Dr James Field & Dr Simon Stone Lecturers in Restorative Dentistry

1. Improving student satisfaction within a clinical setting Dr James Field & Dr Simon Stone Lecturers in Restorative Dentistry

2. The problem • Dental clinical educators are faced with the unique challenge of providing a quality teaching experience for students whilst, at the same time, ensuring quality of care and appropriate levels of service provision within the National Health Service (NHS) • The environment within which this is carried out is also unique, requiring close integration with University and NHS resources; achieving a balance is critical to the success of both organisations. • Within these professional and organisational constraints, Dental clinical teaching staff must also ensure that students have the opportunity to fully engage with, and reflect upon, each patient encounter. • With appropriate support and direction, most will find this transition manageable and rewarding. The challenge is to ensure that all clinical students receive the appropriate levels of individual support. Competent in basic operative procedures (procedural knowledge) Adaptive approach to patient care Internalising values – self-reliance, teamwork, objective approaches to problem solving, professional commitment to ethical and indiscriminate practise Some students prefer to have techniques verbally explained, others prefer to watch the technique performed, do it themselves or a combination of the three. Time is limited, and it is important to impart the necessary information and check knowledge and understanding where appropriate. The experience of the clinical encounter has the potential to be extremely valuable – an opportunity to problem solve and experiment that’s almost unique to dentistry.

3. The literature • Teaching styles • Typically school teachers verbally dominate the classroom • Some students may become passive and dependent (Flanders 1963) • Very little is known about how clinical teachers teach (Sahlberg 2008, Blatt 2008) • Evidence suggests that medical teacher-student interactions were also heavily teacher-centred • We have no idea how this affects individual students! • In isolation, this style does not easily facilitate a transition towards adult learning • Effective practical teaching • Positive reinforcement, positive atmosphere, higher-order questioning & feedback (Walberg 1986) • Continuous professional learning, critical thinking, teamwork and professional trust (Hargreaves 2003) • These developments are unlikely with an overly dominant teacher (Sahlberg & Boce 2010) • Increasing student participation, peer to peer interaction and active questioning can improve professional attitudes (Smith 1977)

4. The literature • Group teaching • Students may value learning opportunities and teaching interactions differently • Although level of engagement can correlate with performance, classroom interaction style contributes little (Foster 1979) • So does a generic classroom approach work? Should we relate to individual student preferences? • Flexibility in teaching will not be forthcoming if the teacher has fixed philosophical views or educational ideas (Weinstock 1974) • This ability to be flexible and differentiate individual or smaller group needs has been referred to as “Quality of influence” (Flanders 1960) • But little is known about how this Quality of influence can add value to an individual student’s teaching experience

5. Aim • To investigate patterns of verbal communication and determine methods to positively influence student satisfaction • Objectives • Observe a series of clinical encounters and record the patterns of verbal interaction • Record the level of student satisfaction over a number of domains • Investigate emergent themes through qualitative interviews

6. Clinical encounter with patient Methods Consent Initial treatment discussion Record verbal interaction • Interactions • Verbal interaction analysis • Coded observations • Content-free • Temporal • Satisfaction • Immediate anonymised questionnaire • Follow-up qualitative interview • Student involvement – innovation fund Record student satisfaction Treatment Transcribe data Analyse sub-components against overall student satisfaction and carry out qualitative interviews Post-treatment discussion and discharge Analyse against overall student satisfaction

7. Findings - quantitative • We observed 122 teaching episodes over 4 different clinic disciplines • No students were dissatisfied with their teaching encounter (Surprising? Pilot?) • No VIA components were significantly associated with student-reported satisfaction • We found several significant associations for satisfaction with student-reported measures: Opportunity to clarify theory/techniques Level of explanation or demonstration I received Level of praise I was given Opportunity to pause for thought or develop answers

8. Findings – what does this mean? • We found no significant associations for satisfaction with observed interaction analysis: Not enough poorly satisfied students observed (unlike pilot?) We are unable to generalise – it is the individual student interaction that is important • We found several significant associations for satisfaction with student-reported measures: Clearly there are student-perceived factors that impact on satisfaction The key here is ‘perceived’ Students who reported receiving little praise often had praise recorded in the VIA This is not just about the make-up of the encounter, but the delivery as well The factors relate to a level of ‘respect’ between teacher and pupil We could consider this to be an educational ‘quality of life’?

9. What do we do now? • It is probably useful to understand the environment in which we conduct our clinical teaching… • The opportunities for interaction with students in this environment are often brief. • There is the constant challenge of balancing patient safety and care with ensuring quality teaching for our undergraduates.

10. Current processes • There are opportunities throughout the ‘patient encounter’ for interaction, discussion, challenges of knowledge and feedback. • We have a number of processes of monitoring student satisfaction with our clinical teaching (course reviews, staff 360 feedback, student led staff-student committees) as well as the more formal accreditation processes that are requirements of the University (ISR) and our professional regulator (GDC). • All of these processes are poor at looking at student satisfaction at an individual level. • We therefore undertook a series of qualitative interviews in an attempt to understand further the factors that influenced student satisfaction with clinical teaching.

11. Methodology • Two trained interviewers undertook a series of face-to-face semi-structured interviews with a convenience sample of third and fourth year dental students. • The sample included male and female students including overseas undergraduate students. Interviews took place away from the clinical environment by staff that did not directly supervise those students but had previous contact with them. • A topic guide was populated based upon our satisfaction data and continually added to as interviews were conducted • In total 15 students were interviewed either individually or in pairs, the mean interview length was 10:27.

12. The freedom within an interview allowed us to explore reasons for both satisfaction and dissatisfaction • Thematic, framework analysis was undertaken to determine the emergent themes. • These related to student satisfaction and dissatisfaction related to: • Direction and supervision • Clinician (staff) behaviour • Feedback

13. Direction and supervision • There was a perceived need for the clinical supervisor to balance giving students freedom to try things out but with sufficient direction and sometimes intervention to ensure that the task was accomplished. • The amount of direction desired was highly personal that differed at an individual level. It was also dependent upon their own past clinical experiences and self confidence. • “It wouldn’t be very useful to have constant supervision, it would hinder our progress…its good to be left to our own devices to a certain extent.” (Stage 4 Dental Student) • Some elements of autonomy were important to be able to independently problem solve without the input of the supervisor. “Very close supervision puts us under more pressure…I don’t like it when people stand over your shoulder and watch, it makes me nervous.” (Stage 3 Dental Student)

14. Direction and supervision The frequency by which staff were needed to support fluctuated depending upon the complexity of the procedure and the level of clinical experience. This was again a very personal thing but clear instruction by the member of staff was expected. “It is beneficial to have a considerable amount of direction, particularly in third year, because you are just starting out, I think it has decreased somewhat as your clinical skills and ability to carry out procedures improves.” (Stage 4 Dental Student) Students seemed to establish their own (unwritten) ground rules with individual members of staff with whom they had frequent contact. “Clear instruction and knowing exactly what is expected of you…but also being given the freedom to proceed.” (Stage 3 Dental Student)

15. Clinician’s behaviour • Approachability, consistency and accessibility were recurring themes, generally staff were seen to be friendly and fair. • The approachability of staff is important in providing good standards of care…it also means that we can make progress (Stage 3 Student) • A professional relationship developed over time between staff and student which allowed them to gauge their current performance on how they had done with other, similar, cases. • Some staff were frequently away and clinics were covered by different staff. Students did not like conflicting differences of staff opinion that this brought, they generally wanted to see the same members of staff to check their work. There was some acknowledgment that this could have its drawbacks in the diversity of the opinions however: • “It just gets confusing… It also puts us in an awkward position.” (Stage 4 student)

16. Clinician’s behaviour • It was important for the staff to be accessible before a clinic to allow the opportunity for students to check and confirm their knowledge or treatment plans. • There are always potential points of conflict when students’ knowledge is inaccurate or they carry out something to a poor standard. • “As long as the clinician deals with it in a professional manner then personally I just see it as a learning experience.” (Stage 3 Student) • Students welcomed the ability of staff to ensure that the student appeared competent in front of the patient so that confidence was maintained, any flaws in treatment or knowledge could be highlighted in end of session feedback. These discussions were more important than grades. • “It is not helpful to be grilled in front of the patient…but it is helpful to get ‘B’ grades, if you were getting merits and you weren’t the best student then it would make you too relaxed, so I think the grading should be quite harsh.” (Stage 3 Student)

17. Feedback • Feedback was generally seen as a process that occurred at the end of a clinical session, rarely did students put forward that it was a continual process. • The clinical environment was seen to be a potentially stressful and intimidating one, prompting students was often necessary and helpful. • “I think that if you are intimidated then even if you know something you might find it harder to get the information out because you feel like you are being put on the spot.” (Stage 3 Student) • Staff were seen to be thorough in their questioning but it was important for this to be done when the patient was not present: • “You don’t feel as stupid if you have to be corrected [if the patient is not there].” (Stage 3 Student)

18. Feedback • Fourth year students were more accepting of being challenged about their performance, initially they found it intimidating. It was important that there was sufficient time available to be reflective of their performance. • It was important to obtain a balance between positive and negative feedback to ensure that progress continues to be made. • “It can make you feel a bit down...sometimes it may be warranted but if you don’t get any praise then you don’t leave the clinic feeling massively great about yourself.” (Stage 4 Student)

19. Summary • Clearly we are not perfect! • These interviews were important to attempt to understand the processes that lead to student satisfaction and dissatisfaction with clinical teaching, particularly given the results of the quantitative work. • We have a real challenge of ensuring consistency with around 50 part-time NHS employed Associate Clinical Lecturers delivering a significant proportion of the clinical teaching.

20. What next? • We plan to develop a small teaching booklet to draw together the bulk of our findings • This will also include details about reflective practise and a model for effective clinical teaching Thank you for listening!

21. References • BLATT, B., CONFESSORE, S., KALLENBERG, G. & GREENBERG, L. 2008. Verbal interaction analysis: viewing feedback through a different lens. Teaching and learning in medicine [Online], 20. • CANTOR, N. 1953. The teaching-learning process, New York, Dryden Press. • FLANDERS, N. A. 1960. Teacher influence, pupil attitudes and achievement. • FOSTER, P. J. 1979. Verbal participation and outcomes in medical education. A study of third-year clinical discussion groups. Annual Conference on research in medical education. California. • HARGREAVES, A. 2003. Teaching in the knowledge society: Education in the age of insecurity, New York, Teachers College Press. • SAHLBERG, P. 2008. The more you talk, the more you learn: Missing conditions for cooperative learning in secondary schools. Conference for Cooperative learning in multicultural societies: critical reflections. Turin, Italy. • SAHLBERG, P. & BOCE, E. 2010. Are teachers teaching for a knowledge society? Teachers and Teaching: theory and practice, 16, 31-48. • SMITH, D. G. 1977. College classroom interactions and critical thinking. Journal of educational psychology, 69, 180-190. • WALBERG, H. J. 1986. Synthesis of Research on Teaching. In: WITTROCK, M. C. (ed.) Handbook of research on teaching. New York: Paragon. • WEINSTOCK, H. R., STARR, R. J. & FAZZARO, C. J. 1974. Comparing secondary teachers on logical consistency in educational philosophy and flexibility in teaching. Instructional science, 3, 115-126.