Eur J Dent Educ 2005; 9: 131136

All rights reserved

Copyright Blackwell Munksgaard 2005

european journal of

Dental Education

Teaching and learning in dental student clinical

practice
M. Fugill
Dental School, Wales College of Medicine, Biology, Life and Health Sciences, Cardiff University, Cardiff, Wales, UK

Abstract Clinical learning in restorative dentistry is principally

centred around the provision of patient care, yet we know very
little about the learning processes occurring within the clinical
environment. A study of undergraduate dental student clinical
practice used a combination of group interview and questionnaire techniques to explore some of the characteristics of
student/teacher interaction that students finds significant, and
which they consider to affect their learning of clinical skills.
Study data, when analysed, revealed three major categories of
teacher or student behaviour which appear to be of importance

to students. This paper focuses on one of these, describing a

number of behaviours, grouped together under the category of
teaching/learning behaviours. The aim of the paper is to
report these results and to discuss their application to clinical
teaching of restorative dentistry.

also includes the patient, who adds extra complexity to

the learning process. For the student, clinical practice
involves irreversible operative procedures, which
must be executed without harm to the patient (3).
In order to prevent harm to the patient, the clinical
teacher must also be a clinical supervisor, and a tension
exists between the learning needs of the student, and a
duty to prevent harm to the patient.
This paper is based on a study carried out as part of
a further degree (4). The study examined aspects of the
clinical teaching carried out on a mixed restorative
clinic in Cardiff Dental School, University of Wales
College of Medicine. The study used a combination of
group interview and questionnaire techniques to
explore some of the characteristics of studentteacher
interaction that students finds significant, and which
they consider to affect their learning of clinical skills.
The aim of this paper is to report certain of the
results of that study and to discuss their application to
the clinical teaching of dentistry.

significant part of dental student training

consists of clinical practice on patients, under
the supervision of qualified dentists. Although many
health care professions use a clinical environment in
the teaching of students, the teaching of dentistry has
a number of unique aspects.
There is a good deal written in the literature on the
assessment of dental student clinical practice. But,
whilst medicine and nursing have a literature rich in
discussion of student learning in clinical practice, in
dentistry that literature is almost non-existent. Studies
that do exist focus principally on appropriate teacher
behaviours in the clinical setting (1, 2).
Dental students may be expected to learn from a
number of sources during their clinical practice; for
example from the clinical procedures themselves,
from interactions with patients, dental nurses, dental
technicians and student colleagues. The way in which
the student learns from each of these sources appears
to be largely unexplored.
Clinical learning in restorative dentistry is principally centred around the provision of patient care. In
providing patient care clinical teacher and dental
student interact on a one-to-one basis, a relationship
which has been traditionally perceived as one of the
key elements in student learning. Yet this process may
not be particularly conducive to student learning,
principally because the clinical learning environment

Key words: education; dental clinical skills.

Blackwell Munksgaard, 2005
Accepted for publication, 8 March 2005

Study methodology
Qualitative research methods
There are a number of research methods for collecting
and analysing qualitative data. In general they rely on
verbal, non-verbal or written communication between

131

Fugill

researcher and sample, rather than on physical measurement. Examples of such research methods include
group interviews and questionnaires.
Interviews have the advantages of being able to
collect a depth of data often inaccessible using questionnaire techniques. They are considered useful for
exploratory research. This is especially true if the
interview is unstructured, and the extra dimension of
a group interview style increases the potential for
understanding the issues affecting a group as a whole
(5).
Questionnaire surveys are well-recognised tools in
both qualitative and quantitative research. It is
common in qualitative research to collect data in
more than one way, because such triangulation is
thought to increase the validity of the information
being collected. It is also common to use group
interviews for preliminary investigation in order to
inform the development of an appropriate questionnaire.
Content analysis is a research method frequently
used to understand and to make valid inferences from
textual data (6). Central to content analysis is the
breaking down of the material into individual items
sometimes phrases and sometimes individual words.
Once identified, such items can then be allocated into
a finite number of categories for analysis. Such
categories are derived by the researcher, either from
the data itself, and/or from an external source if
available. Derivation of categories, whilst ensuring
that the interpretation of the data remains reliable and
valid, is the most challenging aspect of textual
analysis. Because categorisation is dependent on
meaning as understood by the analyst, he or she
becomes an integral part of the research process (7, 8).
In the present study it was the derivation of the
categories themselves which provided important
insights.

The study
The study cohort consisted of all the students from the
third and fourth years of the Bachelor of Dental
Surgery programme (4th BDS and 5th BDS) at the
Dental School, University of Wales College of Medicine. All students in the cohort were involved in
clinical practice on the same mixed restorative dentistry clinic.
Collection of data took place in two distinct stages.
The first of these involved a number of group
interviews with a self-selected subset of the study
cohort. Subsequently data from these interviews
informed the development of a questionnaire which
was then administered to all students in the cohort.

132

Group interviews
The first data collection took the form of two group
interviews; one with a self-selected group of 4th BDS
students, the second with a self-selected group of 5th
BDS students. Both groups were taught by a similar
mixture of dental clinical staff on the same clinic.
Because students interviewed were volunteers, the
composition of the interview groups was not random.
The interviewer played no part in the make-up of the
interview groups. The interview process was unstructured in each case, on the basis that this might allow
the most significant elements to enter into discussion.
The interviews were recorded on audio tape (with
group permission) and later transcribed for analysis.
From this content analysis three major themes of
student concern were derived as depicted in Fig. 1.

Questionnaire-based survey
Questionnaire development was informed by the
issues raised during the interviews. The questionnaire
was piloted with both staff and a selection of students
from the cohort. It contained principally closed questions to be answered using binary and Likert-type
response scale, though there were also three openresponse questions.
After piloting and adjustment the questionnaire was
administered to all students in the cohort. Over a
1-week period 98 questionnaires were issued to students at the beginning of an appropriate clinical session.
It was intended that students complete the questionnaire directly following the clinical session, providing a
cross section of comment on the session. All returns
were anonymous. Eighty-five questionnaires were
completed and returned, though in 15 cases return
was delayed until the following day. The return rate
was 83%, giving a representative sample. Distribution
of returns by year of the course and by gender is
described in Table 1.
The collected data were analysed for frequency,
mode and median and, where appropriate, mean and
standard deviation. Many of the open responses
contained reflection on teacher comments. All such
reported comments were interpreted with caution,
being based on recollection which may be incomplete
or misunderstood.
Comparison between group interview and questionnaire results showed a high degree of agreement.
Using group interview data to inform the development of the questionnaire will have played a part in
this. Nevertheless it is assumed that the level of
agreement between the two data collections increases
confidence in the data.

Dental clinical skills

Student behaviour

Teaching/learning
behaviours of
importance

Student confidence (or lack of

confidence) in the presence of
the patient
Student relationship with the
clinical teacher, and its
importance to student learning

Desirable
characteristics of the
clinical teacher

Professional competence
Approachable personality
Punctuality
Availability
Consistency
Practicality
Understanding of the limits
of student knowledge
Respect for the
student/patient relationship

Importance of feedback
Importance of demonstration
The integration of theory and practice
Importance of student autonomy
Importance of self-assessment

Fig. 1. Three major themes (with subthemes) derived from interview data.

tion, integration of theory with practice, and student

autonomy.

Discussion of results
During the content analysis process it became apparent that there were three broad categories of elements
within the studentteacher relationship. These were
student behaviour, teacher characteristics and teaching/learning behaviours, though it is true that these
areas overlap in a number of ways. The focus of this
discussion is on some of the teaching/learning behaviours that appeared to be of importance to students.
Students made a number of significant comments
concerning teaching/learning interactions, both at
interview and as responses to open questions in the
questionnaire. Such comments should be understood
in context, that context being clinical teaching in
dental student clinical practice, and that the comments come exclusively from dental students. Nevertheless many reflected themes common to other
teaching environments, such as feedback, demonstraTABLE 1. Distribution of returns by gender and year of course
Year of course

Female

Male

Total

4th BDS
5th BDS

22
21

22
20

44
41

Total

43

42

85

Feedback
The importance of the quality and especially of the
emotional tone of feedback to the students in the study
was made very clear by comments at interview, such
as:
One clinician said to me the other day, Look, if I
was doing that, I dont know if Id be able to do it
anyway, so dont worry, you are here to be
taught. So he said a positive thing, but then he
said Youve got to improve on this. You felt like
going back to your patient and doing [the task]
really well, and instead of [saying to yourself]
hes really put me down, I just want [the patient]
to go now. You really want to strive to do better.
The study also underlined the power that feedback
puts into the hands of the clinical teacher. As one
student commented, even the smallest word or the
shortest sentence can make a difference.
Because interview data indicated the importance of
feedback to students, the questionnaire included three
closed and one open question on feedback. The open
question asking for a description of feedback received,
to which there were 69 (out of a possible 85) responses.

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Fugill
TABLE 2. Student perception of the amount of feedback received
No. of returns

1 No feedback
2
3
4 Sufficient feedback

28
16
28
13

33
19
33
15

Total

85

100

The first point to mention is that (Table 2) very few

students thought they had received enough feedback.
The data indicate that most feedback consisted only of
staff reassuring students that their work was fine,
though a few more detailed staff comments were
reported. Most such comments were reported as being
positive in nature, though there were criticisms of the
feedback in some open responses, suggesting that
teachers focus on negatives.
Feedback is generally recognised as important to
student learning, as it provides the student with
understanding on which to base future learning (9).
Feedback perceived to be incorrect by the student, or
negative feedback which is personality or ability
related, may affect self-efficacy and motivation
(10, 11). Moreover, the emotional tone of feedback is
thought to be closely interlinked with student motivation and self-efficacy, and important to the students
ability to learn effectively (12). Mager (13) provides a
useful way of understanding feedback in clinical
teaching by classifying it as adequacy, diagnostic or
corrective: adequacy feedback providing information
on the adequacy of the clinical outcome, diagnostic
feedback providing detail on the shortcomings in the
clinical outcome, and corrective feedback suggesting
action to be taken to ameliorate those shortcomings.
It does appear that students appreciate feedback
which is accurate, comprehensive and systematic, and
provided in a positive emotional environment. Given
the importance of feedback to student learning,
perhaps dental clinical teachers should be encouraged
to offer feedback in a more comprehensive, structured
and positive way; more comprehensive in that
feedback should contain diagnostic and corrective
information; more positive and encouraging in
tone. Structure, perhaps using a standardised form,
would give dental teachers a focus for the feedback
process.

Demonstration
Students in the study commented on how useful they
found demonstration of procedures by staff. Of course
this happens regularly in pre-clinical restorative dentistry, but it does appear that students find demonstration on patients to be useful:

134

TABLE 3. Student procedures and demonstration

Was this
procedure
demonstrated
by your clinical
teacher?
Was this a new
procedure to you today?
No
Yes

No

Yes

115
20

12
8

Total

135

20

Total

127
28
155

Some will actually do part of the prep for you.

Thats when you actually gain, when you see
what a 1.5 mm shoulder looks like.
In practice the study showed that, although new
procedures did generate more (P 0.006) demonstration than did familiar ones, demonstration actually
appeared as a feature in relatively few student
procedures (Table 3).
Demonstration is thought to be a significant factor in
learning psychomotor skills (14, 15), and ought to be a
common feature of dental student clinical practice.
Clinical teachers should be encouraged to make
demonstration a regular practice where students are
learning new procedures, even though it does take
significant time.
Although essential to student learning, demonstration needs careful managing. Knowledge underlying
demonstration is often tacit and not visible to the
student (16), and needs to be clearly communicated as
part of the demonstration. It should also be borne in
mind that demonstration has the potential to undermine the studentpatient relationship.

Integration of knowledge and skill

In the group interview data a number of students
complained that the theoretical teaching they receive
was non-contextual, and that they were offered no
help in the integrative process. As one student
commented, people tell us get on with it, you
studied it two years ago, you should know this. As
a result two questions relating to student preparation
for clinical activity were inserted into the questionnaire. Responses to these indicated that most students,
when faced with new procedures, did prepare themselves, and found personal preparation to be useful.
Nevertheless, because the student does not yet
have the experience to categorise and link information to experience, and because not all students have
had the same clinical experience, contextual teaching
should be part of clinical practice. It appears from the
student perspective that there is a reluctance to
engage in this.

Dental clinical skills

It has become usual to divide, and think of,

professional activity as consisting of separate
domains of knowledge, attitudes and skills. It may
be more accurate to envisage student learning as
taking place in a number of different domains
simultaneously during clinical practice, or perhaps
in the interaction between them (17). It is the
responsibility of the clinical teacher to facilitate
learning within clinical activity, which might be
structured (18) to promote learning by interaction
between knowledge, attitudes and skills, so that both
cognitively and also physically, the clinical practice
environment becomes a convergence of academic
and practical understanding.

Student autonomy and student self-assessment

Because the clinical teacher is legally responsible (in
the UK at any rate) for the patients well-being, there is
a tendency inherent in dental student clinical practice
towards teacher-led clinical decision making. All
clinical teachers have had occasion to take over the
students work occasionally to protect the patient.
Many students in this study had experienced this
infringement of their autonomy, and it appeared to
cause some resentment for a variety of reasons. For
example:
Were supposed to be diagnosticians as well, not
just technicians. If they say do this, do that then
we get into the habit of going OK rather than
thinking carefully and thinking why, specifically
am I using this material?
If its going wrong, the best person to sort it out
is the clinician. Sometimes you dont want them
to pick up the handpiece; its just knowing when
you need the help and when you dont.
Dentists, as professionals are expected to take
responsibility both for their clinical decision-making
and in their own professional development. In this
context it seems reasonable to suggest that student
clinical activity needs to be directed towards increasing autonomy to prepare the student for practice.
It also appears important, for a number of
reasons, to familiarise students with assessing their
own clinical work. First, it is recognised that selfassessment is an important promoter of learning (19)
at the heart of the educational process itself and one
of the aims of professional education (20). Second,
the ability to self-assess is thought to be important
in the development of the motor skills which are
important to clinical activity (21). Third, the ability
to self-assess is thought to be important to the
professionals ability to monitor personal standards
of care (22, 23).

Conclusion
For most of its life, research in dentistry has been
dominated by quantitative research methodologies.
Yet qualitative methods of information collection
and analysis are on the whole more suitable to
understanding a complex physical, social and psychological environment in which the isolation of any
particular variable for study is impossible (24). It can
be suggested that the emphasis on quantitative
methodology has resulted over time in a relative
neglect of the social and interactive aspects of
dentistry (25), and may go some way to explain
the lack of discussion in the dental literature of
clinical teaching.
It is also true that qualitative methodologies have
their limits. The research process is primarily descriptive, and the understanding gained may not be generalisable nor predictive. It means that the conclusions
noted in this paper must be specific to the clinic and the
study cohort. Adequacy, or otherwise, of the clinical
teaching provided cannot be taken as indicative of other
clinical teaching environments without much broader
examination, though many of the concepts noted do
also appear in discussions of clinical teaching in other
health care professions (2630).
This paper focuses on some of the significant
teaching/learning behaviours revealed by the study.
These behaviours are examined uniquely from the
student perspective, providing a necessarily incomplete understanding. Even so, some tentative conclusions can be drawn, and will need to be tested in other
contexts. An obvious complement to this study would
be to examine dental student clinical practice from the
clinical teachers perspective.
Many of the ideas discussed above, such as demonstration, motivation and positive affirmation, also
occur in the concept of role modelling. The idea of
the dental clinical teacher as a role model was
discussed by Chapnick and Chapnick (2). Mentoring
and role modelling are an accepted part of medical
educational literature, but the idea seems also to be
relatively neglected in dental educational literature.
Perhaps appropriate role modelling has a useful part
to play in the process of helping dental students to
learn the knowledge, skills and attitudes appropriate
to independent clinical practice.

Acknowledgements
The author wishes to express his thanks to the dental
students who enthusiastically participated in the

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Fugill

original study and to Mr Mark Brennan for his helpful

comments during the preparation of this paper.

18.

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Address:
Martin Fugill
Dental School
Heath Park Cardiff, CF14 4XY
UK
Tel/fax: +44 (0)29 20743704
e-mail: fugill@cardiff.ac.uk