructors verbal skills, stage presence, audio-visual aids, and attitudes toward the students and the topic al so influence factors in communication. Interest in the topic, the curriculum, the students and th eir success, and the desire to do the best job possible go a long way toward improving comm unication (Lizzio, Wilson, & Simons, 2002). An adage in education states that the best classroom is one in whic h both the students and the instructor are learning. Teachers try to co mmunicate information to students that will expand their knowledge base and promote acquisition of skills as they progress towards degree completion but teachers in higher education also have career goals: prom otion, tenure, expanded opportunities, and recognition (Fraser, 1998). Open, two-way communication between students and teachers is one of the most effective ways to determine how well these aims are being met. Dental education, like all postsecondary educ ation, has the advantag e of dealing with adult students. Often instructors teaching styles are mismatched with adults learning needs. However an effective communicator will seek and promote dialogue with the students so that both profit from the experience (Beasley, 1997). Accepting the principle that effective communication is bilateral, in structors strive to create a democratic, humane atmosphere in both classrooms and clinics (Branch, et al., 2001). An environment that encourages communicatio n between instructors and students, andeven more importantlyamong the students themselves, especially outside the learning situation, will provide the most successful learni ng experience (Emerson & Groth, 1996). The Role of the Teacher Many medical and dental educators think that the only role of the teacher is to be a reservoir of knowledge and skills that occasionally, and unpredictably, spills over its dam, letting information flow randomly down a canyon of learning (Benor & Levy, 1997). However, as McKeachie (2002) emphasized, expe rtise in a particular disciplin e is not sufficient to ensure 23

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good teaching. Clinical teachers assume multiple roles in th eir interactions with their students. In a review of 20 of the most significant studies of perceptions of excellent clinical teaching Stockhausen (1998) found that the be haviors and characteristics of ex cellent clinical teachers fall into four roles: Physician/Provi der, Teacher, Supervisor, and Person. The Physician/Provider is consider ed to be the expert and th e source of all knowledge. There is considerable discrepancy between the Physician/Providers le vel of experience and wisdom and that of the students. This discre pancy is the reason the me dical/dental teacher and students are together. The physic ian is also responsible to sc hool administrators, specialty boards, and hospital credentials committees for evaluating and certifying the competency of students. The physician upholds professional st andards and is a socializing agent of the professional discipline. As Teacher, the medical/dental edu cator is acutely aware of th e needs and aspirations of students, but does not automatically assume it will be possible to provide them everything they need. The Teacher can listen, question, paraphrase, encourage, or doubt students, but cannot always provide for them. As a Supervisor, the medical/dental educator demonstrates pro cedures, provides practice, observes and assesses performance, and provides feedback. Finally, as a Person, the educator develops an atmosphere of su fficient trust so that the students are comfortable sharing ideas, feelings and thoughts. The physic ian/dentist-educator does not necessarily have to like the students, but does need to accept their learning needs and imperfections. The Person may pr ovide significant personal help and support outside the formal teaching setting. 24

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The Role of the Learner Research on student learni ng in higher education has shown that students adopt qualitatively different approaches to thei r studies, depending upon their prior learning experiences and the particular c ontext in which they find themselv es (Prosser & Trigwell, 1999). Because of the varied experiences students have had, they are likely to have qualitatively different learning outcomes. These experiences can be characterized as surface and deep learning. Surface approaches, in which students focus on reproducing the content and processes they are studying, are associated with high workload and assessment demands that are expected to be met by reproductive learning. Deep a pproaches are associated with good teaching experiences whereby goals and standards are clear, and students have some freedom and choice in how and what they learn. Deep approaches to study are in turn associated with an understanding subject matter, whic h can be broadly described as relational, while in surface approaches, the understanding can be described as multi-structural (Biggs, 1999). That is, students can understand the outcomes of their courses and program s and what their courses and programs are about in terms of a c oherent (relational) or of an unr elated (multi-structural) set of ideas and procedures. The way institutions st ructure the teaching and learning contexts of students has a substantial impact on what and how students learn (Gendrop & Eisenhauer, 1996). Students perceptions of teaching and learning contexts are a functi on of both their prior experiences of teaching and learning and th e present context (Anderson & Speck, 1998; Brown & Gillis, 1999). Through prior learning experiences students develop perceptions that guide the ways that they approach future studies. To improve student s learning outcomes, university teachers need to be concerned with the context, students, and their own perceptions of that context (Fenderson & Damjanov, 1997). 25

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Conditions for Effective Learning Since medical/dental students are ad ult learners, professional education should follow the principles of adult learning (Irby, 1983; Klineber g, et al., 2002). Unfortunately, this does not always happen. Medical/dental learners are certainly adults chronologically, and they are pursuing a field of study that re quires discipline and maturity. Medical/dental education is, or should be, an adult learning process (Lyon, 2004). There are several prin ciples that enhance adult learning (Spencer & Jordan, 1999). Malcolm Knowles was the first to theorize a bout how adults learn. As a pioneer in the field of adult learning, he described adult learning as a proce ss of self-directed inquiry. Six characteristics of adult learners were identified by Knowles (1970), they are: autonomous and self-directed, accumulated a foundation of experiences and knowledge, goal oriented, relevancy oriented, practical and need to be respected. He advocated creating a climate of mutual trust and clarification of mutual expectations with the learne r. In other words, a cooperative learning climate is fostered. The reasons most adults enter any learning experience is to create change. This could encompass a change in (a) their skills, (b) behavior, (c) knowledge level, or (d) even their attitudes about things (Adult Education Centre, 2005). Compared to school-age children, the major differences in adult lear ners are in the degree of motiv ation, the amount of previous experience, the level of engagement in the lear ning process, and how the learning is applied. Each adult brings to the learning experience preconceived thoughts and feelings that will be influenced by each of these factor s. Faculty are well advised to asse ss the level of these traits and the readiness to learn should be included each time a teaching experience is being planned. Adults learn best when they are convinced of the need for knowing the information. 26

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Often a life experience or situ ation stimulates the motiva tion to learn (O'Brien, 2004). Meaningful learning can be in trinsically motivating. The key to using adults' "natural" motivation to learn is tapping in to their most teachable moments (Zemke & Zemke, 1995). Adults have greater depth, breadth, and va riation in the quality of previous life experiences than younger people (O 'Brien, 2004). Past educational or work experiences may color or bias the students perceived ideas about how education will occur. If successfully guided by the health care provider, former experiences can assist the adult to connect the current learning experience to something learned in the pa st. This may also facilitate making the learning experience more meaningful. However, past experi ences may actually make th e task harder if the teacher does not recognize these biases. Adults learn and process information in di fferent ways. There ar e different ways to classify learning styles. Learning styles can be classified into general categories: perceptual modality, information processing, and personality patterns. The categories represent ways to focus on the learner. Perceptual modalities define biologically ba sed reactions to the physical environment and represent the way people most efficiently adopt data. It is advantageous for learners and educators to know perception style so that information can be given in the format that the learner can process most efficiently. E ducators should pay attention to modalities to ensure programs incorporate all physiologic levels (Dunn & DeBello, 1999). Information processing distinguishes between the way people sense, think, solve problems, and remember information. Each learne r has a preferred, consistent, distinct way of perceiving, organizing, and retaining informa tion. Personality patterns focus on attention, 27

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emotion, and values. Studying these differences allo ws educators and researchers to predict ways learners will react and feel about di fferent situations (Dunn & DeBello, 1999). Most adult learners develop a preference for learning that is based on childhood learning patterns (Edmunds, Lowe, Murray, & Seymour, 1999). Several approaches to learning styles have been proposed, one based on the senses that are involved in processing information. An assessment of the students l earning style is a fundamental step prior to beginning any educational activity. Determining the students learning style will help identify the preferred conditions under which instruction is likely to be most effective (Richardson, 2005). The most frequently used method of delineating learning styles is identifying visual, auditory, and kinesthetic learners. Visual learners prefer seeing what they ar e learning. Pictures and images help them understand ideas and information better than e xplanations (Jezierski, 2003). A phrase you may hear these learners use is "The way I see it is." The teacher needs to create a mental image for the visual learner as this will assist in processing the information. For a visual learner to master a skill written instructions must be provided. Visual learners read and follow the directions as they work and appreciate when diagrams are included. Auditory learners prefer to hear the message or instruction given. These adults prefer to have someone talk them through a process, rather than reading about it first. A phrase they may use is "I hear what you are saying." Some of these learners may even talk themselves through a task, and should be given the freedom to do so wh en possible. Adults with this learning style remember verbal instructions well and prefer that someone else r ead the directions to them while they engage in the physical work or task. 28

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Kinesthetic learners want to sense the position and movement of the skill or task. These learners generally do not like lectur e or discussion classes; they prefer to "do something." These adults do well learning a physical skill when ma terials are available for hands-on practice. The adult learner has many res ponsibilities that must be bala nced against the demands of learning. Because of these responsibilities, a dults may have barrier s that mitigate their participation. Melton Calder and McCollum (2005) discuss the barriers that adult learners face such as time, confidence, convenience, and motivation. They propose alternative types of education delivery such as distance and open learning to reduce the barrier s. If the learner does not see the need for the behavioral change or acquiring knowledge, then a barrier exits. Likewise, if the learner cannot apply learning to his/her pa st experiential or educ ational situations, the teacher will have barriers to overcome. A successful strategy includes s howing the adult learner the relationship between the knowledg e/skill and the expected outcome. Dental students are considered professional students and typically are 22 years of age or more. Leaving aside the question of whether chr onological age is an appropriate definition of adulthood (Fraser, 1995), for the purpose of this study, the researcher makes the assumption that dental students are adults From there, it follows that we should ask how they learn and how they should be taught. Does andragogy describe th e way dental students learn? Doubts have been expressed about the validity of the assumptions on which Knowles model is based. Stephen Brookfield (1995 p.75) is among such critics: We are far from a universal understanding of adult learningTheory development is weak and is hindered by the persis tence of myths that are etched deeply into adult educators mindsIndeed, a strong case can be made that as we examine learning across the lifespan the 29

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variables of culture, ethn icity, personality and political ethos assume far greater significance in explaining how learning occurs and is experienced, than does the va riable of chronological age." Typically, adults want to apply what they learn soon after they have learned it. This rule is broken somewhat less in clinical teaching than in other areas of medical/dental education. Even so, clinical teachers should feel compelled to ju stify any clinical teachi ng that cannot be shown to have relevance or be applicable to a patient problem or clinical situation. Adults are interested in lear ning concepts and principles; they like to solve problems rather than just learn facts. Medical/denta l education suffers terri bly under the weight of unrelated, and often relatively us eless, facts. As medical/den tal knowledge expands, so does the density of the medical/dental education process, often to the detriment of the problem-solving and clinical reasoning skills of future professionals By the emphasizing use of facts, rather than their mere retention, clinical e ducators will not contribute to wh at is already recognized as a major problem by national authorities. Behar-H orenstein, Mitchell, and Dolan (2005) used a case study to illustrate how an evaluation strategy was used to assess classroom instructional practices following a multi-year institutional curriculum revision process in the first and second year basic science courses. Observations reveal ed that seventeen of the twenty classes observed were teacher-centered, passive, and lacked obser vable efforts to help students understand the relationship of the lecture cont ent to the oral health problem s. The findings of their study illustrated the importance of using formative evaluation as a mechanism to assess change efforts. In addition this study showed how evidence-based study can support initiatives directed toward assessing active student learning and problem solving. Behar-Ho renstein, et al., (2005) also reported that raising faculty awareness about the importance of acquiring evidence-based educational skills, aligning inst ruction with course goals and objectives, formatively assessing 30

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teaching, and providing practice-ba sed learning experiences are essential to ensuring that demonstration of active learning and critical thinking are demonstrated in the curriculum. Adults like to participate actively in the learning process by helping to set appropriate learning objectives, yet can student s realistically know what they need to know? The teacher possesses considerable k nowledge and experience that learners do not. Adults also like to know how well they are doing, thus, providing timely formative feedback helps them evaluate their own progress. Medical and dental edu cation offers numerous opportunities for making decisions about comp etence, promotion, or advancement using summative evaluation (Bardes, 1995). Clinical teachers play a critic al role by providing feedback and critiques, particul arly negative ones, which can he lp shape students professional behaviors, decision-making, and skill performance. Personal, well-intenti oned feedback is the critical element for cementing a teacherstudent relationship and bringing closure to the learning process (Gillespie, 2002). Although it is each individuals responsibility to learn, a teacher can help or hinder a students attempt to learn; by f acilitating learning and helping the students, a teacher can exert a positive influence (Gerzina, 2003). Good teachers of adults are people-centered, more interested in people than things, more interested in indivi duality than conformity, and more interested in finding solutions than following rules (Hekel man, 1996). The teacher must be understanding, flexible, patient, humorous, practical creative, and prepared (Ziv, 1998). Students are individuals, with individual experiences and individual abilities. Thus, knowing the strengths and weaknesses, rather than the age of the student may be more important in teaching. 31

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The Interaction Between Clinical Teacher and Student The physicianpatient relationship has been characterized as a continuum with two complementary control scales along which physicians and patients move at equal rates and in the same directions. The conceptual model for this is shown in Figure 2.1. As the physician moves from left to right and uses interviewing and communication behaviors that are increasingly less assertive or controlling, the pati ent moves from left to right, with the opposite results. An example of a situation to the far right of the scales would be a traditional psychoanalytic relationship in which th e patient takes almost total responsibility for the outcome of the interacti on and receives little or no feedback or comment from the psychiatrist (Pasquale & Pugnaire, 2002). The interactions between teacher and student can be characterized in a similar manner. A high degree of control and activity on the part of a teacher calls for a relatively passive role for the learner, and vice versa. Communication Skills The clinical teacher draws upon a broad rang e of communication skills and behaviors and chooses the specific technique th at is appropriate to the part icular situatio n (Benor & Levy, 1997). The necessary repertoire of communicati on skills ranges from a group that might be labeled attentive silence whereby the teach er is passive, to a group labeled cooperative negotiation when teacher and learner take a fair ly equal stance, to a group labeled persuasive confrontation when the teacher takes an activ e and controlling stance in the relationship. Attentive silence is a group of skills that co mmunicates that the teacher is paying attention and gives the learner time to think. One of th ese skills is observation, whereby the teacher gathers behavioral and nonverbal data about th e student. The clinical teacher may also use purposeful eye contact to engage learners who require special attention and tracking to indicate 32

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understanding and general approval (Mana gue, Brown, & Foster, 2001). Open-ended encouragement and advocacy is used to provi de a supportive learning environment. Although it is not a completely anxiety-free, learning e nvironment, surface paraphrasing, and exploration helps the clinical teacher gain additional gene ral information from the learner. The selfdisclosure approach is used to strengthen the teachers image and credibility by revealing personal experiences and war stories (difficu lt cases and mistakes) and active listening, when the clinical teacher probes th e students thinking for purposes of clarification, expansion, justification, and correlati on about patients presenting pr oblems and potential treatment planning. Intense paraphrasing allo ws the teacher to more aggre ssively question the learner for specific information or for specific responses. Open-ended questioning is used to expand the discussion and to probe the st udent about treatment options. Giving positive and negative feedback allows the teacher to give negative in formation in a way that the learner can improve future performance, whereas summarizing and inte rpreting enables the clinical teacher to take control of a discussion and add appropriate em phasis, clarity, and emotional punctuation. The clinical teacher transmits expert knowledge di rectly to the learner by information giving and prescribing (Mark, Saayler, & Geddes, 1997). Cr itiquing, correcting, and closed questioning is a technique that provides the student with summative evaluations and examines the students knowledge in a focused and convergent style. Pe rsuasion, challenge, and confrontation allows the teacher, in the most activ e and assertive way possible, to challenge old knowledge and attitudes in an effort to persuade the stude nt to adopt new knowledge and attitudes (Cameron, 1996; Elnicki, et al., 2003; Enge l, 1996; Irby, 1987; James, 1998). Interpersonal skills involve such care-related areas as commun ication, provision of a safe and comfortable environment, privacy and confiden tiality, respect, and courtesy, all of which are 33

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vital to the effectiv e performance of skilled provider s (DaRosa, Dunningham, Stearns & Fernchick, 1997). Effective role modeling is also essential to te aching interpersonal skills (Elnicki, Kolarik & Bardella, 2003). Whether working with a model or a patient, demonstrating a skill, or coaching a student who is developing a skill, the teacher mu st incorporate effective interpersonal skills. For example, the teacher must communicate with the anatomic model while performing a procedure. The teacher must be careful to drape the model a nd be aware of the need for privacy and respect as if the model were a patient. When assessing the students care of the patient, the teacher must give as much attention to interpersonal skills as to psychomotor skills. Post-clinical conferences should bring up issues and practices around communication and inte rpersonal skills as well as those pertaining to the more technical aspects of care (Schaefer & Zygmont, 2003). Effective verbal communication is a key factor in interpersonal skills, whether in interactions with patients, families and commun ities, administrators, supervisors, and other healthcare workers. Interpers onal communication is a person-to-person, verbal or nonverbal exchange of opinions, feelings, and information (Spiegel, 1995). Effective communication is a two-way process. To be eff ective, counseling, for example, must be a two-way communication process. Good communication skil ls are as important as good clin ical skills in providing high quality healthcare (Emerson & Groth, 1996). Communication skills are fundamental to medical and dental practice (Epstein & Hundart, 2002). These skills are critical for information ga thering, diagnosis, treatment, patient education, and health team interactions. Patients benef its resulting from effective communications with health care providers include increased satisfa ction, greater symptom re solution, lower referral rates, improved functional status, and enhanced h ealth outcomes. Health Ca re Providers benefits 34

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from effective communications include increased satisfaction, efficacy, and reduced malpractice claims (Hickson, Federspiel, Pi chert, Miller, Gauld-Jaeger, & Bost, 2002). Recognizing the importance of communication skills in medical and dental encounters, the Association of American Medical Colleges and the American De ntal Education Association have called for medical and dental educators to carefully define, teach, and ev aluate communication skills for physicians and dentists in training (Stewart, Br own, Boon, Galajda, Mered ith, & Sangster, 1999). Patients expectations regarding health communications have also shifted as more patients take active roles in information gathering and d ecision-making. Many medical and dental schools have established programs to respond to these new expectations (Little, Everitt, & Williamson, 2001). Students develop communication skills by observing others and then practice these skills in settings where they can receive feedback. Co mmunication skills are usually introduced in the preclinical years, but these skills have been le ss frequently reinforced and evaluated during the clinical years when students ar e actively practicing communicati on in clinical settings. Although fast-paced clinical teaching environments pr esent challenges for systematic teaching of communication skills, attention to communication duri ng clinical encounter s can bring these skills to life and allow student s and faculty to see their relevance (Haq, Steele, Marchand, Seibert, & Brody, 2004). Patients are more likely to seek timely care, cooperate with necessary procedures, follow through on recommendations, and return for follow-up care when they have trust and confidence in their providers. Developing a relationship of trust and confidence requires the ability to communicate well. Effective communication skills are therefore powerful and essential tools for all providers. Verbal communication is more than the words themselvesit also involves the 35

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tone and volume of words. Tone can communi cate compassion, hostility, anger, or indifference (Irby, 1978). Nonverbal communication can be as powerful as, or even more powerful than, verbal communication. Therefore, providers must be especially alert to the nonverbal messages they convey. Besides the position and stance of the body, nonverbal messages can be communicated through hand shaking, laughing, gently patting, handholding, eye contact (in some cultures), and facial expressions (e.g., frowning, furrowing the brow, and smiling) (Ferenchick, et al., 1997). Negative verbal or nonverbal communication ca n be a barrier to healthcare. Not only should providers be careful about the message s they are communicating through verbal and nonverbal means, but they must also pay clos e attention to the verb al cues and nonverbal behavior of other people. The learning environment is also an influential factor in effective interpersonal communication. The provider should try to create an environment that is culturally appropriate, emotionally safe, and comfortable. Examples of factors that shoul d be considered in the cultural environment are gender preference in providing healthcare, the language and culture of the provider (if different from that of the patient), traditional food customs, beliefs about blood transfusions, and values and ideals related to modesty (Ellis & Llewellyn, 1997). Lack of regard and respect for cultural values can become an obs tacle to receiving care. The negative attitudes of providers can frighten patient s away. Therefore, providers should respect patients culture, values, and beliefs, even when they ar e unfamiliar with them (Gillespie, 2002). Just as interpersonal skills are part of every patient-provider intera ction, these skills are woven throughout the learning reso urce process. Case studies can be used to acquaint students with the sociocultural environment of the patient and teach them how to communicate so that 36

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they can effectively gather data and manage complications (James, 1998). During training, attention must be given to development of the st udents attitudes and interpersonal skills, as well their psychomotor and clinical decision making sk ills (Knight, et al., 1997). Patients require attention to emotional and psychos ocial needs as well as to physical needs. Effective teachers are constantly attentive to th e students need to develop in terpersonal skills throughout the learning experience (Kernan, et al., 2000). Clinical Education Clinical education is a problem-centered approach in the context of professional practice, an experience-based learning model, and a comb ination of individual and team learning (Bligh, Lloyd-Jones, & Smith, 2000). The focus of clinical education is on the pa tient. Patient problems provide teaching opportunities for the faculty and learning opportuniti es for the student (James, et al., 2001). The richness of that learning experience depends in large measure upon the faculty members instructional skills and the patient mix available. Since clinical instruction takes place in the context of professional practice, students questions about the relevance of what is to be learned are minimal and motivation is high. Students actively strive to emulate facu lty and resident role models (Colliver, 2000). In clinical education, the process of learning is principa lly by doing. This form of experiential learning differs from most classroom settings, where the symbolic medium is used to transmit information. In experiential learning, information is generated through the sequence of steps (OMalley 1999) whereby the student: (a) acts in response to a particular situation and experiences the consequences, (b) infers the e ffects of action in the particular case, (c) generalizes understanding over a wider range of circumstances, and (d) acts in a new circumstance anticipating the consequences. 37

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Experiential learning is time consuming and requires repeated actions in enough circumstances to allow for the development of a generalization from experience. When the consequence of action is separated in time and space, the learning process is not effective (Karuhije, 1997) A typical observation of thos e who have learned something through this process is that they cannot verbalize it, but they can do it. The weakest link in experiential learning is in generalizing from the particular experiences to a general principle applicable in other circumstances. Thus, post-experience discussion is critical to the le arning process so that students can infer general princi ples from the experience (Li, 1997). The strengths of this learning process include intrinsic motivation. Recall is often str onger from experiential learning than during learning through information processing. Clinical education relies heavily on experiential learning, but al so uses information proce ssing for knowledge acquisition. Bligh, Lloyd-Jones, and Smith (2000) proposed an instructional model for clinical settings that postulates a developmental sequenc e for educational activities. Learning begins with the attending physician providi ng an orientation to the service and to the work at hand. This is followed by the acquisition and application of knowledge and skills in the context of practice and finally, the termination of the instructional/work sequence. This model is tied directly to the tasks of the work group and relies heavily upon the instructional leadership role of the faculty. The term clinical practice appears to suggest that learning occurs th rough student practice. But how is this experience converted into learni ng? There seems to be a belief, inherent in dental school curricula, that student learning in the clinic occurs through practice. Until recently, most dental schools used a quot a or requirement system, where by students were required to achieve at least a minimum number of different operative procedures. Though the quota system 38

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has been changed with the introduction of compet ence-based curricula, the changes so far appear to relate principally to student assessment rather than to teaching (Chambers, 1998; Walsh, 2000). The assumption remains that students can learn operative procedures through multiple repetitions. The processes of learning in the classroom and learning to carry out clinical activity do not appear to be the same. Much has been written a bout experiential learning (i.e., the idea that we learn by doing things), and ther e are many definitions of what is meant by the process (Kolb, 1984; Clark, et al., 2001). This idea has beco me a popular educational ideology, so much so, that there now appears to be a divergence of opinion and lack of clarity about the process. The development of experiential learning as a co ncept is attributed pa rticularly to Kolb. The Kolb learning cycle describe s experiential learni ng as involving four stages which follow each other in a cycle (Gibbs, 1988), viz, concrete experience, reflective observation, abstract conceptualization, and active expe rimentation. Some researchers believe that Kolbs learning cycle describes the way that ad ults learn (Best & Rose, 1996; Fr aser, 1995). This may or may not be completely true, but ideas expressed in th e Kolb learning cycle have directed curriculum development for adults and various aspects of students clinical prac tice (Stockhausen, 1998). From Kolbs observation learni ng is cyclicalthat repetitions do allow the student to make changes based on past experiencebut as di scussed above, the basic tenet of Kolbs work was that it is not sufficient simply to have an experience in order to le arn (Gibbs, 1988). Yet there have been few studies in dentistry that have examined how students learn in clinical practice. Individual and Team Learning Strength of clinical education is the combination of indivi dual and team learning. While students are responsible as indivi duals for their learning during a c linical clerkship, this learning 39

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occurs in the context of the work team (Barfi eld, 2000). Instructional time and effort are allocated in the context of t eamwork and team function. In a field study of instruction by attending physicians in an internal medicine department, Branch and Paranjape (2002) observed that learning by individual team members appeared tied to overall team development. As individual team members learn, they appear able to contribute and use the contributions of others to their teams, and as teams develop their abiliti es to work together. They also appear to promote additional learning among their individual members. Clinical education is a challenging experience for most students because it allows them to participate actively in the health care team, seek solutions to real pr oblems, and learn by doing, all while caring for patients. Findings Relevant to Studies on Clinical Education The review of the health care education literat ure that differentiates clinical and didactic teaching sharpens the definition of clinical t eaching for this study. Some researchers have identified basic components or dimensions of heal th care teaching that claim to be exclusive to clinical teaching but, in fact, are applicable to both didactic a nd clinical practices. Several studies in medical or health ca re education make clear distinc tions of clinical teaching in comparison to didactic teaching. These distinctions have been categorized as: (a) Purpose or goal of teaching, (b) Learning context, (c) Requirements and demands from th e learning setting (d) Role modeling and (e) Concept of service. Purpose or goal of clinical teaching Clinical teaching in dentistry is primarily centered on the provis ion of patient care. (Fugill, 2005) While providing patient care, the c linical teacher and student interact on a one-toone basis. In the clinical envir onment, students interact with pa tients to learn how to care for 40

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them in the most skillful manner possible. This is distinctively different from didactic teaching where cognitive learning prevails and experiences are based on course-specific objectives that are less frequently correlated to clinical experien ce (Karuhije, 1997). Learning context Clinical teaching in medicine occurs at the bedside, which refers to an acute care hospital setting, a client/patient in teraction in an examining room at an ambulatory setting, or an out-patient clinic with walk-in clients. Irby (199 4) states that clinical education occurs at the bedside. In dentistry, the operatory is the realm for clinical teaching. The teacher and student form a relationship that has traditionally been perceived as a key element in clinical teaching (Fugill, 2005). The clinical learning environment also includes the patient, who adds complexity to the learning process. For the student, clinical practice involves irreversible procedures, which must be completed without harm to the patient. The clinical teacher must ensure that patients treatment is acceptable and s/he has a duty to pr event harm to the patient while providing a learning experience for the st udent. (Henzi, et al., 2007) Didactic teaching most often occurs in a cla ssroom environment, away from the vicinity of patients (Perry, 1997). Didactic teaching may emphasize theoretical concepts, whereas clinical teaching utilizes psyc homotor skills involving patient care (Sharp & Spence, 1999). Requirements and demands from the learning setting The key distinctions between clinical teachi ng and didactic teaching are the requirements and demands that arise in the learning setti ng. According to James and Shipengrover (2001), these include the element of risk for safety and wellbeing of the patients with whom the students are interacting. There is limited control over outside factors that occur in the clinical setting, such as interactions with unan ticipated personnel, patient treatm ent procedures, or a change in 41

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the status of the patient. Thus, learning experi enced in a clinical environment may be unique and cannot be repeated (James & Osborne 1999). Diversity of facilities is a factor in the distinction of clinical teaching (Talwar & Weilin, 2005). Within the teaching time frame of the day, many rooms, units, or bedsides become the location for t eaching within the institu tion, unit, or facility. Thus, the clinical teacher must be able to function within various settings as learning opportunities arise and as the n eeds of the patient change. In contrast, didactic teachi ng utilizes lecturing primarily to transmit new knowledge and reinforce previous knowledge that is often infrequently correlated to clinical expe rience. Behar Horenstein, Mitchell and Dolan (2005) utilized a case study in first and second year dental basic science courses to assess clas sroom instructional practices. Observations revealed that most of classes observed were teacher-centered, passive, and lacked observable effort to help students understand the relationship of the lecture conten t to the oral health problems. The didactic teacher has full authority over a classroom environment. Learning experiences are planned for a full term or a semester (Karuhije, 1997), whereas in clinical teaching, experiences planned for a day can be ch anged by others and are dictated by case loads and patient conditions. In clinical teaching, the clinical instructor must address the patients concerns and identify the students goals (Spe ncer & Jordan, 1999). This emphasizes the dual role of the clinical instructor, a need to assess concomitantly the patients oral health needs and the students learning needs. The didactic teac hing encounter is focused solely on the students learning needs. Professional role modeling The clinical teachers job is complex and the teachers main responsibility is to provide opportunities for practical experien ce, discuss and review patients respond to questions, provide explanations and be supportive (P arsell & Bligh, 2001). The clinical teacher acts as a role model 42

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for the profession (Bergman & Gaitskill, 1990; Chapnick & Chapnick, 1999; Irby, 1978). Biddle (1996) demonstrated that both faculty and st udents ranked being a good role model of the profession as the highest-rated characteristic of the best instructor s and the lowest-rated characteristic for the worst clinical instructors. Clinical teaching takes place w ithin the context of the professional environment. Since teaching takes place at the bedside, or operatory, the clinical instructor is in his or her roles both as instructor and medical, dental or health care professional. During clinical teaching, students participate in a teaching/learning process while observing the clinical teacher as a role model for the profession. Sharp and Spence (1999) found that students ranked the professional role of their instructor higher than person or teacher role ch aracteristics. Irby (1978) also identified the modeling professiona l behaviors as one of the factor s that is unique to clinical teaching. The didactic teacher is primarily concerned with transmitting knowledge and is not necessarily acting in the professi onal role of his or her discipline while teaching. The didactic teacher does need professional knowledge of his or her field but is not actively engaged in such actions during classroom teaching. For clinical teachers to be role models, th ey must teach the psychosocial aspects of medicine and dentistry, demonstrate the im portance of building positive doctor-patient relationships, and have a comprehensive approach to patient care (Branc h, et al., 2001). This example set is the most powerful way for learners to acquire the values, attitudes, and behavior needed for professional and ethica l practice (Parsell & Bligh, 2001) Concept of service In the clinical learni ng environment, the clinical inst ructor provides education to the learner and also delivers a servi ce to patients (Stemmler, 1988). In other words, the instructor has an obligation for providing competent, thor ough, and up-to-date instru ction to students, and 43

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good patient care within the same encounter. Seve ral authors (Biddle, 1 996; Branch, et.al., 2001; DaRosa, et al., 1997; Elnicki, et al., 2003) have pointed out that medical clinical instructors are members of two service professions as they are clinicians whose goal it is to help patients as well as teachers whose goal it is to help students. In this service role, the clinical teacher not only assesses the needs of the patient, but must also assess the students needs. The didactic instructor provides educational learning expe riences only to the student w ith no other immediate service obligations to patients or others. Advantages/Disadvantages of Clinical Education Clinical education is a c onceptually sound learning mode l, which, unfortunately, is flawed by problems of implementation. Some of th e more glaring problems of clinical teaching include: (a) limited emphasis on problem-solving, (b) lack of clear exp ectations for student performance, and (c) inadequa te feedback to students. Problem solving opportunities One of the persistent complaints about cl inical education is the overwhelming work demands placed upon students, leaving them little time for thinking and reflecting, but primarily memorizing facts. The clinical years perpetuate non-thinking; b ecause an inordinate amount of time is spent in mechanical doing. Operatingroom work, repetitive wards, rounds, and nights and weekends lead to fatigue, which dulls thou ght. Most bedside teaching is mini-lecturing, noneducational chores, and the refl exive ordering of test after test. Student s rarely have an opportunity to reflect on their learning, make connections to basic science information, restructure the knowledge that they already have and engage in real problem-solving about patients under their care. In order for students to learn problem-solvi ng skills, they must actively participate in the learning process. Gordan, et al. (2000) stressed the importance of e ngaging students as active 44

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learners at an early stage, so that they can acquire knowledge and sk ills that are relevant, organized, accessible and functional. There is so me evidence to suggest that students are not active participants in their c linical education. Brown and Gillis (1999) concurred when they stated that students should be active, independ ent learners and problem solvers, rather than passive recipients of information. The simplistic approach of see one, do one, teac h one, prevalent in clinical teaching for years, is no longer acceptable, although the statement does imply a strong relationship between practical learning, skill acquisition and t eaching (Parsell & Bligh, 2001). Students must recognize their own thin king and learning strategies in or der to develop and organize a knowledge base for problem solving (Gordan, et al., 2000). Expectations and feedback Another problem with clinical teaching is th e lack of clear expectations for student performance. Few clerkships have clearly defined objectives and de scriptions of work responsibilities. As a result, students encounter differing and sometimes conflicting expectations. As a consequence, each student tends to have a di fferent educational experience with respect to the information learned and th e proficiency of skills developed (Beasley, 1997; James, et al., 2002). Students frequently compla in about the lack of feedback on their learning and performance. Although feedback on their sk ills and abilities is essential for efficient and effective learning, students often experience clinical clerkships in a feedback vacuum. Feedback from written evaluations of their performances is as inadequate as oral feedback, due to the lack of specificity by faculty members in identifyi ng their students strengths and weaknesses. 45

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Clinical Teaching Definition of Clinical Teaching In regard to dental educ ation, it has been suggested, the clinic is the learning environment to which all our students aspire, (Mullins, et al., 2003 p.35), requiring the transfer of knowledge from the basic sciences to the c linic by tuning and restru cturing of knowledge. How learning and teaching best occur in this environment for the preparation of dental students to advance to independently prov ide patient clinical care is im portant and a central business of dental educators and clini cal supervisors alike. The learning environment of the clinic or hospital is challenging for both teacher and student. In this setting, the st udent is a trainee-clinician resp onsible for patient care, and the clinic is both a patient care facility and a learni ng environment. In clinic, students are expected to demonstrate diverse competencies simultaneously, including a range of skills, a broad knowledge base, professionalism, and empathic, et hical behavior. Recent reports in dental education point to the value of the early introduc tion of students to the clinical environment, largely because of the demonstr ated value of contextual learning and the facilitation of integration of knowledge from basic to clin ical sciences (Mullin s, et al., 2003). Role of Clinical Instructors Clinical teaching typically involves the supervision of a trainee clinician by an experienced clinician, and as a consequence, i nvolves a range of teac hing modes. Clinical supervision may be defined as the provision of monitoring, guidance, and feedback on matters of personal, professional, and educational de velopment in the context of patient care (Kilminister, et al., 2002). The student/clinical teacher relationship has also been compared to the therapeutic alliance that exists between pa tient and physician because it represents an educational alliance (Tib erius, et al., 2002). 46

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Clinical teaching in medical education has been extensively examined (Irby, 1995). Effective medical clinical teachers are considered to be thos e who have empathy, are capable of providing support, exhibit flexibil ity, and have the ability to ga uge student development, in addition to being interpretive, focused, and prac tical (Kilminister, et al., 2002). Effective supervision of learners involves problem solvi ng by students and instructors together, along with feedback, reassurance, and theory-practice linking (Hirons & Velleman, 1993). There is preliminary evidence that effective clinical te aching in medicine may have a positive impact on patient outcomes. For example, Fallon, et al. (1 993) found that patient outcomes improved when direct supervision of the student clinician is combin ed with focused feedback. Davis, Thomson, Oxman, and Haynes (1995) have conducted rigorous reviews of the research literature related to what educational methods are most likely to produce desirable changes in physicians patient care strategies. These publications were the catalyst for similar reviews in health profession educatio n that addressed a variety of questions: What constitutes effective clinical instruction? Do effective clinical teachers have unique attributes that less effective instructors do not po ssess? Are there components of the educational process that are more effective than others in the clinical setting? These questions have been the subject of several comprehensive reviews (Irby, 1995; He idenrich, et al., 2000) numerous observational studies and surveys (Ende, Operant, & Ericks on, 1995; Epstein, et al., 199 7; Frank, et al., 1997; Goertzen, Stewart, & Weston, 1995; Hekelman, et al., 1996; Irby, 1994; OMalley, 1999; Pinsky & Irby, 1997), and countless anecdotal teaching tips, guidelines (Da Rosa, et al., 1997; Biddle, 1996; Cunningham, et al., 1999; McGee & Irby, 1997)primarily in the medical education literature but also, to a lesser extent, in dental education. Irbys (1995) massive summary of the 47

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literature for best practices in ambulatory teaching in medicine remains the most comprehensive and most frequently cited review of clinical teaching practices. Irby identified four key f actors that distinguish the excellent clinical teacher from other instructors. He/she 1) serves as a positive role model of a competent and compassionate health care provider, 2) provides effective supervision and mentoring for learners, 3) employs a varied and dynamic approach to teaching, and 4) is a supportive pers on. Teaching strategies consistent with effective supervision and mentoring include communicating cl ear expectations for students behavior and performance, providing pract ical and helpful just-in-time teaching (commonly known as prompting), explaining concepts and techniques clea rly at the students level and then confirming their understanding, providing how-to feedback in a non-belittling manner understanding students learning needs at different leve ls of training and adjusting teaching accordingly. In 2000, Heidenreich and colleagues reported the results of a comprehensive review of more than 600 articles on clinical teaching strategies in medical education to identify empirical evidence supporting frequently recommended teaching strategies. Hekelman, et al. (2003) identified forty-one papers that reported eith er quantitative or qualitative data related to eleven clinical teaching methods, but concluded that there was inadequate evidence to support the effectiveness of any of these techniques in spite of widesp read student and faculty belief in the desirability of these methods. In contrast to Heidenreich, et al. (2000) and Hekelman, et al. 2003, reviews conducted by Davis, et al. (1995) identified a group of learning strategies that are strongly associated with modifying providers clinical behaviors. These strategies include persistent feedback on performa nce in relation to standards, comparison of performance to other practitioners, emotionally intense activities such as role -play, observed performance and peer 48

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feedback, participation in live-action simulations that require decision making, personal reflection on performance, and notably, an absence of lecturebased instruction (OBrien, et al., 2003). Many investigators have studied clinical teaching effectiveness and the clinical learning environment in dental school. Chambers, et al. (2004), Manague, et al (2001), and McGrath, et al. (2005) reached essentially the same conclusions as Irby, Heidenreich, and other medical school investigators about what effective clinical teachers do. Teacher attributes associated with effective clinical teaching in dental school include provid ing specific feedback about performance, demonstrating an interest in teaching, making an effort to motivate students, knowing how to translate didactic information into pati ent care situations, explaining difficult concepts clearly, showing compassion, and approaching treatment in a proactive manner (Chambers, et al., 2004). De ntal students also reported that the most effec tive instructors took their teaching responsibilities seriously, behaved in a profe ssional manner during interactions with students and patients, and were technically competent. Contributions of Clinical Teac hing to Dental Practitioners Research conducted in the 1980s and 1990s demonstrated the importance of orienting learners prior to task performance, providing frequent formative (progress) feedback to students, guiding students with questions, and helping students understand the desired outcome for a technical procedure (Berk, et al., 1998; Croft, Wh ite, Wiskin, & Allen, 2005; DaRosa, et al., 1997). In a dental school environment, Behar-Horenstein, et al. (2000), and in medical education (family medicine residency programs), Taylor et al. (1998), both found that instructors in their respective settings were aware of teaching best practices such as asking students open-ended questions to stimulate critical thinking but rarely us ed these techniques when working with students. McGrath, et al. (2005), recently pilot-test ed an instrument known as the Effective 49

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Clinical Dental Teaching Inventory (ECDT) to gauge student views of clini cal instruction. This instructional environment survey elicits students opi nions about an instructors skill in creating a positive learning climate, controlling the clinic, communicating goals, promoting understanding and retention, evaluating performance, providing f eedback, and promoting self-directed learning. Authors of the ECDT suggested that the inventory can be used to collect data for assessment of instructors clinical teaching effectiveness. One difference in the literature on effective clinical teaching in medical and dental schools is that dental students place more emphasis on evaluation skills in their reports of teachers best practices (Chambers, et al., 2004). This may occu r because dental students are graded/rated far more frequently and in greater detail than medical students. From a students point of view, faculty members who are able to provide helpful and prompt feedback and accurate (fair) evaluations are viewed as the most effective instructors. Chambers, et al. reported that certain faculty members who saw themselves as experts were likely to be seen as poor evaluators by students because they were out of touch with students actual capabilities a nd thus unrealistically expected expert level performance from the studen ts. In this situation, students reported that they were graded down for performing at an appropriate level of competence for a student in training. Challenges Associated with Clinical Teaching To identify best practices for evaluation of dental students, Manague and colleagues. (2001) surveyed dental faculty to identify their perceptions of the most effective evaluative techniques. Faculty members viewed selfand peer-assessment, portfolio-based learning, the provision of consistent feedback to students, and the use of objective criteria as crucial to student evaluation. However, when asked how often these evaluation techniques were implemented, faculty indicated that these methods were used infrequently. Ma nague, et al. (2001) found that 50

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the most prevalent assessment tools in dental sch ool were day-to-day observations and the number of competency exams (competency patients) completed. Although observations and completing competency exams were the primary forms of assessing student learning, the faculty perceived that these assessment methods we re not particularly valuable to student development (Chambers, et al., 2004). In summary, the literature related to the question of what constitutes effective clinical teaching in dentistry and medicine is extensive but has been comprised primarily of observational studies, opinion surveys, and anecdotal teaching tip guidel ines. There is limited evidence to support the actual influence of these techniques on student le arning, although Davis, et al. have associated a number of instructional strategies with positive learning outcomes in the arena of continuing education (Davis, et al., 1995; OBrien, et al., 2003). Key elements of effective clinical teaching are quite similar in both disciplines. However, there are four limitations to these data that constrain generalizability. First, most of the observational studies and opinion surveys that form the ba sis for this literature were limited to one set of students in a single academic program or health care facility. Second, in many of these studies, the numbers of survey respondents or teaching observations were quite small. Third, in studies where re searchers collected student impressions of clinical teaching by surveys and interviews or implemented protocols to observe teaching, th ey used a wide variety of data collection instrumentsmany of which were created by the investigators and not subjected to pilot-testing to verify validity and reliability. And fourth, much of the data that still provides the basis for assumptions about student perceptions of their clinical education that were collected in the 1980s and 1990s. 51

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High Control Low Control Physician --------------------------------------------------------------------------------------------Patient -------------------------------------------------------------------------------------------Low Control High Control Figure 2-1 Conceptual model for phys icianpatient relationship continuum 52

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CHAPTER 3 MATERIALS AND METHODS Theoretical Framework for Data Collection and Analysis The theoretical framework for this study is interpretivism. Proponents of interpretivism seek to understand human action by understa nding the meaning of that action (Schwandt, 2005). The interpreter objectifies (i.e., stands over and against) that which is to be objectified. In that sense, the interpreter remains unaffected by and external to the in terpretive process. (p. 191) This method of participant observation allows the resear cher to objectively understand someones intent by studying his or her acti ons in the context of the situation. The epistemological framework for interpretivism is understanding. Schwandt (2005) states that understanding is an intellectual process whereby a knower (the inquirer as subject) gains knowledge about an object (the meaning of hu man action) (pp. 193-194). For this study, the researcher will analyze interaction between the student, teacher, and patient to interpret the students perspective of the clinical teaching/learning that ta kes place during student, faculty, and patient interaction. Methodology The methodology used in this research was participant observation and interviews. Participant observation is a process whereby the researcher immerses himself or herself in the subject being studied to gain understanding, perhaps more deeply than could be obtained, for example, from participants responses to survey items. Observations between patients, students and faculty were used to acquire insight about interactions that are characteristic of each group as well as the relationship between the three 53

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groups. As a result, an understanding of the attr ibutes that are common to the relationships were developed. Observations in the clinic over a sevenmonth period were used to collect data for the assessment of the characteristics of the educators-students-patients interactions. A qualitative interview research design was chosen to obtain data relevant to the educator studentpatient relationship and clinical teach ing/education. According to Taylor and Bogdan (2005), qualitative methodologies re fer to research procedures which produce descriptive data: peoples own written or spoken works and observa ble behavior (p.128). Glesne (1999) noted that qualitative research is be tter understood by the characteris tics of its methods than by a definition. According to DeWalt and DeWalt (2002), qualita tive researchers want study participants to be heard and to actively provide their perspe ctives. Therefore, qual itative research is an interactive process in which the persons studi ed teach the research er about their lived experiences. Qualitative researchers attend to th e experience as a whole, not as separate variables. Thus, the aim of qualitative research is to understand experience as unified. One qualitative research method that lends its elf to this study is the interview. Kvale (1996) noted that an interview is a purposeful conversation usually between two people (but sometimes involving more) that is di rected by one in order to get information (p.151). He also stated that the major purpose of an interview is to learn to see the world from the eyes of the person being interviewed. The res earcher learns from the interviewees and seeks to discover how they organize th eir behavior. The interview should be approached as one in which the researcher asks those who are studied to become the teachers and to instruct her or him in the ways of life they find meaningful (p.163). 54

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Researcher Qualifications and Bias In studies where extensive qualitative fiel dwork is conducted, th e researcher is the primary research instrument because all data are collected through observations, and interviews and are filtered through the lived expe riencespast and presentof the researcher. The level of contact that occu rs during the observation and inte rview places the research under the microscope and requires persistent self-mon itoring to ensure that data are documented and reported objectively. The research er should describe his limitati ons as the primary research instrument. A personal biography and a description of data collection methods are essential to describe the researchers limitations (Fischer, 2005). As a practicing dentist and dental educator, I have worked in private practice and the dental college for the past twenty-five years. Consequen tly, I have insight into the daily operations and culture of dental practice and dental education. Since 1996, I have been an associate professor in the Department of Operative Dentistry at th e college where this study was conducted. As a result, I have to acknowledge any biases resulting from this experience to prevent them from influencing my analysis a nd discussion of the data. As a qualitative researcher, I received formal training in participant observation as a program evaluator and experience in usi ng qualitative research methods. Subsequently, I co-authored and published a research article delineating the findi ngs of a nursing study (Tasso, Behar-Horenstein, Aumiller, Gamble, Grimaudo, Guin, Mandell, & Ra mey, 2002). The publication resulted from a study that involved participant observation of health care providers, and patient interviews about their satisfaction. I have published several other qualitative studies dealing with patients attitudes, beliefs and opinions concerning dental care. The purpose of one of these studies, Qualitative Description of Dental Patients Perceived Rights by Grimaudo, Behar-Horenstein and Yantorni (2003) was to describe and characterize how dental patients perceive thei r rights and to 55

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identify which specific rights patients remember after reading and asking questions pertaining to the form. There appeared to be some correlati on to ethnic minority and beliefs/perceptions. The findings of this study suggest th at patients perceive the form more as a legal or protective document for the school rather than an informative tool and suggest that many patients were unaware and unsure of thei r rights as patients. Another study by Stewart, Grimaudo, Behar-Horenstein and Rawal entitled, Description of Patient Perception of Quality Dental Care (2003) reported that a major issue in clinical dentistry is providing quality dental care. Luborskys thematic analysis was used to analyze structured interview and it was shown that the percepti ons provided by the patients emphasized that providing quality dental care has more to do with interpersonal skills, empathy, care, concern, and provider relationship with the patients than the actual technical dental care provided. Grimaudo and Piedra (2004) reported patients per ceptions of the ideal dentist using a survey that included topics such as: cleanliness, ope nness of discussion, recommendation of relatives, primary language and ethnic origin gentleness, and time spent. The data from this study indicate that there are differences in th e way that ethnic minorities choose an oral healthcare provider. These differences were between the minority and majority as a whole and between the specific minority groups. And finally, Grimaudo, Bhaktha, and Potter (2 007) compared patient knowledge of HIPAA from 2003 to 2006 and through surveys showed that patient knowledge and understanding of HIPAA has significantly declined over time. Pati ents involved with health care knew more about HIPAA, but even after patients were given information, they di d not know what HIPAA was. This 2007 was a follow-up study concerning HIPAA completed by Grimaudo and Potter (2004) that showed about 60% of patients were aware of HIPAA because they had recently heard about 56

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it from media advertising and the dental students. HIPAA wa s enacted to protect patient information and patients are not fully aware of the law. From these experiences, I developed a deep understanding of the f actors that influence patient and dental provider inte ractions. The progression from these studies was to study the facultystudentpatient triad relationship and clin ical teaching/education. Consequently, from my experiences as a researcher and patient care provider, I feel I am qualified to conduct this study. While bias cannot be ignored, it can be kept on the side. My role as researcher has been to listen and allow the participants to speak ope nly about their experiences My hope is that the findings in this study will contribute to developi ng a better understand ing of facultystudent patient interaction and improve clinical teaching/education. Participants Because I am a faculty member at the Univ ersity of Wallace (a pseudonym), College of Dentistry, gaining access to the clinics was nonproblematic. Institutional IRB approval was obtained for facultystudentpatient observations and interviews. (Appendix A contains a copy of IRB 2006-U-0433.) The participants in this study were comprehensive care patients at the College of Dentistry, faculty members of the Colle ge of Dentistry, and student dentists in the classes of 2006 and 2007. The four clinics used fo r observations and interviews were operative (opr), oral health maintenance (ohm), prosthodon tics (pros), and periodontics (per). Eighty (80) students were in the Class of 2006 and 81 in the Class of 2007. A total of 168 interviews/observations were conducted among th e class of 2006, of which n=84 (50%) were female and n=84 (50%) were male. The males we re aged 24 to 34 and the females were aged 24 to 32. The class of 2007 completed 162 interviews with approximately n=65 (40%) female and n=97 (60%) male. The males were aged 23 to 35 and the females were aged 24 to 29. 57

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Overall there were 330 patient observation /interviews in all. The patients ranged in age from 19 to 84 years including n=166 (50%) male and n=164 (50%) female, n=198 (60%) Caucasian, n=56 (17%) African-American, n=50 (15%) Hispanic, n=17 (5%) Asian, and n=9 (3%) unknown. Instrumentation The researcher-constructed inte rview protocols were based on literature research. The protocol used in this study was comprised of open-ended questions (See Appendices B and C). The semi-structured format allowed for the part icipants to elaborate on their viewpoints. Data Collection Data were collected from three primary sources: patient interviews, student interviews, and participant observations of the facultystudent patient interaction. Tr iangulation of the data contributes to the credibility of the results (Creswell, 2002). The observations and interviews were conducted on regular clinic days during re gular hours. The observations and interviews took place over a seven-month period. Each clin ic was observed one half-day per week on an alternating basis. This strate gy was adopted because different f aculty members were assigned to each clinic on a given day and the process allo wed access to more faculty rather than observing the same faculty repeatedly (See Appendix D). An interaction consisted of the dialogue be tween the student and f aculty member, student and patient, and a student and faculty member during the treatment appointment. Student and patient interviews were completed at the end of the appointment and lasted fifteen to twenty minutes. All interviews were conducted by th e researcher. Running notes were used to document the interactions and nonverbal cues we re also recorded. The written notes were entered into a word processing program for analysis. 58

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Data Analysis There are two major purposes for analyzing da ta in qualitative studies: interpretation and translation into concepts. In this study the latte r process was used. Identifying concepts help to explain the relationship between the data. Data from the student interviews were compiled and analyzed to determine if there were common pa tterns among the students regarding what they learned, how the faculty fostered their learning, and what they pe rceived to be important about clinical teaching. Data from the patient interviews were compiled to see how patients felt the faculty and student intera cted with them and each other, if th ey knew what dental treatment they were receiving, and their main reasons for coming to the dental school. Data gathered during patient interviews was compiled and analyzed to see if there were co mmon trends and patterns among the patients responses. The constant comparative method (Denzin & Lincoln, 2005) was used in this study to analyze and determine common attributes among the student, faculty, and patient interviews. Student and patient interview responses were compared to assess common patterns and themes in relation to each question. Responses from student and patient interviews are also used to compare the perspective of th e patient and student to the same interaction. Data from the facultystudentpatient interac tions was coded. The data were classified and categorized to allow for development of common themes, patterns, and concepts. The researcher used memo writing during the c ode, which enabled him to express personal reflections from the data analysis. Trustworthiness of Data The basic question regarding tr ustworthiness in naturalistic inquiry is: How can an inquirer persuade his or her audi ences that the findings of an inquiry are worth paying attention to, worth taking account of? (Denzin & Lincoln, 2005). Criteria for trustworthiness include credibility, transferability, dependability, a nd confirmability (Denzin & Lincoln, 2005). 59

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In qualitative research, the trustw orthiness of data is equated with validity in quantitative research (Glesne, 1999). Trustworthiness is ac hieved through prolonged engagement in the field that allows for persistent observation and the opp ortunity to acquire suffi cient data to support the study. The data collection process for the pr esent study took place over a seven-month period. The observations consisted of mo re than one-hundred hours spent in the field. Student and patient interviews were an additional 150 hours. Approximately 350 hours were spent analyzing the data from interviews and observations. Anot her contribution to the trustworthiness of the study is triangulation of the data. Member checks are also used to establish trustworthiness of data (Glesne, 1999). Member checking is a process through which respondents verify data and the interpretations thereof (Den zin & Lincoln, 2005). To ensure the accuracy of the data, a summary was reviewed with the data source in order to under stand the perspective of the participant. In this study, duri ng interviews, verbal information was restated to the patient or student as a means of member checking. Credibility Denzin and Lincoln (2005) recommend a variety of strategies for improving the likelihood that findings and interp retations produced through natura listic inquiry methods will be credible. Two of these strategies are peer de briefing and member checking. Denzin and Lincoln (2005) define peer debriefing as a process of exposing oneself to a disinterested peer in a manner paralleling an analytic session and for th e purpose of exploring aspects of the inquiry that might otherwise remain only implicit w ithin the inquirers mind. (p.122). The peer debriefer for this study was Dr. Sandi Anusavi ce who analyzed ten percent of the data. Her interpretation of the data agrees with the findings of this study. 60

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Transferability The emergent theory of na turalistic inquiry is dependent on a specific context and interactive dynamics, necessarily lowering the possi bility and desirability of a focus on external validity, as compared with positivistic i nquiry (Denzin & Lincoln, 2005). Qualitative observational research describes a nd classifies various cultural, racial and/ or sociological groups by employing interpretive and natu ralistic approaches (Fischer, 2005). It is both observational and narrative in nature and relies less on the experimental elements normally associated with scientific research (reliability, validity, and ge neralizability). Qualitative observational research is a systematic inquiry into the nature or qualities of observable group behavior s in order to learn what it means to be a member of that group. The rese archer's job, rather than to describe a stable entity, is to give continually updated account s of observations on multiple levels of group interactions that occur on both a temporal and continuous basis simulta neously (Patton, 2002). Qualitative study lends itself to thick narrative description, and it may be intensive given the complexity of group interactions. It takes place on site, in the group's natural environment, and attempts to be non-manipulative of group be haviors. The purpose is to aim for objectivity, while it must take into account the views of the participants (D eWalt & DeWalt, 2002). Qualitative observational research is naturalistic because it studies a group in its natural setting. Patton (2002) explains, "Nat uralistic inquiry is thus contra sted to experimental research where the investigator attempts to completely control the condition of the study" (p. 42). In order to enable others to make an informed decision about whether to apply the findings of this study to their own resear ch, extensive description of the experiences and identity development of the participants, as well as the definitive exposition of the researcher, are provided. 61

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Dependability and confirmability Denzin and Lincoln (2005), both dependability and confirmability can be determined through one properly managed audit. To establish dependability, the auditor examines the process by which the various stages of the study, including analyt ic techniques, were conducted. The auditor determines whether this process was applicable to the research undertaken and whether it was applied consistently (Denzin and Lincoln, 2005). To illust rate confirmability, a record of the inquiry process, as well as copies of all taped interviews and discussions, notes from interviews and discussions, and hard copies of all transcriptions have been maintained. 62

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CHAPTER 4 RESULTS The results obtained from student intervie ws, observation of student-patient-faculty interactions, patient interviews, and descriptions that typify these relationships in the dental school setting are described in this chapter. These results will be described in the context of the six research questions. Research Question 1. What are the Characteristics of Oral Health Care Educators PatientsStudents Interactions in th e Clinical Learning Environment? Clinical observations were made during regularly scheduled c linic appointments. Across all observations, the faculty interacted with a student at the beginning and the end of the procedure. However other types of interactions ensued as desc ribed below. At times, students called upon the faculty if assistance was needed dur ing the procedure. At other times, faculty were observed walking around the clinic and as king students how they were doing during the clinic period. Some faculty waited for the student to come to them after the student had finished the treatment. Student and patient dem ographics are described in Table 4-1. Four styles of interaction emerged from these observations: 1) faculty-centered, 2) student-directed, 3) studentfaculty collaborations, and 4) patient-driven. The frequency of each is as follows: faculty-cente red (n=192, 58%), student-driven (n= 76, 23%), studentfaculty collaborative (n=53, 16%), and pati ent-driven (n=9, 3%). In the fo llowing section each style will be defined and observations that typified each are presented. Faculty-Centered Faculty-centered interactions were those where the faculty member told the student what to do and the student completed the procedure w ithout much input. These interactions usually involved patients who already had their treatment plans comp leted and were scheduled for restorative procedures. During the interactions, the faculty member would look at the treatment 63

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plan and radiographs and tell the student whic h procedure to complete. The faculty member would answer questions concerning the procedure as needed providing input as an expert in the field. During these interactions, faculty were usually sought out by the student. After approaching faculty for help, the faculty memb er treated the patient without giving much feedback to the student during th e process. An example of this occurred in prosthodontics, where a student was completing a crown preparati on on a tooth and he asked the faculty member to check to see if the margins were okay. The faculty member sat down and modified the preparation. When he was finished, he told th e student to go ahead and make the impression since the procedure was now complete. The faculty member did not tell the student what or why the modifications were being done. Thus, this teachable moment was not utilized. Another example occurred in operative when a student had trouble anesthetizing a lower molar. The student called over the faculty member and told him the problem. The faculty member told the student to get a specific type of anesthesia and then proceeded to inject the patient. The student was not told why a different anesthetic was us ed or if this was a different procedure being employed. In another faculty-centered inte raction, a junior student treated a patient in the operative clinic. The patient was seated and the faculty member approached and greeted the student. The faculty member looked at the patients treatment plan and said to the student and patient that they should complete a silver filling on tooth number 19. The faculty member signed the necessary forms for the patient and student to begin; the st udent began the procedure and called the faculty when the procedure was completed. The faculty member signed the chart notes and the patient was dismissed. The interaction with the student and patient was minimal and cordial. Faculty 64

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input was only in response to the procedure completed. Minimal teaching was performed by the faculty. In the clinic the teacher must supervise beca use s/he has responsibil ity for patient safety as well as treatment. However, the teacher is also expected to address the learning needs of the student simultaneously. Teaching takes more time than supervision. Student-Driven Student-driven interactions were those whereby the stude nt would tell the faculty member what s/he was going to do in that clinic The faculty member would verify that this procedure was needed per the tr eatment plan, check the patient, and then tell the student to proceed with the procedure. In these interactions, stude nts took the initiative in providing patient care and the faculty member still checked his/her work at the comp letion of treatment. In these interactions, the faculty members allowed the students to make decisions about the given treatment. Other interactions included in this category occurred when the students initiated the faculty interaction. In one example, a student asked a faculty member to evaluate a bridge preparation; the faculty member told the student that it looked okay. The student then asked the faculty member to discuss what could be done to make the preparation better. In a similar example the student prepared the tooth for a large filling and asked the faculty member to evaluate it. The faculty me mber said it was good, but the student wanted to know what could be done to make it better. In the operative clinic, a senior student had a patient who needed composite restorations on teeth 8, 9, and 10. The patient was seated and the student brought th e faculty members over and told them that s/he planned to place restorations on all three t eeth during the same visit. The faculty member checked the plan and told the st udent to complete those procedures. After the 65

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procedure, the student told the faculty member that the work was ready to be checked. Afterward, the faculty member checked the procedur es and said that they were acceptable. The student asked the faculty member, What could be done to make the aesthetics better? This led to a discussion concerning the facultys experi ence and expertise. The student reported a positive experience and said that s/he learned advanced aesthetics techniques that day. During these observations, the faculty member would usually remain in one area of the clinic. To attain the faculty me mbers attention, the student w ould contact the faculty member when s/he needed assistance, or the student would follow the faculty member from operatory to operatory until s/he was next in line to be seen. Clinical teaching is directed toward incr easing autonomy to prepare the student for practice. As seen in the aforementioned exampl es, autonomous learning in cluded: goal setting by students, use of teachers as guides rather than instructors, and students using self-assessment and reflection. Clinical teaching is designed to promote students taking an active role in their professional education over the course of two years. StudentFaculty Collaborative Studentfaculty collabo rative interactions occurred when students and faculty members examined the treatment plan together and decided which procedure would be completed that day. The procedures completed were clinic dependent. Collaborative interactions occurred mostly in the operative clinic, where there are several proce dures listed on a patient's treatment plan. In periodontics and prosthodontics, th e treatment options were limited by the specific nature of the specialty involved. For example, scaling and root planing occurs in peri odontics; there is not much choice as to what else can be done. In these interactions, the faculty and student had a dialogue concerning the days treatment. 66

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These observations also included ongoing di scussions between faculty and students during the treatment process. In one example, the student had a large restoration. The faculty and student discussed what material should be us ed to fill the tooth. Du ring this discussion, the faculty member asked the student many questions about how and why different materials could be used. In another example, a student was having trouble anesthetizing a pa tient. The faculty member and the student discussed reasons why this may have been happening. Then the faculty member demonstrated an alternative technique to anesthetize the patient. The professors asked students questions about the treatme nt plan and alternative treatmen t. During one interaction in the periodontics clinic, students repo rted: The faculty member fo stered learning by listening to me, because he knows that I see the patient clinic ally more often than he does and we worked together to come up with a treatment plan that was best for the patient. The student reported that the most important thing about clinical t eaching was for the faculty member to be thorough, not talk down to me, and make sure that I have all of my questions answered. Another interaction was described by the student as incorp orating social caring and good conversation. The student learned from the f aculty members ideas and experiences. The faculty member helped during the procedure a nd discussed potential problems. During these observations, the faculty member actively moved around the clinic and went from operatory to operatory to check students pr ogress. Interactions were conversational and reciprocal. Patient-Driven During the patient-driven interactions the st udent and faculty memb er asked the patient what s/he wanted to complete that day. The patient had input and could select from a list of necessary procedures on the treatment plan. What distinguished these inte ractions from others was the patient's involvement in the dialogue. In so me of the dental clinic s, the patients wishes 67

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and concerns were taken into consideration wh en developing a personalized sequenced treatment plan for the patient. However, this category of observation is limited because the faculty member could not deviate from accepted treatment protocols and guidelines. A good example of this type of interaction follows. A junior st udent in the operative clinic had a patient who had lost a filling in a front tooth. The pa tient told the student that s/he wanted to have that tooth filled that day. The student told the faculty member about the patient's request and was allowed to complete the proced ure for that day. While the patient had other restoration needs, this tooth was filled first per the patient's request. Research Question 2. How are Oral Health Ca re EducatorsPatientsStudents Interactions Perceived by the Student? Students were interviewed about the faculty's interaction with their patients (Table 4-2). The interactions were classified into four major categories based on the students' descriptions and described by terms used by the students. Th ese four categories consisted of none, minimal, good, and excessive. About 3% (n=10) of the students stated that the faculty did not interact with their patient and described interaction as nonexistent, or without communication entirely. About 10% (n=33) reported that the faculty did no t interact well with the patient and describes the interaction as minimal or very cursory," "did not talk much," and "could have been more friendly and professional. Approximately 8% (n= 27) of the students repo rted that the faculty interacted with the patient. They described facu lty members' actions in these interactions as very talkative, too much conversation, left patient confused, and spen t too much time talking about extraneous material. The majority of the students 79% (n=261) reported that the interaction was good. Representative descripti ons of good interactions included: explained step-by-step to the patient"; "paid attention to the patient and the patients feelings and "was friendly and courteous with the patient 68

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Students reported that faculty interaction with their patients were pos itive; however, they also stated that a certain amount of interaction that is acceptable. For example, students indicated that they wanted the faculty to explain to th e patient when a procedure was complex. Students reported that the faculty should be cordial to the patient, explain what is necessary, and help as needed depending on the students level of expe rtise. Tangential and too much conversation were viewed as counter productive because the amount of available clin ical time is limited. Students also reported that they perceived aloof ness or quick interactio ns as unfriendly and unprofessional. Students were asked to describe the type of faculty interactions with them. The interactions were categorized into two main as described by the students: good or poor. The majority of the student 85% (n=281) described th e faculty interaction as good. Representative examples of these interactions included: the faculty was kind and generous; and "...they handled problems appropriately... In addi tion, 15% (n=49) of the students described interactions as poor when faculty: did not spend enough time with me; "they were aloof", "they were too busy", "not much interaction;" and "could have been more patient with me and less demeaning Students explained that they wanted the faculty to interact with them concerning patient treatment and that when they did interactions were easy. Faculty members that did not spend much time with a particular student may have be en due to the number of patients in the clinic and the complexity of procedures on a given day, causing the amount of time available for supervision to fluctuate. Diffe rent procedures among faculty me mbers on the same clinic caused difficulties for students. 69

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Students reported that inc onsistent feedback was a co mmon occurrence in the dental school clinics. They described s ituations in whic h two instructors would look at the same work performed by the students and each would give different feedback. The following three examples depict students frustrations with lack of instructor calibration: A big problem is inconsistent feedback and instructions." Inconsistency of instructors. One will start a case with you and suggest their philosophy, then another teacher changes the way you do things; a waste of time. Different instructors tell me to do different things even though the treatment has already been approved by another licensed and practicing dentist. Students also wrote about their appreciation for faculty members who they perceived to be knowledgeable and eager to help. They frequently described how fortunate they felt to work with faculty who had a firm understanding of clinical skil ls and the ability to communicate these skills at the students level of understanding. The following written response s are representative: Instructors encouraged me to try new procedures, become more independent, and expand my abilities. Faculty bring their clinical experience, share the different ways of restoring a lesion, allow you to ask multiple questions as to the pros and cons. Instructors give positive feedb ack and never belittle me. They share clinical advice and patient management." The faculty are very committed to educating us." In addition students reported situations where instructors communicated respect to students and worked in a collegial manner, such that students felt confident that the instructor was there supporting y ou. Approachability, ope nness to questions, and willingness to give 70

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guidance and feedback were charact eristics of faculty that students considered to be important. Instructors who displayed these characteristics were able to motivate students. Enthusiasm for the subject matter, patience, and a sense of humor were personal qualities displayed by instructors in positive learning incidents. Perceived instruct or commitment was also reported as important. Students were asked what they learned during their clinical session. The responses were varied and ranged from nothing" "I've done this procedure many times, to I learned a new technique today. Their response seemed to co rrespond with the students year and the clinic assignment. For example, senior students descri bed treatment in the periodontal and operative clinics as routine proced ures that they had already done, wher eas juniors reported that they were learning new things in these clinics. Senior students reported learning new techniques in prosthodontics. Students did not comment on re quirements or competencies. Many students considered a clinical session as a poor learning experience if they did not get a requirement or competency completed. Where the dental clinics strive to provide comprehensive patient care, the education requirement fosters students that must meet various competences for graduation. Thus, there is a tension between the goals of pati ent care and students' educational need. When asked how faculty fostered their lear ning, students reported that during routine procedures faculty fostered learning about 65% (n=215) of the time, however 35% (n=116) reported that faculty did not fost er learning. Senior st udents reported than f aculty fostered their learning (40%, n=67) of the time, while junior studen ts (80%, n=130) reported that faculty fostered their learning twice as much of the time. Descriptions of how faculty fostered (facilitated) learni ng included responses such as telling (me) what to do;" "giv ing verbal expressions;" "help ing to build my confidence;" 71

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"giving me different perspectiv es and opinions concerning th e treatment;" "teaching me a new method;" "demonstrating and reinforcing what was given in lectures;" and "giving real world experience and allowing me to do th e procedure myself and coming back and making suggestions for improvements Instructors, who engaged the students, were eager to help, and were actively involved with the students, were seen as faculty w ho facilitated student learning. Instructors who facilitated learning in the clinic frequently shared with students tips and tricks from their own clinical experience. Students perceived their sharing of knowledge to be valuable because it was written and available in textbooks and of ten helped them understand a concept more deeply or learn ho w to complete a procedure successfully. Students written comments incl uded more frequent descriptions of exceptional learning experiences than negative ones. Overall students reported that th eir learning experiences were positive, 90% (n=297), while 10% (n=33) reported that particular faculty's teaching skills and traits inhibited their learni ng. Representative examples of students' comments follow. It all depends on your faculty coverage. Some people make you feel comfortable; some make you feel very uncomfortable and then it becomes more difficult to perform to a high level. Certain instructors are great extremely helpful and provide positive feedback. My clinical experiences are pred ictable based on which instructor will be in the clinic." Negative learning experiences were often characte rized by a lack of communication between the instructor a nd students and/or problems with the organization or presentation of the material. For example, communication pr oblems occurred when the instructor was perceived as unapproachable, uninterested in the students learning, or discouraged questions. At times, instructors failed to de termine students prior level of knowledge about a topic, and 72

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used terminology that was unfam iliar and confusing to the stude nts. Unclear directions about tasks to be completed and lack of timely and/or co nstructive feedback were also problems reported by students. Students viewed their interac tions with knowledgeable faculty members as a highlight of their education, but a high percentage described situations in which they felt their progress in the clinic was hindered either because too few faculty were assigned to clinic or because faculty wandered off and could not be located when they were needed to supervise patient care, evaluate work, or sign off on paperwork. One of the most frequently written comments made by students was that lack of clinical faculty made it difficult for them to attend to patients in a timely manner. Students who wanted the best possible care for their patients and to meet the educational expectations of the various clinical depart ments were frustrated by this occurrence. The following four examples illustrate students experiences with the lack of faculty coverage: There was not enough faculty covera ge on the floor at all times. Prolonged waiting for instruction and assist ance This is the most recurrent and frustrating aspect of my de ntal education in clinic. Some (not all) faculty fail to be effi cient as clinical instructorstalking on their cell, and so forth. Is this the proper way to spend clinic time? That time should be dedicated to teaching and helping students. Instructors are not availabl e in a timely manner. I feel this is a HUGE problem in my clinical education. When students reported positive learning experiences, they described the educators focus and efficiency. In these instances, students re ported that information and instruction were presented in a clear, concise, and easily unde rstood format. Goals for the session were made 73

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clear, and instructors were organized. Instructors focused on the topic at hand and avoided what the students termed tangents. In these experien ces, instructors acted as guides for students, led them through a large quant ity of information, pointed out the most important deta ils, and helped students to grasp essential concepts. Positive lear ning experiences were also high in relevance, that is, instructors communicated and students coul d clearly see how what they were learning related to specific patient treatment needs as well as to problems the students would encounter in the future Some of the students' clinical learning experiences involved learning from peers. Many students reported that opportunitie s to observe and assist senior students in the clinic were valuable and eased the transition from lab to clinic. Students also reported that prom pt, informative, and sometimes critical feedback was necessary for development of their clinical skills. However, many student s described situations in which feedback messages were delivered in a manner that was abrupt and rude, embarrassing, and condescending, especially when criticisms were communicated in open areas of the clinic where other students, patients, and faculty members could hear the conversation. Three representative examples follow: The faculty were downright rude to me and extremely critical." At times I feel unsure about as king questions for fear of being ridiculed. I wish I could be more open about not knowing something without being scared of insulting comments. Instructors try to make us students feel stupid in front of our patients." Students were asked to identify the most im portant thing about clinical teaching. Their responses emerged as four cat egories: faculty characteri stics (65%, n=215), student characteristics (15%, n=50), pati ent interaction (12%, n=40), and characteristic of the learning 74

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experience (8%, n=26). The majority of their responses reflected how faculty characteristics impacted their learning experience, where by the faculty took the onus for teaching... Representative examples follow. patient friendly faculty who are not condescending;" "faculty giving helpful and practical hints and tips;" "faculty should not just tell you what to do;" "faculty should be supportive and faculty has to resp ect the students and patients Students taking the onus for their learning refl ected how they thought about their education include, want constructive criticism to better myself;" want re al world and practical advice; want to understand better to make my skills be tter; "want to progre ss through the curriculum, educate my patients, and provide quality care for them"; "being able to speak with the faculty one-on-one about the patie nt and to get constructive criticism after a procedure is completed;" "getting help at having freedom to make decisions; and students should be prepared for clinic and provide quality care to their patient Students also reported that the most important thing about clinical teaching was having positive experiences and opportunities to work with patients. Interactions with patients helped dental students increase thei r confidence when performing new skills. The following quotes illustrate this theme: One positive experience was being able to give comprehensive care to my patients and being involved in every step of the wayfrom treatment planning to carrying out treatment. I have a well-rounded patient pool with diverse needs and responsibilities. I enjoy working with my patients and formulating a treatment plan suitable for each individual. 75

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Students offered characteristics of their learning experiences. Th ey described intentions as hands-on learning;" "explaining, showing, and letting the students do the work;" "...learning experience and skill in a compassionate clear manner... A last theme that evolved from the st udent interviews concerned the large amount of legwork that they were required to perform while working in the clinic. This work involved tracking down patients, completing paperwork, scheduling appointments, and performing other clinic tasks that students felt should be accomplished by support staff. These issues take away from providing patient care and requi red concentration on administrative activities that interfere with students chair time with patients and accomplishment of educational tasks required by the clinical departments. The following written responses are representative of the students experiences with admi nistrative activities: Too many hoops and hurdles. New things thrown at us constantly. Bombarded with paperwork. Considerably more time spent jumping through hoops than actually practicing dentistry." The paperwork, calling patients and often harassing them to come in, and the amount of lab work. I know that some of this is needed, but it takes away from time that could be utilized working on patients, trying to meet requirements. Students reported that the pa perwork and administrative issu es concerning patient care were sometimes overwhelming. Administrative i ssues, such as schedul ing patients and calling them to confirm appointments, are an importa nt part of patient care education. Although students might dislike doing these tasks they are developing essential patie nt management skills for use in dental practice. 76

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Research Question 3. How are Oral Health Ca re EducatorsPatientsStudents Interactions Perceived by the Patient? An overwhelming majority of the patients 99 % (n=327) described th e faculty in teraction with them as positive and used descriptors such as great, exceeded expectations, fantastic, excellent, beautiful, professional, and nice. Three patients described the faculty patient interaction as poor. One patient said: "The in teraction was poor, as th e first doctor told the student the wrong thing to do and the second doctor corrected him. Another patient stated the interaction was poor and I felt th at the faculty member did not re ally speak to me. Patients' descriptions of student in teraction were unanimously favorable (Table 4-3). Patient description of the facu lty student interaction fell into two major categories: good and could be better. The majority of patient s 97% (n=320) described the interaction between the student and faculty as good, using terms such as: "Good communication, professional, they were nice to each other," "top-of-the-lin e work together," "f aculty questions student and answered students questions and communicated greatly;" "thi s faculty member was better than the last time. Ten patients (3%) describe d the interaction between the faculty and student as could be better as depicted by the followi ng statements. "there really was not much interaction; the work was checked at the end... More patients described the facultystudent interaction in a negative light th an the facultypatient interaction. Two of the patients reported a negative response to both interactions. Patients were asked to identify who explained th e treatment plans to them. Their responses fell into three categories: the st udent, student/faculty, and faculty. Most of the patients (92%, n=304) stated that the student described the nece ssary treatment, 6 % (n =20) stated that the student and faculty explained thei r necessary treatment, and 2 % (n=7) reported that the faculty member explained the treatment to the patient and student. In the last instance, the faculty 77

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member explained the treatment to the student and patient in situations that required a specialty consult because plans are typically t oo complex for the attending student. Patients stated that the main r eason that they came to the dent al clinic was financial (85%, n=281), because of a recommendation (7%, n=23), they had a problem or bad experience with a private dentist (4%, n=13), they wanted to receiv e expert advice (2%, n=7), or to improve dental health (2%, n=6). When asked what could be done to make th eir treatment better, the vast majority of patients (95%, n=314) said that th e treatment was fine and nothing was needed to make it better. The remaining patients who gave recommendations for improvement asked: for evening hours; appointments that were efficient and flexible; lower fees; and less time between visits. Some patients commented that the stude nts shouldn't be in charge of scheduling and collecting fees. Patients perceptions were predominately posit ive, and provided no fi ndings that could be used to revise or enhance clinical education. Patients seemed satis fied if they are treated fairly, felt no discomfort, were charged a reasonable fee, and had a good relations hip with their student dentist. Research Question 4. How do the Student and Patient Perspectives of the Oral Health Educators-Students-Patients Interaction Compare? Responses to questions involving faculty in teraction with the patient and faculty interaction with the student were compared. Overal l, patients' descriptions of their interactions with the faculty were more positive than the st udents' responses. The student would typically say that the interaction was okay while the patient described it as excellent. When the student reported that the faculty member was very friend ly and spent much time addressing the patients concerns, the patients response wa s that the faculty member aske d a lot of questions and it was comfortable. One student reported that the interaction was profe ssional, and the patient reported 78

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that it was a beautiful, professional, and nice experience and that the interaction was very comfortable. Comparison of Observations and Interviews Observations where students reported a negati ve interaction were mostly categorized into the faculty-centered style. Students reported this kind of interaction as less favorable. The student-directedand patient-inpu t-style encounters were report ed as mostly positive by the students. The studentfaculty collaboration style r eceived no negative repor ts by the students or patients. Student reports of condescending faculty inpu t were not corroborated by the observations in all cases. For example, 15% (n=49) of the stud ents reported poor interactions with the faculty and condescending behavior by the faculty. Eigh t interactions that students described as condescending behavior by the faculty member were instances in which the student came to clinic unprepared for the clinical procedure. As a result, the faculty member appeared to the observer as annoyed with the student. While the situation could have been handled differently, the researcher did not observe belittling of the studen t in front of the patient. The other seven cases involve two non-American female faculty members. The students perceived one faculty members demeanor as condescending. The student reported the faculty member's pointed critique was too harsh. At times, students reported particular faculty as condescending when the observer perceived them as really stern. Research Question 5. How does the Clinical Specialty Influence the Type of Interaction between the Oral Health E ducators-Students-Patients? A comparison of interactions across different clinics provided insight into the procedures involved in each clinic. The information from interview and observations were assessed to describe the influence of the cl inical specialty on the educator s-students-patients interaction. 79

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Interactions in the periodontal clinic were unanimously favorable. Students reported positive experiences with the faculty and their learning ex periences. The operative clinic interactions were mostly positive. There were a few negative in teractions that typicall y involved two specific faculty members. The prosthodontics clinic intera ctions were also mostly positive, but several negative interactions were report ed. Senior dental students reported more negative interactions with faculty. Patient interviews did not report that their interactions were different by the clinics where they were treated. Research Question 6. From the Students Persp ective, What are the Elements of an Ideal Clinical Teaching/Learning Experience? Data from the interviews and observati ons was compiled to provide the students perspectives of an ideal clin ical teaching/learning experience. Dental students made a number of significant comments concerni ng student attributes, characteri stics of teaching/learning and desirable characteristics of clin ical teachers. These comments pertained solely to clinical teaching. Nevertheless, themes common to othe r teaching environments, such as feedback, demonstration, integration of theory with practice, and student autonomy, were described by the dental students. The findings were categorized as student at tributes, characteristics of teaching/learning, and desirable char acteristics of clinical teachers. Student Attributes Dental students reported th at their level of confidence was important and that their relationship with the clinical faculty affected th eir learning experience. Confidence in providing oral health care for patients is considered important as an educational outcome (Talwar, et al., 2005). Among medical students, increased confidence has been associated with increased clinical competence, though th e relationship between the two is not well understood (Barrows, 2003). Confidence cannot be directly measured, but self-reports of student perceived confidence 80

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is commonplace (Frank, et al., 1997). Some students reported feelings of uncertainty when they are treating patients; they were not completely confident with what they are doing. This was reflected in some survey comments, such as when you have messed up beyond belief and When I do procedures, I get quite scared of doing things wrong. Need for support. Perhaps, because of uncertainty concerning patient treatment, these students preferred to be supervised by a s upportive teacher. Student comments included the following: Yes, I do a filling but Im not always sure [that] Ive removed all the caries. Its nice to have someone when youre doing it sayi ng okay and maybe talk you through it step by step and nice to be reassured instead of the faculty expecting you to fail..." Student autonomy and student self-assessment. Because clinical faculty are legally responsible for the patients well-being, there is a tendency in dental stude nt clinical practice towards faculty-led clinical decision-making. A ll clinical teachers have had occasion to take over students work to protect the patient. Many students in this study experienced this interaction as an infringement of their autonom y, and it appeared to cause some resentment. For example: We're supposed to be diagnosticians as well, not just technicians. If they say do this, do that then we get into the hab it of going okay, rather than thinking carefully and thinking Why, specifically am I using this material? In this context it seems reasonable to suggest that student clinical activity needs to be directed towards increasing autonomy in or der to prepare the student for practice. However, it also seems important to teach st udents how to assess their own clinical work. Researchers have reported that self-assessment promotes learning and is at the heart of the 81

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educational process within professional educ ation (Croft, et al., 2005; McCunniff & Holmes, 1999). Students also made a number of comments a bout their autonomy: I think options are important. I was doing a filling last week and I was going to line it, then one clinician explained the options to me, gave me three options, and then asked me to choose. So I chose with my limited knowledge and thats what I used, and he didnt mind which one I did. And that was constructive because he gave me the options and le ft the decision to me, rather than deciding and not giving me the reason why. Characteristics of Teaching/Learning Communication/discussion, feedb ack, demonstration and the integration of knowledge and skills were characteristics of th e teaching and learning process that students frequently described as important. Communication/discussion. Several times students disc ussed faculty and staff communication with students, not student comm unication with patients. They placed an emphasis on willingness to discuss rather than on ability to communicate, which the students appear to take for granted. The following comments illustrate this point. briefing helps. Dr. X is very good. He asks us about our treatmen t beforehand;" and there are some that will say it to you in such a tone, volume and in such a nasty way th at youre not going to ask them again. Feedback. Students reported that the quality and the emotional tone of feedback were important. Comments that indicate the powerful role that feedback plays and how important feedback is coming from clinical teachers follow. As one student commented, even the smallest word or the shortest sentence can make a difference. 82

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The data indicate that most feedback consiste d of faculty members reassuring students that their work was fine." Most of the feedback students received was positive. Feedback is generally recognized as important to student learning, because it provides students with understanding (Berk, Close, & Weyant, 1998). Fee dback that is perceived to be negative or unkind may affect self-efficacy a nd motivation (Lawrence, 2003). Mager (1997) provides a useful way of understanding feedback in clin ical teaching by identifying it as adequacy, diagnostic, or corrective. Adequacy feedback pr ovides information on the efficacy of the clinical outcome; diagnostic feedback provides confirmation of the shortcomings in the clinical outcome, while corrective feedback suggests action to be taken to ameliorate those shortcomings. From these interviews, students viewed fee dback as very powerful. "Encouragement definitely reduces your anxiety. One student reported being motivated by an instructor's feedback. When he said, Youve got to improve on this. [I] felt like goin g back to your patient and doing it really well, and inst ead of Hes really put me down; I just want you to go now and book another appointment, you really want to strive to do better. Students seemed to appreciate feedback that was accurate, comprehensive, systematic, and stated in a positive manner. Given the importan ce of feedback, perhaps dental clinical teachers should be encouraged to offer feedback that is comprehensive, stru ctured, and provides both diagnostic and corrective information. Perhaps the use of a standardized feedback form would provide dental teachers with a rubr ic for organizing their feedback. Demonstration. Students described how dem onstration aided their ability to learn procedures. Demonstration is considered a significant factor in influencing learning psychomotor skills (Clark, Oyen, & Feil, 2001), and ought to be a common feature of dent al student clinical practice. When clinical teachers make demonstr ation a regular practice, it helps students learn 83

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new procedures, even though it does take signi ficant time. Demonstration needs careful managing. The knowledge underlying demonstration is often tacit and invi sible to the student (OShea & Parsons, 1999), and it needs to be clearly communicated during the demonstration. Students were unanimous when they suggest ed that demonstration was a good teaching method for dental procedures. They lamented the fact that faculty were generally unwilling to sit down and demonstrate, but found it useful when they did. Some [faculty] will actually do part of the prep for you. Thats when you actually ga in, when you see what a 1.5 mm shoulder looks like. None of the students suggested that faculty do their work for them. They just appeared to want short demonstrations: He gave a little tw o-second demonstration, [saying] thats what Id like" Yet, students felt ambivale nt about teachers taking over from them. If you think you are doing nicely then its a bit upsetting If a faculty takes over a procedure, students typically worry that such action will have a negativ e impact on their patent relationship. Integration of knowledge and skill. During interviews, a number of students complained that the theoretical teaching they received was n on-contextual and that th ey received no help in linking it with practice. As one student commented, People tell us get on with it, you studied it two years ago, you should know this. Nevert heless, when the student does not have the experiences that help them assim ilate content information, they re ported that faculty appeared to be reluctant to help them see the theory to practice relationship. While it is the responsibility of the clinical teacher to facilitate learning within clinical activity, perhaps dental curriculum could be restructured so that there is integration between knowledge, attitudes, and skills (Levinson, 1999) and that the c linical learning environment becomes a convergence of academic and practical understanding. 84

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The difficulty of such integration has already been mentioned in the literature review, and it was interesting to see it occupied a signi ficant place in student opinion. Some students pointing out the difficulty they had learning theo ry because theory had not been taught in a contextual manner: When they do it [teach] in a cl ass room [it is] miles away from the patient. There is nothing to reinforce it. Effective learning should involve opportunities not just to hear or learn new information, but to apply that informati on immediately in a hands-on situation. This aspect of instru ction is lacking in de ntal education when th e first two years are spent in the classroom and the last two years ar e in the clinic. Topics taught out of context might not be used in clinic for a year. Students also regretted that they had not been given any assistance with integration. There seems to be this theory that if they lead us too much, were not going to learn anything, you should remember every facet of it. While in tegrating theory and practice into a learning process, it should also be integrated into t eaching orientation. There seemed to be some reluctance among clinical teachers to engage in this area of teaching because they perceived it as "spoonfeeding. Although learning is the students responsibility, some students have not had the experiences that allow them to link information to be able to link information with experience, or they had not had the same clinical experiences. Understanding the limits of student knowledge Students appeared concerned that they did not have identical clinical experience. In a learning environment driven by patient need it is difficult to ensure identical student experience. Several students mentioned that faculty often assumed that they have had exactly the same experience: There should be a lack of assumption by clinicians that youre going to be good at something simply because of the year youre in or because youre confident about other things. 85

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Respecting the student/patient relationship. A number of comments reflected students anxiety about the triangular relationship betwee n student, patient, and teacher: Its a learning environment but you dont want to be made to look like an idiot in front of your patients. The teacher will often need to correct the student in some aspect of the procedure s/he is carrying out, but students appear to see this as damaging: [They] turn up in front of your patient and say you are doing it wrong. Then the patient loses confidence in you, some students reported that they prefer that corrective inst ruction take place away from the patient: Its good if they take you aside from the patient, otherwis e the patient is sitting ther e with her mouth open wondering whats going on. As supervisors, there are time s when faculty need to intervene and take over the procedure from the student; however, students regarded this with ambivalence because while they considered it to be useful, they also saw it as potentially damaging. The way faculty act is important here. There are ways and means of do ing things, rather than Get out of the way, you are doing that wrong. "if the faculty takes over the task, the student needs to know why. Desirable Characteristics of the Clinical Teacher The students reported several characteristics th at they felt were desirable for clinical faculty. Students preferred faculty who were professional and competent in their field, approachable, and possessed a love for teaching. They also considered punctuality important because they wanted to use their time efficiently Students also reported that the faculty member should be available in the clinic when the patient and student needed their help and visible in the clinic when questions arose c oncerning patient treatment. Students preferred to be evaluated with consistency so that when criticism was give n, it was consistent for each and every student. Students preferred faculty memb ers who understood the limits of their knowledge and did not speak above their level of comprehension. The stude nts reported that faculty should have respect for the studentpatient relations hip, treat the patient and stud ent professionally, and not 86

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undermine this relationship. Professional competence The knowledge and clinical competence of the faculty member is crucial to the quality of teaching in all clinical teaching settings. Students reported that although they were taught by sp ecialists in dental fields, some of the faculty did not have an appropriate level of general competence to provide support or fo resight to provide comprehensive patient care. These comments run counter to the basic philosophy of the dental school. The school is based on a specialist model which means that each specialty is taught in a specific clinic. Another model of dental education is the gene ralist approach where the clinical teaching is supervised and taught by general dent ists with general practice experience. The following professional competencies emerged from analysis of data in this study. Approachable personality Some students seemed fearful of particular faculty and reported how their teaching styles impacted thei r learning unfavorably; for example, If you are scared, you are less likely to ask, and are not go ing to learn. One st udent reported that he preferred to ask a colleague rather than go to ce rtain faculty because then s/he [didn't] feel stupid asking questions. Punctuality. Students liked to discuss patient treatm ent matters with their faculty before patients arrived. They reported feeling displeased when faculty do not arrive in time for this: Clinicians should be in clinic at a reasonable ti me for the 8:30 session so theyve actually got time to spend with students to go through what theyre planning on doing. Availability Students appreciated the close presen ce of their teacher for two reasons. First students did not want to take time looking fo r the faculty. As one student stated, Theres nothing worse than putting a matrix band in place, getting moisture control and then youve got to go and find a clinician. Another reason was the psychological reassu rance of seeing the 87

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faculty nearby. Another student report ed that, What is really benefici al as well, Ive noticed that Dr. X doesnt disappear like some clinicians like to do. Students' comments indicated that at times they feel there was an insufficient num ber of faculty in th e clinic. Absence or unavailability of faculty contributed to losing chairside time and an insufficient amount of time spent with each student that in terfered with learning. As one student stated, The trouble with this is, sometimes in clinic, there might be 2 clinicians on if were lucky and the amount of time that the clinician has to spend with you, even though he might only have 6 students, I just dont think they have time; they might ha ve time to do this if youre lucky. Consistency. Students also reported the difficulties that arise wh en faculty disagreed over treatment plans. I have had a treatment plan that has changed every single time I have brought my patient in clinic. We dont get much further, it is all that continued debate about what were going to do. Students also repo rted feeling without support when faculty criticized each other. One student reported, It is quite hard for us when some clinicians frown on other clinicians opinions and were left thinking well now what. 88

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Table 4-1. Student and patient demographics Group N Gender Ethnicity Class of 2006* 168 50% Male (n=84) 50% Female (n=84) 70% Caucasian (n=118) 18% Hispanic (n=30) 8% Asian (n=13) 4% African American (n=7) Class of 2007** 162 60% Male(n=97) 40% Female (n=65) 72% Caucasian (n=117) 14% Hispanic (n=23) 11% Asian (n=18) 3% African American (n=5) Patients*** 330 50% Male(n=166) 50% Female(n=164) 60% Caucasian(n=198) 17% African American (n=56) 15% Hispanic (n=50) 5% Asian (n=17) 3% unknown (n=9) Age *Male24 to 34 yo, Female-24-32 yo **Male-23 to 35 yo, Female-24 to 29 yo ***Male-19-82 yo, Female-20-84 yo 89

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Table 4-2. Student interview responses Interview Topic Response Faculty interaction with patient 3% (n=10) No interact with patient 10% (n=33) Did not interact well 8% (n=27) Excessive interaction 79% (n=261) Very good interaction Faculty interaction with student 85% (n=281) Positive interaction 15% (n=49) Negative interaction What you learned Varied from Nothi ng, I've done this procedure many times to I learned a new technique today. How faculty fostered learning Class of 2006 40% (n=67) Reported that faculty fostered learning Class of 2007. 80% (n=130) Reported that faculty fostered learning Make learning experience better (90%, n=297), Positive repor ts of learning experience 10% (n=33) Negative reports of faculty teaching skills and traits Importance of clinical teaching 65% (n=215) Faculty characteristics 15% (n=50) Student characteristics 12% (n=40) Patient interaction 8% (n=26) Characteristic of the learning experience 90

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Table 4-3. Patient interview responses Interview Topic Response Faculty interaction with patie nt 99% (n=327) Positive 1% (n=3) Negative manner Student interaction Unanimously favorable FacultyStudent Interaction 97% (n=320) Good communication 3% (n=10) Could be better Who explained treatment 92% (n=304) Student 6% (n=20) Student and faculty 2% (n=6) Faculty explained Main reason for coming to college 85 % (n=281) Financial 7% (n=23) Recommendation 4% (n=13) Problem or bad experience with a private dentist 2% (n=7) Expert advice 2% (n=6) Improve my dental health Make care better 95% (n=314) Treatment was fine nothing needed to make it better 5% (n=16) Eveni ng hours, appointments efficient and flexible, lowering time between visits, students shouldn't be in charge of scheduli ng and collecting fees 91

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CHAPTER 5 CONCLUSION Characterization of Healthcare Educ atorPatientStudent Communication Four major styles of communication interac tions emerged from the observation/interview data: faculty centered, student directed, st udentfaculty collaborat ion, and patient-driven. Faculty-centered Faculty-centered interactions resulted when f aculty instructed students what to complete at the appointment, when telling students where modifications were needed in the treatment, or when faculty completed a procedure without involv ing the student. These interactions are based on the expert model. When the faculty told th e student what to do or made modifications, the student reported both kinds of interactions as ne gative because they did not feel involved in the learning process. Students reported that they would rather be shown what to do and then do it than have the faculty member do it for them. Student-directed During student-directed interactions either students told the faculty member what procedure they were doing or students sought out the faculty member when they needed assistance. In these instances, faculty usually a llowed the student to perform the treatment with supervision. For the most part, th e students reported these learni ng experiences as positive. The observations showed that these opportunities we re limited and studentpa tient interaction was minimal. In this interaction the student's learning pr ocess was primary. The faculty member would usually stay in one place during th e clinical procedure. The facu lty member interacted with the student and patient but at th e initiative of the student. 92

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StudentFaculty Collaborations In studentfaculty collaborati on, the student and faculty deci ded together what would be done at that appointment. During these types of interactions, the faculty member approached the student at different phases of the treatment and offered suggestions and pointers. The faculty member looked for teachable moments and inter acted with the student and patient during the treatment. The students and patients reported this style of interaction was positive. Faculty student collaborations promoted an open, collegial atmosphere; stud ents reported that these types of interactions fost ered their learning. Patient-driven During patient-driven interacti ons, the patient decided what procedure would be done that day. Typically, the student explained to the facu lty member what the patient desired for that particular day. A faculty member interacted w ith the student and patient during treatment to insure that the treatment was necessary and correct, but the patient had more input as to what was done. Student Perspective of Triad Relationship Student responses indicating what was most important about clinical teaching were classified into three major categories: facu lty characteristics, stude nt characteristics, and characteristics of the learning experience. Th e majority of the responses were the faculty characteristics and their impact on the learning experience. The faculty characteristics were characterized by traits of the faculty and placed the onus for learning on the faculty. The majority of the students placed the importance of clinical teaching on the faculty members. The observations showed that student s preferred facultystude nt collaboration in clinical teaching. The student s preferred faculty members w ho were more interactive and 93

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involved in the learning and treatment process. They expressed a dislike for faculty members who were dominating and completed the treatment for them. Students also reported that student characteri stics were important to clinical teaching. They stated that they wanted to learn to become better clinical dentists and wanted constructive criticism. Students also reported a preference fo r a hands-on (demonstrative), active approach to learning. Patient Perspective of Triad Relationship Patients are essential to clinical teaching. The majority of patient responses were positive. The patients wanted faculty to have oversight of their care and they did not feel negatively when the faculty took over a procedure instead of a student. As described in a study by Grimaudo and Beha r-Horenstein (2004) it was evident that patients related quality dental care to many different factors and that the age, gender, or ethnicity of the patient influenced their impressions. Gene ral themes that were apparent were that the perceived technical skill of th e student was less important than the empathy students showed towards patients. Overall, the information gather ed in this study from patient interviews and observation provided little new in formation or suggestions to change clinical teaching. Influence of Clinical Specialty on Interaction Students and patients did not report major differen ces in faculty/patient interactions within the Operative, Oral Health Maintenance, Periodontics, a nd Prosthodontics clinics. The procedures in Periodontics such as root plan ning and scaling were reported as routine by students. The students had only favorable remarks about this clinic. Students commented favorably about Oral Health Maintenance and reported some concerns with specific faculty in Operative. Most of the unf avorable remarks concerning faculty were reported in the Prosthodontics clinic, where the students perf orm the most complex and time-consuming 94

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procedures. Faculty members spend large amou nts of time with some students, while other students must wait. This is out of necessity sinc e the faculty must ensure that the procedures are done correctly and of a high qual ity. Most of the procedures ar e completed at the end of the clinical curriculum when student s are scrambling to graduate. It is at this specific time, when most senior students reported th at they felt junior students were unprepared and took away from their clinical time with faculty. Students described a number of characteristic s of the clinical teacher that were both desirable and undesirable. Students generally expre ssed a desire for their teachers to use teaching behavior such as demonstration, feedback, and a willingness to talk about treatment. As noted above, the adequacy of such teaching is generally disputed by the students. Students also reported that it is important to have a faculty member constantly available in the clinic. This need is influenced by time constraints such as fixed-length appointment times and need for reassurance. The need for teac her availability also prompted comments about teacherstudent ratios. Students also expressed a desire for increased autonomy. While this may be a desirable outcome of clinical practice, it is possible that faculty may see this as an impediment with ensuring patient safety. Also, experiences suggests th at increasing student autonomy takes time, which may not be available in a busy clinical session with current faculty to student ratios. Students also described the importance of teacher competence. Certainly, knowledge allows the clinical teacher to explain concepts to the student, and competent demonstration may lead to better student performance, but students appeared to link competence more with psychological support. Students gained confidence from knowing that whoe ver is backing them up has the knowledge. 95

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Of all the teacher characteristics described, it is apparent that st udents view a positive relationship with the teacher as most important to them. In interviews, words such as approachable friendly, understanding and helpful were used. But students also used words such as domineering authoritarian, condescending sarcastic, and patronizing. Student comments elaborated that point: There are some that will say it to you in such a tone, volume, and in such a nasty way that youre not going to ask them again, or If you are scared, you are less likely to ask, and are not going to learn. Student Perspective of an Ideal C linical Teaching/Learning Experience Based on the findings of this study, a descri ptive model of clinical teaching based on student preference is proposed. The studentteacherpatient triad is at the center of the model, and the overall environment is the clinic. The st udent brings to the environment his/her basic preclinical knowledge and level of confidence. The student feels a level of confidence which can be affected by faculty interaction. The student re lationship with the clinic al teacher is important and the student will learn more efficiently if this relationship is viewed as positive by the student. Good rapport and respect between the three members of the triad is essential. The student wants the faculty member to have respect for the student patient relationship, as th is relationship is the basis for clinical care. Desirable characteristic s of the clinical teacher are professional competence, punctuality (so that the student is able to use the allotted clin ical time), availability during clinic and after for questions and concerns, consistency with treat ment and evaluation, and practicality concerning clinical matters. The teaching and learning technique preferred by the student is demonstration. As the student brings background knowledge, the faculty member shows them how to do the procedure, and then the faculty member lets the student do it. The students vi ew feedback as very 96

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important. Students appreciate feedback which is accurate, comprehensive, and systematic, and which is provided in a positive emotional enviro nment. In clinical learning, the faculty should help students integrate knowledge and skill by combining theory into practice. The triad and interactions should lead to qua lity care for the patient. Other factors that are important are student autonomy and student self-assessment. These two factors help the student to become a better practitioner. Th e outcome of the triad teachinglearning interactions that lead to quality patient care should be clinical competence. This model is only valid under the circum stances presented and within the context of this study. Several key characteristics of positive learni ng experiences were iden tified by students in this study. Instructor personal qualities such as approachability, enthusiasm, commitment, and willingness to give guidance and feedback contributed to effective learning experiences and the specific instructor skills. Particular characteristi cs of the learning proc ess also contribute to effective learning experiences. These included a focus on the big picture, modeling and demonstrations, opportunities to apply new knowledge, availab ility of high-qua lity feedback, learning opportunities that were focused, specific, and relevant, and the opportunity for learning with and from peers. These results are consistent with principles of adult learning. For example, adult learners want their learning to be relevant to their learning goals, which parallels our focus on the big picture and relevanc e themes. Adults learn best in a supportive environment in which they can experiment with new behavior s and skills, which parallels our instructor characteristics, opportunity to apply new know ledge, and culture of the learning environment themes. Finally, adult learners need and want feedback, which parallels our highquality feed-back theme. 97

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These results are also consistent with experi ential learning theory as described by Kolb (1984), in which both active experimentation, wh ich parallels an oppor tunity to apply new knowledge theme, and reflective observat ion, which parallel s our modeling and demonstrations theme, are inte gral components of the lear ning cycle. Learning style assessments of incoming studen ts should be performed to determine the variety of learning styles represented within the student body. Some students favor active experimentation, the hands-on opportunity to try things out for themselves, wh ile others favor reflective observation, the opportunity to observe a faculty member or senior student demonstrate a behavior, skill, or procedure. Instructors may wa nt to provide a variety of modes of learning in order to meet the needs of learners with varied learning preferences. Theoretical Implications of this Study Summary of Findings Clinical experiences in dental school encompass a wide variety of learning opportunities. Findings from this study demonstrate that students viewed their clinical education as a positive experience with some exceptions. Clinical instructors did not rely heavily on questioning strategies to guide or stimulate student thinking, rarely asked students to reflect on performance or to self-assess, and often employed less-than-ideal strategies for provi ding feedback. In particular, the results suggested that many clinical instructors could enhance their technique for providing feedback with emphasis on improving delivery of the message based on the traditiona l communication heuristic: Its not what you say, but how you say it. Dental students did not perceive that they gained as much from the overall clinical setting as they did from the interactions with individual clini cal instructors. Many dental students saw 98

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the clinical environment as being inefficient and characterized by non-productive down time that was devoted to noneducational task s in order to make the system work. Students described the impact of faculty shortages on th e quality of the educational program, either real coverage shortages (not enough faculty on staff) or availability shortages (faculty could not be found when needed). Students preferred more opportunity to work in a variety of patient care settings, not just the dental school cl inic, and preferred to work more consistently with a core of instructors rather than interacting with different faculty every day. Many of the ideas discussed above, such as demonstration, feedback, and positive affirmation are fundamental to role modeling. The idea of the dent al clinical teacher as a role model was discussed by Chapnick and Chapnick (1999). Mentoring and role modeling are an accepted part of medical educationa l literature, but the idea seems to be relatively neglected in dental education. Appropriate role modeling could help dental students learn the knowledge, skills, and attitudes appropriate to independent clinical practice. The characteristics of po sitive learning experiences pres ented here may provide insights for instructors who wish to increase the effe ctiveness of their teach ing and their students learning. For example, instruct ors may be able to quickly an d relatively easily implement changes in how they give feedback to students, or in the extent to which their classroom sessions are interactive in nature, and the frequency with which they check-i n with the class. Instructors within the same institution may not be aware of effective and/or innovative teaching strategies used by their colleagues. One easy appr oach to faculty development may be to provide a forum for faculty to share thei r best practices for teaching. 99

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Many effective learning experiences happen outside the formal curriculum. For example, studying with peer s and working with senior students in the clinic are not necessarily formal curricular activ ities, yet they were valuable for the students Curriculum planners should consider how to best capitali ze on these effective modes of learning. Findings from this study were compared with the key concepts of studies on teaching and learning in health care environments (Table 5-1). There are characteristics of the clinical teachers that students perceive as favor able when determining teacher effectiveness. According to Chambers, Geissberger and Lekinus (2004), char acteristics identified by the students were: expert, enthusiastic, judicial, and good soldier. These characteristics were not confirmed by the present study. This study agreed with the fi ndings of Fugill (2005) where characteristics of effective clinical teachers identified by student s were: competent, approachable, practical and consistent. Effective clinical teachers provide accurate comprehensive feedback to students in a positive environment (Berk et al 1998, Mager 1997). The present study confirms this concept and agrees with Croft, et al (2005) and McCuniff and Holmes (1999) that effective clinical teachers allow students to have autonomy depending on their clinical level and encourage self assessment and evaluation Chapnick and Chapnick (1999) st ated that effective clinical teachers are role models to students and the students in this study reported that they look up to clinical faculty and view them as role models. Levinson (1999) and Ma nague, et al., (2001) conc luded that effective clinical teachers integr ate knowledge and skill by incorporating the basi c sciences into the clinical process and contextualiz ing dental education. The students in the present study confirm this concept 100

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Clark, et al. (2001) and OShea and Parsons (1999) reported e ffective clinical learning includes demonstration. This study confirms this concept and stude nts reported that they prefer to see and then do. The students also prefer faculty that are flex ible in clinic and allow the student to complete the assigne d tasks. This is not in agreement with Biddle (1996), Cunningham, et al. (1999), Ende, et al. (1995) and Hirons and Velleman (1993). In those studies, students preferre d faculty that provided strict clinic al supervision and completed tasks for the student. This study agrees with Fugill (2005), Kilminster, et al. (2002), and Jame s, et al. (2001) as students prefer faculty that act as facilitators. This study also confirms Chambers (1998) and McGrath (2005) which reports that students prefer faculty that respect the student/patient relationship and do not undermine the student in the presence of the patient. Students in this study preferred open discussion and communication with faculty and preferred an active role in the learning process which confirms findings by Chambers (1998), Fugill (2005) and Henzi, et al. (2006). The students in this study did not report that they treated patients based on requirements which was reported by Chambers (1998) and McGath (2005) but stated that they want to provide comprehensive care and do wh at is best for their patients regardless of requirements which confirms reports by Manague et al. (2001) and He nzi, et al. (2007). Future Research Future research should investigat e clinical teaching from the faculty members perspective. The model that emerged from such a study could be proposed and compared to the model from this study. The model from this study could be used to develop a curriculum in a specific clinical discipline and determine the effectiveness of this curriculum in clinical teaching. The same could be done for the faculty perspective model, and comparisons could be made in order 101

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to develop a curriculum for clinical teachi ng based on the data from several different perspectives. Although this study is limited in scope and scal e, it raises important issues that require further study and perhaps changes in teaching pr actices in dental schools. One recommendation would be to examine dental stude nt clinical practice from the clinical teachers perspective, perhaps using a semi-struc tured interview technique. Teaching and learning interactions between st udent and clinical te acher are also worth further study to document more precisely some of the issues surrounding communication, demonstration, feedback, and integration. Such a study could be carried out using structured observation and/or videotaping bu t would need to be designed carefully because of patient confidentiality issues and concerns about the intrusiveness of vide otaping. A study of this type may also provide further understanding of the pa tientstudentteacher tr iangular relationship. Other possible avenues for study include similar de scriptive studies in ot her clinics or other dental schools that could be conducted for the purposes of comparison and generalization. The findings from this study showed that many of the clinical teach ers are appreciated by students. Nevertheless, there is room for improvement in clinical teaching. A more studentcentered approach to the balance between teachi ng and supervision should be encouraged and better use made of both demonstration and feedback. Finally, clinical teachers should be aware of their power, that their smallest word or shortest sentence can make a difference. Walsh (2000 p. 21) pointed out that: The evident desire of students to be tr eated more like peersconflicts with the reality that [teachers] know more about the subject at hand[,]bear the burden of evaluating students[,]and gene rally manifest far greater commitment to the learning process. 102

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The importance of cultivating a positive relati onship between student and teacher has been evident throughout this study, is r ecognized as important to stude nt learning, and needs greater attention. Perhaps a way to further mutual understanding could be through the concept of building an alliance between stud ent and teacher (Tiberius, et al ., 2002). The key features of this alliance are mutual respect, shared respons ibility for learning, effective communication and feedback, cooperation, willingne ss to negotiate conflict, and a sense of security. 103

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Figure 5-1: Descriptive model of clini cal teaching based on student preference Respect & Rapport Clinical Environment Clinical Environment Clinical Environment Clinical EnvironmentOral Health Patient Oral Health Patient Oral Health Patient Oral Health Patient Competent Punctual Available Consistent Practical Professional Clinical Teache r Clinical Competence Clinical Competence Quality Care Quality Care Oral Health Patient Oral Health PatientClinical Competence Clinical Competence Quality Care Quality Care Feedback Respect Professionalism Respect for the student patient relationship demonstrated Clinical Competence Clinical Competence Quality Care Quality Care Knowledge Lel of Con evfidence Sel f -Assessment Autonomy Dental Student Dental Student Knowledge Level of Confidence Self-Assessment Autonomy Feedback Respect Professionalism Respect for the student patient relationship Clinical Competence Clinical Competence Quality Care Quality CareClinical Teache r Competent Punctual Available Consistent Practical Professional nt Compete Punctual Available Consistent Practical al Profession 104

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Table 5-1. Findings of study based on theoretical framework/perspective Key Points of Theory Findings Theory confirmed or refuted Characteristics of Effective Clinical Teachers Chambers, Geissberger, and Lekinus, 2004 The characteristics identified by students were: expert, enthusiastic, judicial and good soldier. Refuted There are characteristics that students perceive as favorable when determining teacher effectiveness Fugill, 2005 The characteristics identified by students were: competent, approachable, practical and consistent Confirmed Providing feedback Ber k, et al., 1998, Mager, 1997 Effective clinical teachers provide accurate comprehensive feedback to students in a positive environment Confirmed Role modeling Chapnick & Chapnick, 1999 Effective Clinical teachers are role models to students Confirmed Learning Environment Demonstration Clark, et al., 2001; OShea & Parsons, 1999 Effective Clinical learning includes demonstration. Students like to see and then do. Confirmed Integration of knowledge and skill Levinson, 1999; Manague, et al., 2001 Effective Clinical teachers integrate knowledge and skill. They incorporate the basic sciences into the clinical process and contextualize dental education Confirmed Supervisor Biddle, 1996; Cunnigham, et al., 1999; Ende, et al., 1999; Hirons & Velleman, 1993 Students prefer faculty that provide strict clinical supervision and complete tasks for the student Refuted Fugill, 2005; Kilminster, et al., 2002; James, et al., 2001 Students prefer that the faculty act as facilitators and allow them to complete patient procedures Confirmed Student/patient relationship Chambers, 1998; McGrath, 2005 Student prefer faculty that respect the student/patient relationship and do not undermine the student in the presence of the patient Confirmed 105

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Table 5-1--Continued Key Points of Theory Findings Theory confirmed or refuted Student autonomy and self assessment Croft, et al., 2005; McCuniff & Holmes, 1999 Effective clinical teachers allow student autonomy depending on their clinical level and encourage self assessment and evaluation Confirmed Communication/discussion Chambers, 1998; Fugill, 2005; Henzi, et al., 2006 Students prefer open discussion and communication with faculty. They want an active role in the process Confirmed Requirements Chambers, 1998; McGrath, 2005 Students claim that requirements drive their clinical experience. Manague, et al., 2001; Henzi, et al., 2007 Students want to provide comprehensive care and do what is best for their patients regardless of requirements Refuted Confirmed 106

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APPENDIX A INFORMED CONSENT Protocol Title: Qualitative description of Clinical Dental Teaching Please read this consent document carefully befo re you decide to participate in this study. Purpose of the research study: The purpose of this study is to identify and describe the faculty-studentpatient interactions that charact erize communications in the dental education clinic setting. What you will be asked to do in the study: You will not be asked to do anything specific. Your interactions/conversations with the dental student and faculty member will be observed. You and the student will be asked a few questions about your treatment at the end of the appointment. Time required: 1.5 hour. This will be during a regul arly scheduled dental appointment and will not affect the lengt h of the appointment. Risks and benefits: There are no risks or benefits. The re sults will help us to better educate future dental students. Compensation: You will not be paid for participation. Confidentiality: Your identity will be kept confidential to the extent provided by law. Your information will be assigned a code number. Your name and chart number will not be recorded on any of the observation information. Your name will not be used in any reports. Voluntary participation: Your participation in this study is completely voluntary. There is no penalty for not participating. This will have no effect on your status as a dental patient or your treatment. Right to withdraw from the study: You have the right to withdr aw from the study at any time without consequence. Whom to contact if you have questions about the study: Dr Nicholas J. Grimaudo, Associ ate Professor, University of Fl orida, College of Dentistry, 352392-0348, grimaudo@dental.ufl.edu Whom to contact about your rights as a research participant in the study: UFIRB Office, Box 112250, University of Flor ida, Gainesville, FL 32611-2250; 352-392-0433. Agreement: 107

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I have read the procedure described above. I volunt arily agree to pa rticipate in the procedure and I have received a copy of this description. Participant (Patient): ________________________________Date: _________________ Participant(Student): ________________________________ Date: _________________ Principal Investigat or: _______________________________ Date: _________________ 108

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APPENDIX B PATIENT INTERVIEW PROTOCOL 1) What dental work was done today? 2) How did the faculty interact with you? 3) How did the student interact with you? 4) How did the faculty and student interact with each other? 5) Who explained the treatment to you? 6) What further dental treatment do you need? 7) What are your main reasons for coming to the dental college? 8) What could be done to make your care better? 9) Please include any additional feeli ngs/responses concerning todays appointment? 109

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APPENDIX C STUDENT INTERVIEW PROTOCOL 1) What procedure(s) were you doing today? 2) How do you feel the faculty in teracted with your patient? 3) How do you feel the faculty interacted with you? 4) What did you learn today? 5) Describe how the faculty fostered (facilitated) your learning? 6) What could the faculty have done to make your learning experience better? 7) What is most important to you about Clinical teaching? 8) Please include any additional feelings/response s concerning todays cl inical interaction? 110

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APPENDIX D CLINIC OBSERVATION SCHEDULE GRID Monday Tuesday Wednesday Thursday Friday Month 1 Operative OHMC Prosothodontics Periodontics Periodontics Operative OHMC Prosthodontics OHMC Prosthodontic Periodontics Operative Prosthodontics Periodontics Operative OHMC Month 2 Periodontics Prosthodontics OHMC Operative Operative OHMC Prosthodontics Periodontics OHMC Prosthodontics Operative Periodontics Prosthodontics OHMC Periodontics Operative Month 3 Operative OHMC Prosthodontics Periodontics Periodontics Operative OHMC Prosthodontics OHMC Prosthodontics Periodontics Operative Prosthodontics Periodontics Operative OHMC Month 4 Periodontics Prosthodontics OHMC Operative Operative OHMC Prosthodontics Periodontics OHMC Prosthodontics Operative Periodontics Prosthodontics OHMC Periodontics Operative Month 5 Operative OHMC Prosthodontics Periodontics Periodontics Operative OHMC Prosthodontics OHMC Prosthodontics Periodontics Operative Prosthodontics Periodontics Operative OHMC Month 6 Periodontics Prosthodontics OHMC Operative Operative OHMC Prosthodontics Periodontics OHMC Prosothodontics Operative Periodontics Prosthodontics OHMC Periodontics Operative 111

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BIOGRAPHICAL SKETCH Nicholas J. Grimaudo grew up in Oceanside New York. He graduated in 1976 from Adelphi University with a Bachelor of Science in biology and received his DMD from the University of Florida, College of Dentistry in 1980. Nicholas was in private practice in Inverness, Florida from 1980 to 1992. He returned to the University of Florida to earn a masters degree in materials science and engineering in 1 992 and a masters degree in oral biology from the College of Medicine in 1995. Nicholas became an assistant pr ofessor in the Department of Biomaterials at the College of Dentistry in 1995. He is currently an asso ciate professor in the Department of Operative Dentistry. 124