Dental student perceptions on clinic supervision: A qualitative study

INTRODUCTION

The Philippine Doctor of Dental Medicine program is a 6-year course consisting of basic science, clinical science, and dental public health. General education is in the 1^st year, basic medical and dental sciences are taken from the 2^nd to 4^th years, and clinical training for the 5^th and 6^th years. Since dentistry involves skills, the lecture subjects complement laboratory subjects. As the students become safe beginners from their laboratory sessions, they later move to actual patients and treatment in a real dental operatory set-up (clinics). These students are in their 5^th- and 6^th-year levels. Limited dental procedures under the strict supervision of faculty are allowed as part of the students’ clinical requirements for graduation. In their past year, more complex procedures and less supervision from the faculty are expected from the students. The clinical setting is notorious for being an incidental teaching and learning environment.^[1] The faculty has little to no control on the type and number of patients coming to the clinics. Furthermore, they have multiple roles and responsibilities that not only encompass the clinics but also must address issues that hinder the students’ learning.

A qualitative study of student perceptions in the United Kingdom by Fugill in 2005 studied the features of teacher-student interaction that the student finds significant. They utilized a group interview followed by a questionnaire-based survey to study this relationship. Interviews among students revealed themes that they perceive as important, such as the importance of feedback, demonstration, integration of knowledge and skill, and student autonomy, and most of the time, the faculty members were deficient in these elements.^[2]

Jahangiri et al., in 2013, utilized a qualitative study to investigate student perceptions of positive and negative characteristics of clinical supervisors. Two open-ended survey questions asking what qualities the students like most and least in their faculty were answered by 157 junior and senior dental students at New York University College of Dentistry.

Nine hundred and ninety-five written comments were coded, grouped into keywords, assembled into 17 defined categories, and then organized into themes. Competence of the faculty, including the categories of knowledgeable, expertise, efficient, skillful, and effective, were not the top characteristic (29.2%) that students perceived as important. The character of the faculty, including the categories of caring, motivation, empathy, patience, professionalism, available, fairness, happiness, and patient-centered were the most important characteristic (59.1%) that students perceived as important.^[3] Clinics are the platform where the dynamic interplay between patients, teachers, and students is seen. All of these constitute clinical supervision. Adults, both trainees and clinicians, are motivated to learn when they face real-life problems needing real-life solutions that are considered essential for progress or improvement.^[4] Patients play a critical part in the development of the student’s clinical reasoning, communication skills, and empathy. Teachers likewise play an important role in developing students to be critical thinkers and lifelong learners so that their learning continues even after graduation. Thus, it is important to look into student perceptions of clinic supervision.

MATERIALS AND METHODS

This study utilized a qualitative method through focused group discussions (FGDs). For each FGD, the target sample size is six to ten participants. Six to twelve participants are enough if the research scope is narrow and the target audience has a similar background.^[5] Guide questions were prepared to probe through exploration. A facilitator who has a background in Master of Health Professions Education and prior experience in facilitating was requested to conduct the FGD proceedings. The audio recording was used to record the data. The minutes were transcribed to facilitate analysis and sent to the facilitator and participants after 1 week for validation.

Those who agreed to participate in the FGD were asked to fill up an attendance sheet which was stored and sealed. Each FGD group was assigned a number, and participants were also assigned numbers. The data collected were secured with stringent measures to prevent unintentional access to them. All data were stored in a password-protected computer in a secure place before data processing and analysis.

Audio recordings were transcribed, then a content analysis of the validated transcriptions was done. NVivo 12 was used to identify the words, in which the participants often mentioned, thus identifying the common themes. A constant comparative approach^[6] for analyzing data was taken to ensure a rigorous approach. To establish credibility, meticulous checking was done to validate the derivation of themes from the statements of the participants.^[7] To establish confirmability and dependability, peer review by a healthcare professional with a Master’s degree in Health Professions Education was done to gather insights, feedback, and inputs for data analysis and interpretation.

RESULTS

Five FGDs consisting of 6 students each were conducted to probe on students’ perception of clinical supervision. In total, 30 students participated. Most were female junior students. The first theme which arose from the student perceptions was the lack of time due to the high faculty-student ratio. Students agreed that time is precious and the availability of the faculty in the clinics is lacking. Most of the time, they had to wait in line to have their cases discussed, approved, checked, and graded. They believed that discussions helped them understand their cases more, even if at times, there were “irrelevant” questions asked that they cannot answer. “Irrelevant” questions are questions that students perceive to be unrelated to the clinical procedure they plan or are currently working on with their patient. They felt that this made their clinic time much shorter. They do not like being asked in front of their patients because they feel humiliated when they do not know the answer. Although at times, they deem the questions necessary because they see it as a review for themselves. With the apparent times of lack of faculty time to coach, students at times notice a passive kind of feedback given to them. Instead of the assigned faculty’s comment on the quality of the work done, they might just nod or ask the student to proceed to the next step. Some of them noticed that no feedback equates to an acceptable procedure done. Students appreciate constructive, fair, and positive feedback. They felt bad when their work was criticized, but they learned to accept their faults and improve on their next case. The clinical forms have the rubrics on how students were graded, but at times they felt short-changed because the deductions do not have a specific comment. Since time is lacking, the students usually leave their clinical forms while they escort their patients outside, clean their dental instruments, or disinfect their assigned dental chair. Students appreciated when the faculty allotted time in the clinics to demonstrate certain skills, most especially if the case is remarkable.

A second theme which arose was that certain faculty traits affect students’ perceptions of clinical supervision. Faculty characteristics which affected them positively would be patience, approachability, and fairness. Intimidating faculty made them feel uneasy and nervous in the clinics, on top of the load of clinical requirements, they had to finish to be able to graduate. Students think that their difference in personalities makes them perceive differently as well. One might be okay with a faculty who is strict and shouts, but most of them do not welcome it. Most, if not all, liked it when the faculty told them about their errors in a positive way, which made them feel encouraged to do better the next time. Faculty characteristic which affected them negatively was preferential treatment or favoritism that they see in the clinics. Students at times notice this faculty trait in certain students who exhibit familiarity due to mutual organizations, being a former student in the classroom, or just simply a friendly student. Students generally believed that faculty was stricter with the senior students because they had prior experience and reliable skills compared to junior students.

DISCUSSION

The apparent lack of time due to the high faculty-student ratio affected clinical supervision negatively. Similar to the study of Shoaib et al. in 2016, the students shared the sentiments of having a smaller faculty-student ratio to have better clinical supervision.^[8] Clinic time is valuable for students because they are given numerous clinical requirements to finish for the semester. Feelings of being rushed were compounded by the fact that most procedures need to be evaluated on each step before they were permitted to proceed on to the next step. Moreover, the faculty needs to check these multiple steps for all the 12–13 students that they are concurrently checking at any given time during their clinical duty. Other countries employ a 1:6 faculty-student ratio in the clinics.^[9] Students want faculty who can distribute time fairly.^[10] Since time is valuable but limited, it is best that faculty utilizes their and students’ time wisely. Giving feedback in a clear manner and asking questions thoughtfully are just some ways of maximizing time and fulfilling the necessary reflection on experience which is an important component of the explanation cycle of clinical teaching.^[11] Not all those who have Masters or Doctorate degrees have trainings in teaching. Mentoring of “novice” by “expert” teachers is usually done in lecture subjects. A similar practice – for example instituting the practice of “shadowing” of “expert” by “novice” teachers can improve the clinical supervision skills of novices.

Certain faculty traits may affect student motivations positively or negatively. Students regard being patient, approachable, and fair as important qualities of a good clinical supervisor. Affective skills such as caring, motivating, empathy, patience, professionalism, and fairness are majorly regarded as important qualities of a faculty.^[3] Students believed that these skills are important for them to learn efficiently. Dentists have the role of interacting with patients in proximity for at least 30 min, a few times in a year. Patients often can choose their dentists, and they most likely chose the ones whom they are comfortable with. Students experience this in the clinics and they strive to make their patient’s appointment pleasant. This value on positive traits perhaps translates to what they value in the faculty. They want to be approachable to their patients, they want the faculty to be approachable (not intimidating) as well. Students believe that effective learning experiences involve situations of approachable faculty in the clinics.^[12] As such, these affective skills may also be part of faculty selection and evaluation, given the importance that students place on them. The negative faculty trait which was mentioned was preferential treatment or favoritism. Students attribute this faculty trait when they compare themselves with other students who had “easier” experiences in the clinics. Students notice that those who are familiar with the faculty are most often preferred. This familiarity can come from being a former student in the teacher’s class. Teacher expectations can play a big role in teacher favoritism.^[13] Part of this expectation was formed on how the student behaved in the classroom. For example, teachers may view troublesome students as less competent.^[14] Although some may argue that it is possible to have preferential treatment inconspicuously, it can still have negative effects on the teacher’s reputation. Trust between teacher and student may decline, thus producing a poor learning environment. Students perceive that faculty are much more strict with senior clinicians. There are higher expectations of their capacity to apply theoretical knowledge acquired during the pre-clinical years, and in handling patients since they have done so already in the past year level. Students understand the higher expectations and feel burdened when they do not remember the requisite information. But still, they expect the faculty to help them integrate knowledge and practical skills in the clinics,^[2] thus facilitating their learning.

Students often feel insecure in their abilities because translating knowledge to skill is a difficult task. They try hard to perform well in the clinics to finish their requirements. They like supervisors who can give feedback and criticize their work but in a positive way. Faculty who give encouragement and those who promote students’ self-confidence may perhaps help students improve and persevere in more difficult clinical tasks. Students sometimes noted a passive form of feedback wherein instead of a positive comment, all they get is a “proceed to next step” response. This clearly shows that students expect their patient encounters to be converted into the explanation cycle with the faculty.^[11] Reflection, explication, and addition to their working knowledge build up their clinical skills. This also includes deductions in clinical forms with no specific explanation. Students rely on feedback for development and improvement most especially in the clinics.^[15,16]

Students expect respect from the faculty, particularly as they become more skilled and approach the status of becoming a peer with the supervisors. This is also related to faculty traits that students view as positive. The negative faculty trait which contributed to the domain of learning environment was preferential treatment or favoritism. Students see this at times if the faculty has the same student organization as the other student or being a former student of the faculty (familiarity), and if the student is simply friendly. This further reinforces the importance that students place on fairness.^[2] Each faculty must remember that a safe learning environment allows the students to develop and refine their clinical skills as they become professional dentists in the future.

CONCLUSION

Students mentioned faculty traits of patience, approachability, and fairness as positive traits in a clinical supervisor. On the other hand, students agreed that the general lack of time due to the faculty-student ratio made it difficult for the faculty to allot sufficient attention to each student. This negatively affects the learning environment. Understandably, this is a complex and multifactorial problem, and perhaps hiring more faculty is not the sole solution. Looking into the training of faculty, maximizing the competence of the “expert” faculty, establishing mechanisms for faculty feedback, coaching, and mentoring might be a more immediate, economical, and responsible alternative. After all the goodwill of the faculty can be assumed. What is needed is for them to be given the resources and the support to continually improve themselves as clinical supervisors. This study just highlighted some areas and suggestions on how to do that.