Teaching Guide: Teaching Novice Dental Hygienists
Many health care professions receive education in both didactic and clinical training. In dental hygiene, students begin learning within a clinical environment, they transfer didactic theoretical knowledge to mannequin and simulation learning, and then to real patient care. Clinical instructors play an integral role in facilitating the transfer from theoretical to professional patient care. They are not only responsible for overseeing clinical care, but are also responsible for ensuring that students learn how to properly apply didactic theory, gain valuable dexterity skills, practice correct techniques, develop the ability to make professional and ethical decision, as develop into competent and mature clinicians (Lane et al., 2005; Artim et al., 2020).
When learners begin clinical education, they are considered to be a novice. The novice learner is the most primitive and often considered to be ‘unconsciously incompetent’. They are enthusiastic about entering into professional training, but unaware of their own limitations, and lack of skill. During clinical teaching sessions they are heavily reliant on teaching faculty for structuring tasks and thoroughly explaining the methodology and steps for performing them. Novice learners require great structure, clarity of goals, external rewards, and single, clearly defined approaches. They are extremely concrete in their thinking and are hesitant to deviate from specific learned rules and guidelines, requiring precise instruction from instructors. Feedback at this stage needs to be consistent, and often a non-graded manner to allow for the initiation of self assessment (Hendricson & Kleffner, 1998; Chambers, 1998).
In this teaching guide we will discuss the important qualities and aspects of instructors, and methods of teaching novice dental hygiene learners in the clinical setting. This includes instructor personality traits, the importance of creating a safe and positive learning environment, the importance of instructor calibration, how to give effective feedback, as well as the importance of self-reflection to improve one’s own teaching practice.
Teaching Guide
General Tips
Ramani & Leinster (2008) discuss several tips to aid in clinical teaching for all health professions, which can be directly translated and incorporated into dental hygiene.
Preparation – Teachers need to familiarize themselves with the clinical curriculum and attempt to diagnose learners level so that they can use appropriate learning strategies.
Planning – Prior to a teaching encounter, clinical teachers should ask themselves a few questions. What do you hope to accomplish? What is your point of view? How will you meet the needs of each individual learner?
Orientation – Teachers should obtain objectives of learners. This helps to ensure that the instructors are in fact teaching what is meant to be taught.
Interaction – The clinical teacher should serve as a role model during teaching. They should promote a humanistic approach to care, as well as model teamwork and promote positive team interactions.
Observation – Teachers need to observe learners interactions rather than dominate learning encounters. These observations can then be used to shape future teaching, and to provide appropriate feedback.
Instruction – Teachers should consider what learners are capable of at their level of learning and avoid asking impossible questions. Teachers can also role model their willingness to learn by being prepared to learn from students.
Summarize – It is important to ‘debrief’ and summarize what was taught during each encounter, discussing what is important, and what does not apply.
Feedback –Identifying what went well and what did not, provide both positive and constructive feedback to learners.
Reflection – Reflection along with learner feedback can help teachers learn and plan future teaching encounter.
Teaching novice learners can be challenging in that ‘expert’ clinical instructors need to go back to the basics. Instructors need to slow down their thought process, taking things step by step as if they were in the novice clinicians shoes. Pizanis (2019) described a method of instructor interaction called DOC (Demonstrate, Observe, Correct). In this technique an instructor would demonstrate a clinical task to individual or a group of students, observe the students attempt to replicate the task, and then immediately correct any inaccuracies in performance. This method involves immediate feedback, and the creation of a teaching moment. These teaching moments are especially important when novice learners are being taught a new tactile skill. It is also important to note that the instructor is to fully observe the task. This full observation allows students to practice and then receive feedback, rather than an immediate correction.
Personality Traits
In several studies of dental hygiene as well as other health profession students have displayed that students carry a great importance on the personality traits, professionalism, and role modeling of their clinical instructors (Pizanis, 2019; Irby & Papadakis, 2001; Artim et al 2020; Tang et al 2005). Irby & Papadakis (2001) discussed specific skills from a student standpoint that make a clinical teacher stand out and enrich their clinical education. These include displaying a passion for teaching, demonstrating clinical competence, possess a broad repertoire of teaching methodologies, the ability to self-evaluate and reflect, draw from multiple forms of knowledge, target their teaching to the learners level, clear in their expectation, organized, accessible to students, as well as supportive and compassionate. Students also reported that more instructor attention is needed by those earlier in their training (Pizanis, 2019). Many novice learners noted that patience was an important affective trait that students looked for in instructors. Students noted that patience is valuable, especially as a novice learner. It calms their mood, allows learners to slow down, think about what they are doing and leads to a more thorough practice. It has also been noted that enthusiasm for the subject being taught is valuable to students. Students reported that enthusiasm is typically accompanied by a sound knowledge of the subject and a desire to teach and learn more about it (Ramani & Leinster, 2008).
Safe Learning Environments
The ability to learn, especially that of a novice learner is deeply influenced by the safety and comfort of the learning environment (Prashanti & Ramnarayan, 2020). Effective learning relies on good relationships. We learn the most from the people we care about and the people we believe care about us. Students who feel safe and in a comfortable environment are more willing to disclose a lack of understanding rather than hide it. This environment creates students who are attentive, ask more questions, and are more actively engaged in learning. To create this open environment instructors must be approachable, have open communication, give respect to students and their views so that a mutual trust is created (Prashanti & Ramnarayan, 2020). The creation of safe learning environments encourages students, as well as instructors to admit their limitations. As a clinical instructor, it is impossible to anticipate every question, and every difficulty a student may face. It is important to admit when something is unknown. When instructors attempt to show extensive knowledge (or a lack of) they often over complicate things and ask questions that students are unable to answer (Prashanti & Ramnarayan, 2020). Safe and comfortable learning environments are those in which instructors, and students are welcome to accepting feedback, which is critical to the learning process in novice learners (Sherman, 2019).
Instructor Calibration
Novice learners require a significant amount of structure, and clearly defined approaches in tasks they are learning (Hendricson & Kleffner, 1998). This level of structure requires all clinical instructors to be calibrated to teaching, assessing, and providing feedback in the same manner, and with the same expectations. When assessing clinical competence inter-rater reliability is important. Consistency in rating student performance from several instructors is essential to reliable competence assessment. Many dental hygiene programs employ a continuous, formative assessment approach in which students are tested routinely on low weight testing. The reliability of these tests is contingent on consistent sampling throughout the program, and instructors producing reliable assessments. It has been noted that many dental hygiene instructors who lack clinical teaching experience, and formal education in teaching methodologies have a wide range in clinical instruction and assessments. Students are often able to identify instructors who are lenient in grading and seek them out for assessments. This reinforces the need for instructor calibration sessions. At these sessions instructors should be discussing best practice teaching methodologies, assessment criteria, and expectations of students. Instructor subjectivity can also be minimized by utilizing detailed scoring rubrics, and performance standards. Inconsistencies in marking may also have to do with instructors experience. Instructors, especially new instructors with the issue of ‘failure to fail’, which will be discussed in the next feedback section (La Chimea et al., 2020).
Providing Feedback
Feedback is vital in clinical teaching. It aids learners to gain insight to what they did well, or poorly, and the effect of their actions. It also helps instructors and students alter their future actions to prevent or reinforce specific behaviours or skills (Ramani & Leinster 2008). Especially for the novice learner, constant coaching and feedback is essential for evolving skills and gaining the important ability to self assess (Hendricson & Kleffner, 1998). Prior to clinical teaching sessions there should be a discussion to allow learners to understand the expectations and learning objectives for the session. This prevents instructors overcomplicating or oversimplifying material depending on what learners know entering the clinic session. Making expectations clear early in the teaching process minimizes causing any undue stress (Niaz & Mistry, 2021). Principles of providing feedback include the use of mutually agreed upon goals as a guide to feedback, addressing specific moments instead of general performance, discussing decisions and actions rather than the interpretation of students motives, and using non-judgemental and non-evaluative language for formative feedback (Ramani & Leinster, 2008). When educational goals have been set prior to teaching encounters feedback can help to examine if these goals have been accomplished, or if new goals and action plans need to be re-established. Setting goals also informs the learner where they are in comparison to where they should be, and where they should focus their learning. Adequate feedback promotes self-reflection and self-assessment which especially in dental hygiene is a valuable trait for lifelong learning (Ramani & Leinster, 2008). Instructors, in particular new instructors, can be hesitant to giving negative feedback and often avoiding it altogether. If not delivered in the correct way learners can take negative feedback as a personal attack. Inconsistencies between instructors and assessments, as discussed above, can often be influenced by the ‘failure to fail’. Instructors can be hesitant to give negative feedback and fail students when necessary. There are several themes that can influence the level of comfort in instructors for failing and providing negative feedback. These include a lack of confidence, uncertainty surrounding decision making, issues using and understanding assessment systems/grading rubrics, a lack of knowledge of standard student expectations, lack of institutional support, as well as the negative consequences and emotional difficulty of failing a student (La Chimea et al., 2020). Lack of negative feedback can have a significant adverse impact on future patient care, and student’s overall learning. Instructors need to create a positive and safe learning environment in which errors are acknowledged and feedback is expected and welcomed (Ramani & Leinster, 2008).
Negative feedback should always be given in a respectful, constructive, and specific manner. Learners should feel empowered and supported when receiving both positive feedback as well as constructive feedback (Niaz & Mistry, 2021). When giving feedback, especially to novice learners, care must be taken to avoid damaging the self-esteem & confidence. There is a fine line between being overly critical and overlooking poor or potentially damaging practice (Niaz & Mistry, 2021). Effective feedback is given consistently and immediately after an event. It should be specific in nature, encourage self-reflection while remaining mindful of the ways in which it is delivered with tone, and non-verbal cues, it should also be actionable (Niaz & Mistry, 2021; Sherman et al., 2019). As discussed above, feedback is more comfortable when given in an environment that is comfortable, and safe. In these environments students realize that negative feedback is being provided to help them evolve professionally (Sherman, 2019). There are several feedback models that can be utilized when discussing progress with students.
A feedback sandwich can be utilized to sandwich critical feedback in between positive feedbacks (Niaz & Mistry, 2021). A SBI (situation, behaviour, impact) model can also be used to provide negative feedback. First the situation is described along with the details of what went wrong. Then the behaviour is discussed in a judgement free and factual way. The impact that the behaviour had is then described. Finally, the next stage is a discussion about expectations, and how to improve (Sherman, 2019).
Self-Reflection
It is important for clinical teachers to solicit feedback on their teaching from both coworkers, and from learners. Having the ability to self-reflect is key to advancing to the highest level of teaching and moving from a technically sound teacher to a professional and scholarly teacher (Ramani & Leinster, 2008). As a clinical instructor, it is not feasible to anticipate every imaginable question from students. It is vital to be honest and up front with students about the gaps in your own knowledge and seek advice from supervisors and other faculty. Using open and honest language with students reinforces their trust in you. It is important to work within the limits of one’s own competence (Niaz & Mistry, 2021). This also helps to create a safe and comfortable learning environment for learners. Self-reflection creates a greater understanding of both the self and the situation so that the future actions can be informed by this understanding. Reflective habits are vital for individual wellbeing and professional development (Niaz & Mistry, 2021).
Conclusion
Teaching novice learners clinical skills is an important aspect of dental hygiene education, although at times is a daunting task. The purpose of this teaching guide is to assist clinical instructors teaching novice dental hygiene students. This should help clinical instructors foster the development of a safe and welcoming learning environment, provide both positive and negative feedback, as well as value the importance of instructor calibration, and self-reflection.
References
Artim, D., Smallidge, D., Boyd, L., August, J., & Vineyard, J. (2020). Attributes of Effective Clinical Teachers in Dental Hygiene Education. Journal of Dental Education. 84(3). https://doi.org/10.21815/JDE.019.188
Chambers, D. (1998). Competency-Based Dental Education in Context. European Journal of Dental Education. 2:8-13. https://doi.org/10.1111/j.1600-0579.1998.tb00029.x
Hendricson, W., Kleffner, J. (1998). Curricular and Instructional Implications of Competency-Based Dental Education. Journal of Dental Education. 62(2). https://doi.org/10.1002/j.0022-0337.1998.62.2.tb03185.x
Irby, D., & Papadakis, M. (2001). Does Good Clinical Teaching Really Make a Difference? The American Journal of Medicine. 110. https://doi.org/10.1016/S0002-9343(00)00737-3
La Chimea, T., Kanji, Z., Schmitz, S. (2020). Assessment of Clinical Competence in Competency-Based Education. Canadian Journal of Dental Hygiene. 54(2):83-91. https://files.cdha.ca/profession/journal/2729.pdf
Niaz, H., & Mistry, J. (2021). Twelve Tips for Being an Effective Clinical Skills Peer Teacher. Medical Teacher. 43(9). https://doi.org/10.1080/0142159X.2020.1841130
Pizanis, V., & Pizanis, C. (2019). Effective and Ineffective Clinical Teaching in Dental Hygiene Education: A Qualitative Study. Journal of Dental Education 83(8). https://doi.org/10.21815/jde.019.087
Prashanti, E., Ramnarayan, K. (2020). Ten Maxims for creating a safe learning environment. Journal of Advances in Physiology Education. 44. https://doi.org/10.1152/advan.00085.2020
Ramani, S., & Leinster, S. (2008). AMEE Guide no. 34: Teaching in the clinical environment. https://doi.org/10.1080/01421590802061613
Sherman, R. (2019). The Art of giving feedback. Americann Journal of Nursing. 119(9). https://doi.org/10.1097/01.naj.0000580292.79525.d2
Tang, F., Chou, S., Chiang, H. (2005). Students Perceptions of Effective and ineffective Clinical Instructors. Journal of Nursing Education. 44(4). https://doi.org/10.3928/01484834-20050401-09
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