Sharing good practice

The aims of this article are to explore examples of what good chairside teaching could be from the viewpoint of dental students, dental tutors, dental care professionals and patients (the 'stakeholders') by means of analysis of a clinical scenario. In addition, the intention is to enable readers to elicit instances of good chairside teaching practice in their own dental teaching institutions by using the questionnaire provided. The article is designed as a resource for future collaborative workshop activity where chairside teaching innovations can be developed and implemented in and across institutions.

Perceptions of chairside teaching

  • Stakeholder perceptions of chairside teaching and learning in one UK dental school

  • Chairside teaching and the perceptions of dental teachers in the UK

  • Tools to share good chairside teaching practice: a clinical scenario and appreciative questionnaire

  • Educational innovations for dentistry

Background

A study of dental chairside teaching including all stakeholders at a single dental school in the UK1 showed unevenness in the student experience and variation in dental tutors teaching that, upon subsequent evaluation appeared to be common across the UK.2 Dental chairside teaching colleagues who made up the evaluation team indicated that it was possible to work towards a consensus view on what characterises good chairside teaching practice from the many examples of good practice that were identified. This involved attending to issues of optimising the student learning experience, tutor performance and training and working with other dental care professionals involved with clinic organisation. The second step in the sharing process was to identify specific instances of good practice that can be disseminated. Appreciative inquiry3,4 is chosen as a suitable methodology as it can present a focus on what is most valued - integrated practice that 'just works'. Apart from identifying good practice that is already in place, appreciative inquiry encourages collaborative activity that can take innovation through from design to implementation. Since its inception it has been used primarily in organisational development but has recently been described as a tool for evaluation5 and as a research methodology.6

Appreciative inquiry is not the same as positive reinforcement, which is about continually saying things that are positive, because appreciative talk is rather considering things that are valued. It quite simply avoids deficit language. There are major problems with deficit thinking because thinking and talking negatively will continually hark back to what is wrong, with the temptation for the teacher to teach by humiliation, placing blame on students, which does not help learning. Appreciative inquiry is based on the maxim that there is more to be gained by discovering where excellence is possible and to elaborate on this.7 Appreciative inquiry has been described to include four stages:3,4,5,6,7 to visualise where there is current excellence; to imagine what might be; to innovate; and finally to implement change.

The approach deployed here is in essence an extension of appreciative inquiry into clinical teaching behaviours, both those of the tutors and of students. The suggested tenet is the proposed efficacy of developmental dialogue, which is always learning focused and prospective. This is based upon clear commitment to a positive climate and conditions that facilitate teaching and learning around the chair and briefing and debriefing sessions before and after the clinical encounter. A useful, aspirational maxim we have adopted is one of dialogue in clinical teaching, which is characterised by '...'real talk', which includes discourse and exploration, talking and listening, questions, argument, speculation, and sharing, but in which domination is replaced by reciprocity and cooperation.'8

Scenario, commentary and questions

The approach in the article is to provide materials, which would allow those with an interest in dental chairside teaching to conduct a variety of development activities, from large-scale workshops to individual interviews with key innovators in chairside teaching or institutional questionnaires for all stakeholders. The appreciative inquiry sets the tone of the clinical narrative and the different perspectives are explained in a commentary that follows. The questionnaire purposefully contains open-ended questions, which are key to gaining the local knowledge that may express excellence in practice and also where excellent practice might be possible. Essentially it is a process of assisted self-evaluation and review that aligns well with the Quality Assurance Agency's current position on systematic enhancement of university practices.9

Chairside clinical scenario

The dental chairside teaching scenario (Fig. 1) is derived from a compilation of favourable clinical events that have been determined as good clinical practice.1,2 The lines of text in the scenario are numbered so that the behaviours which show where the teacher has attended to individual and collective student learning and patient empowerment can be pin-pointed as shown in Table 1.

Figure 1
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Chairside clinical scenario

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Table 1 Features of good chairside teaching as they appear in the scenario
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Commentaries

The scenario is designed to be a document to promote discussion, not as some clinical ideal. However, just as the approach to students should be non-threatening, also the form of peer observation going on should be too. The peer observation method suggested by Cosh10 is modelled here where the main focus is on the observers and what they can learn from the teachers they are observing, using the teacher and experience of teaching as a resource for their learning. It places the onus on the observers to relate what they see and what they discover from the dialogue they have with the teacher following the teaching session to their own teaching experience. This is quite different from the stereotype of teacher observation where the observer looks on and makes a judgement on the teacher and the teaching. Clearly it is important to have the patient as the main focus of attention at the briefing to ensure that the most appropriate treatment is carried out - urgent care in the case of patient A and related to oral hygiene compliance in the second. The tutor was helpful in giving a level of support to allow student A work out and complete treatment in a way she had never achieved before. Prevention is the keystone of good practice and here a patient empowerment option is in operation. The tutor is aware of the limitations of the students' experience and prepares for this. Despite coming in some distress to the tutor the response to the student was one of reassurance and further carefully placed questions rather than simply telling what to do. The sequence of the tutor's questions and help showed an underlying organisation and a calm role model. The interjection of a dental nurse indicated the great deal of direct help and behind the scenes help that support staff should be encouraged to give. The interests of the patient were continually taken into account and continuity of support was achieved in these cases. Some collaboration between students at different levels in their course should be organised if they are not working together in practice teams (ie for one particular patient junior students carrying out patient education and motivation, intermediate students carrying out relatively simple treatments and senior students more complex treatments). The key feature of good modern teaching is not to humiliate students. The teacher does not need to gain points - students need help to progress and learn even when they do not perform well at all times. Did gentle handling of student B produce the best learning outcomes? The main focus following the practical clinical session is debriefing possibly for a time with the whole dental team, including feedback from patients and dental nurses. Here the focus was on the student talking to the dental tutor and other students of their experiences and what they have learnt from them. The fundamental aim is for the students to start the process of life long learning, to realise their strengths and weaknesses, and to act to strengthen their overall working practice. It is suggested that this can only be inculcated in an environment that offers a positive climate and conditions commensurate with such dialogue.

The intention is that this scenario will serve as a starting point for discussion on chairside teaching. The work of drawing out more concrete examples of good practice lies in questioning specific instances of practice on issues that this scenario approach has raised.

Questions

A major focus is on what it is you value in chairside teaching and why you do so. This produces a resource for asking appreciative questions4 in order to work on what is the best of current practice; then with what might be the best of possible practice; then ask provocative questions to develop innovations and finally to help navigate change and implement it. What good practice is already in place and innovation about to be implemented as a future opportunity at an institution? Is this good practice useful? Could it be transferable and provide a valuable innovation at another institution now? Finally, the questions elicit details about the people involved in chairside teaching (Box 1). An analysis of these findings may help provide the right emphasis in projecting training provision to improve teaching. Sweet, Wilson and Pugsley2 produced five categories of chairside teacher suggesting that each has an important and sometimes unique role in chairside teaching. They suggest that gearing training and professional development towards type may improve allocation of resources. However, they also illustrated that a stakeholder mix at a workshop could produce valuable learning for the group members and consensus views as outcomes. This is a further reflection of our position that appreciative, developmental dialogue is an essential component of maximally functioning educational environments.

Conclusion

This article is a working document based on a case study of chairside teaching at a dental school in the UK and follow up dialogues with colleagues as a UK workshop. It is designed to provoke interest and discussion in chairside teaching by means of a scenario and complementary commentary. The questions that follow provide a resource for an appreciative inquiry into best practice in chairside teaching which could result in the sharing of hard won initiatives and innovations.