INTRODUCTION

Education is a word that is intriguing, even though it is rather familiar. The meaning assigned or attributed to the word is more belief bound than fact bound. In the rapidly evolving stream of education in healthcare, it appears that transfer of knowledge is the sole purpose of education, with application of this knowledge to real-world scenarios as a potential consequential outcome. However, the learning process does determine the acquisition of abilities that enable an individual to deal with the real world in a constructive way. The relevance of the learning process to socially desirable outcomes only increases for education in healthcare in light of the social roles the healthcare students assume in the future¹.

Initially there was refusal from medical schools to incorporate dental education in their curricula, which could find its rationale in the opinions of some groups that the independent establishment of dental schools would be more practical as medical schools may be unwilling to offer the requisite physical space and expensive equipment for the greater technical and mechanical training involved in dentistry². From those times, dental education has gone far during the last century to establish dentistry as one of the most sought after and celebrated healthcare professions. However, the quality and recognition of dental education has not been the same worldwide, leading to evolution of the accreditation process for foreign-trained dental graduates in some nations³. International dental education working groups have highlighted the relevance of students’ perspectives in the quest of improving dental curricula and have urged that students’ views be considered in dental education planning and development^4,5.

In the Indian context, it is evident that there has been a phenomenal growth in the number of dental colleges over the past couple of decades⁶. Currently, there are 313 functional dental institutions in the country making India one of the countries that produces the largest number of dental graduates every year⁷. In this regard, it is essential to continuously review the way in which the curriculum is being implemented at the institutional level to keep the standards of dental education in India abreast with the global dynamics in dental education. It must also be understood that this responsibility of program evaluation and refinement of curricula, as necessary, must occur both at the institutional and national level. Unfortunately, it appears that most of the dental institutions in India have not focused on this responsibility. Seldom has it been in introspect how well the curriculum is being followed and how satisfied the students, the main stakeholders, are with the learning environment and what their problems are in following the curriculum⁸. Regular evaluation and critical appraisement are as cardinal as the design and implementation of these curricula. With this background, the objective of this qualitative study was to document students’ perceptions of the learning environment in two of the thirteen teaching dental institutions in the state of Andhra Pradesh.

METHODS

The dental curriculum in India requires that the dental students undergo clinical training in the third and fourth (final) year of the course and, after successful completion, are required to follow a one year paid rotating internship that must be completed for the students to graduate⁹. This qualitative study involved focus group interviews of dental students in two teaching dental institutions in the state of Andhra Pradesh, India. Focus group interviews are well documented in the literature as effective methods for gaining a deeper insight into the construct of interest. In India, undergraduate dental education has a 5-year curriculum, where the first two years are devoted to basic sciences and pre-clinical exercises in dentistry. Clinical training is offered in the third and fourth years of the curriculum; the fifth year of the curriculum requires the student to complete a rotatory internship with scheduled posting in all the specialties before being awarded a Bachelor of Dental Surgery degree (BDS). In this study, each focus group had representation from all clinical years (i.e. third, fourth and internship); all the participating students were given a pseudonym to ensure anonymity. The number of participants in each focus group ranged from 6 to 8, as recommended in the literature. Two researchers were involved in moderating the interviews. The interviews were semi-structured and a loose set of questions were prepared beforehand to facilitate the discussion. Table 1 shows the interview guide used in this study, which is not exhaustive as other questions emerged from the interaction between the moderator and the study participants. This set of questions was prepared by a group of four experienced dental educators and included the following constructs: teaching skills and attitudes; clinical learning environment; assessment criteria in practice; and challenges in meeting requirements. A pre-session was conducted before the focus group discussions so that the participants and moderator became acquainted. All the focus group interviews were audio-taped and transcribed by two members of the study team. The transcripts were given to two researchers for independent open coding to extract thematic constructs from the discussion. All the themes were reviewed by both researchers and consensus was obtained wherever there were differences in coding.

Theoretical sampling was done with concurrent conduct of purposive sampling for focus group interviews, data collection, and data analysis, which identified if there was a need for further recruitment of participants. Data saturation was considered to have been achieved after seven focus groups were interviewed in Institution A and six in Institution B. The study was conducted between October and November 2019. Ethical approval for the study was obtained from the institutional review board of SIBAR Institute of Dental Sciences and verbal informed consent was obtained from all the participating students with prior information to and approval from the Institutional Review Board (IRB). It was explained to the IRB that the need to obtain written informed consent would limit the rate of participation, given the objectives of the study and that the study participants had yet to complete their course. A script of verbal consent was reviewed and deemed satisfactory by the IRB.

RESULTS

The mean age of the study participants was 22.6±1.71 years, with no significant differences between institutions. The average duration of the focus group interviews was 64.7±8.2 minutes. Within each of the focus groups, there were more female than male students. The following thematic constructs were developed from the responses to determine negative learning outcomes: 1) problems in lectures; 2) problems in clinical learning; 3) dissatisfaction with evaluation processes, and 4) poor academic drive.

The following are some of the responses in the students’ own words. Some of the responses were translated for convenience in presentation, since both the local language Telugu and English could be used in the focus group interviews. After translation, the responses were reviewed by two bilingual experts for any changes in the meaning of the responses. Few of the responses that were representative of the general opinion expressed by students were presented in a construct sense.

DISCUSSION

The changing scenario of education in healthcare, globally, shifted the focus from preparing trainees to developing an institutional culture, with administration, faculty, and the students being recognized as accountable for the latter¹⁰. Literature suggests that faculty development programs (FDPs) in dental education are almost nonexistent in India¹¹. A Master’s in Dental Surgery (MDS) is a clinical training program wherein the necessary skills for educating and training students are not fully imparted, so if one is interested in teaching, the faculty needs to learn pedagogical techniques through FDP or another way. Therefore, FDPs are essential and must be observed as part of the institutional curriculum. Most of the problems faced by students relating to classroom teaching in this study could be comprehended as being consequential to the lack of initiatives such as FDP. Engaging the students in the class translates to facilitating active learning and allowing for intuitive appreciation of instantaneous feedback.

Since there were no large differences in the opinions of the students, and it was not the intention of this study to compare institutions but to try and develop an understanding of the learning environment from the students’ perspective, the responses were not categorized based on the institution. This choice was made since these institutions follow the same curriculum and offer admission to students predominantly from the state of Andhra Pradesh, India. Moreover, initial review of the participant responses did not show marked differences in opinions relating to different aspects of the learning environment. Few incidents were identified in the study where students were reportedly mistreated in the clinics. It was recognized that the students did not report these incidents before and opined that it was senseless to report the incidents. Similar findings were reported by the Association of American Medical Colleges, where students refrain from reporting mistreatment thinking that the incident does not carry enough importance, fearing reprisals and believing that the incidents would be ignored¹². A study on students’ perceptions of the clinical learning environment in New Zealand noted that students were not satisfied with the feedback received¹³. Consistent with the above observations, students in this study expressed disinclination towards receiving feedback.

It is imperative for both faculty and students to understand that misinterpretations and uncertainties are inevitable in clinical practice as the presentation of a clinical condition differs from individual to individual and so does the provision of care. It was suggested by Perry that empathetic teachers in a clinical environment who admit their uncertainty in a given clinical situation helps students in the much-needed transition from right–wrong dichotomy to acceptance of uncertainties¹⁴. Furthermore, the authoritarian attitude of teachers towards students has the unwanted consequence of the attitude being adopted by students towards their patients. It is well documented in the literature that students who face public humiliation and considered unworthy do not empathize with patients¹⁵. In this regard, it becomes the responsibility of any healthcare institution to focus on student-centered teaching which translates to patient-centered care being observed by the students or trainees.

Globally, assessment of students’ academic performance is an area of professional education that has undergone a multitude of changes over the past few decades¹⁶. However, the assessment criteria in most dental educational institutions in India continue to be the same, with no objective methods in place to evaluate the clinical skills demonstrated by the students. It is essential to discern that assessment constructively navigates learning. It is only when the influential role of assessment in motivating the students to learn is recognized that the need for appropriate assessment criteria relevant to the domain to be assessed is understood. The dissatisfaction expressed by the students with evaluation in the present study emphasizes the need to institute more objective assessment criteria. International experience suggests that students show better interest and report better learning when marking and grading are not in concomitance with the learning process^13,17. Inclusion of Objective Structured Clinical Examination (OSCE) in the dental curricula would be beneficial in eliminating prejudice and allows everyone to be assessed by the same criteria¹⁸. Furthermore, use of portfolios facilitating students to reflect upon their own performance would facilitate better learning¹⁹. OSCEs are widely used in undergraduate dental education in European²⁰, American²¹, and Canadian dental education²². A study focusing on the integrated aspects of team-based learning with peer-to-peer teaching at the Harvard School of Dentistry reported that weaker students performed considerably better with less faculty involvement and more self-directed learning²³. These findings highlight the need for preparing customized teaching plans to stimulate students’ quest for learning. Student Evaluation of Teaching (SET) is known to be an effective way for assessing faculty performance by the recipients themselves. When constructed and delivered in the right manner, SETs are acknowledged to be valid and reliable measures for assessment of faculty performance, and should be linked with annual salary increment or promotion of faculty members²⁴. The relevance of SETs in dental curricula has been widely discussed over the years, and can be considered for inclusion in the Indian dental educational context^25,26.

CONCLUSIONS

In countries like India where the burden of oral diseases is very high, it is pertinent that technically well equipped, socially empowered, and cognitively empathetic dental professionals be prepared to meet the ever-increasing need for dental healthcare. Conducive learning environments are necessary for the preparation of such professionals, which demands commitment from educators, administrators and students. Regular introspection of the strength and implementation of the curricula and documentation of the perceptions of the stakeholders demonstrate the need for this commitment and provide an opportunity for better dental education. In a competitive world where mediocrity is not entertained, striving for excellence has become the norm. In this context, it is recommended that all teaching dental institutions develop institution-specific models for assessment of the learning environment and councils regulate the learning environment by instituting fundamental common norms across the dental institutions in the country.

CONFLICTS OF INTEREST

The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none was reported.

FUNDING

There was no source of funding for this research.

PROVENANCE AND PEER REVIEW

Not commissioned; externally peer reviewed.