Introduction

Clinical teaching involves purposeful engagement with the dental student who needs to link 'knowing that' to 'knowing how', so that their learning is contextualised to represent a more accurate reflection of the real world setting of a dental practitioner.1

Outreach clinicians act in a vicarious role as overseers of the transition of dental students from mere repositories of knowledge to safe beginners as new registrants.2 Over 85% of UK dental students will become primary care practitioners3 and thus greater use of community-based clinical teaching, which has become a success in its own right,4 is particularly relevant in dentistry. Outreach teaching has been integrated into the dental undergraduate programme in UK dental schools5,6,7 and it is well-accepted and widely reported in the literature.3,4,9,10,11,12 The educational advantage of community-based dental programmes has also been recognised.13,14 The expectations are that knowledge, acquired by the student in an academic setting, will be used appropriately and that skills will be nurtured and developed beyond the secondary care environment of the dental hospital.15

The clinical teacher plays an essential role in shaping the behaviour and attitudes of the emerging dental professional and thus outreach facilities should be manned by suitably appointed staff.16,17,18 A key concern was whether the individual clinical teacher had the attributes to be an effective teacher, as well as an accomplished clinician, in this more demanding environment.17,18

In 2010 clinicians were recruited to work part-time at a purpose built community-based dental clinic in Bristol. This model had already been adopted by the dental schools of Cardiff5 and Leeds.6 Owing to the delayed opening of this facility, all the recruited staff were employed as clinical teachers in the secondary care setting of the dental hospital for almost two years. While the attributes and characteristics of a good clinical teacher may be common to both environments, the perceptions of their relative importance may be different.

Aims and objectives

A case study was designed to identify the key skills and attributes of a clinical teacher, where the findings of a large scale questionnaire were used to shape the interview guide. The latter was used to explore the perceptions of eight dental practitioners of the skills and personal attributes required of them as outreach clinical teachers and of their preparedness for the task.

Methods and materials

Approval for this study was granted by King's College London Research Ethics Committee and University Hospitals Bristol NHS Trust. A case study of mixed methods was undertaken from July to September 2014. Data were collected electronically (questionnaire) and by audio recording (in-depth interviews).

Extant literature19 informed description of the most recognised skills and attributes of a clinical teacher which were listed until saturation had been reached. The assumption was made that 'bed-side' teaching in medicine was akin to 'chair-side' teaching in dentistry.20 A questionnaire (Box 1) based on the skills list was piloted and distributed to: pre-clinical and clinical dental undergraduates (N1 = 358); dental care professionals which included dental nurses, hygienists and therapists (N2 = 50); part-time and full-time clinical teachers (N3 = 66) (N = 474).

Purposeful sampling was then used to select participants for the second part of the study where the unit of analysis21 was a cohort of eight dentists recruited specifically for outreach teaching. Each of them, identified by an interview number, was interviewed using an interview guide (Box 2) informed by the questionnaire. A conceptual framework was devised, drawing upon the recurrent themes. This framework contained 30 sub-themes (Box 3).

Each interview was coded separately using the themes and sub-themes from the conceptual framework and links between the categories were also identified. The data were then analysed in tabular form across the whole data set. The number of times that each ranked item was mentioned or alluded to in the interviews was recorded.

Results

Questionnaire

The overall response rate was 26% (122/474). Data derived from the questionnaire was analysed using the Stata data analysis and statistical software (Table 1). The ranking analysis was based on 97 people since one person did not give any rankings and 24 people gave most/all the attributes a score out of ten.

Table 1 Ranking of the skills and attributes derived from the usable questionnaire data
Full size table

In-depth interviews

Demographics

A typical teacher graduated between 18 and 40 years ago and professional backgrounds included: independent and NHS general practice; Defence Dental Services; community dental service and the more specialised oral surgery, orthodontics and special care. Teaching qualifications varied from no formal qualification to diploma level. The reasons why clinical teachers were attracted to outreach teaching are shown in Box 4.

The perceptions of the recruited cohort of outreach clinical teachers of the skills and attributes required in their teaching role

While the first two attributes and skills are the same as those identified by questionnaire, two more were acknowledged as being important by the outreach clinicians namely, being very experienced ranked 19 and providing a safe learning environment ranked 21 (Table 2).

Table 2 Ranking of top skills and attributes referred to fifty times or more during the interviews with the outreach clinicians. The frequency of mention was regarded as an indication of their importance
Full size table

'I don't see the point in shouting at students and sort of belittling students' (Int5. Q4).

'I would like to feel they trust us, so they feel they can talk to us about dentistry and not feel threatened' (Int7. Q3).

'They want pastoral care as well as the personal mentoring and tutoring' (Int4. Q4).

Gaps identified in skills and attributes

The main concerns revolved around individual competence and expertise in certain dental specialties. Some worried about deskilling since their own career had become more specialised. Oral surgery was cited most often. Clinicians felt they could perform extractions but they felt less equipped to teach the skill. They expressed a desire to align outreach teaching more directly to that at the main hospital.

'I'd like to go back there [dental hospital] to make sure our teaching is what they are teaching' (Int7. Q7).

There was also some fear of 'not knowing enough' and a concern that what they were teaching may not be completely relevant to the undergraduate course. Several practitioners found grading of students difficult.

The perceptions of this cohort of clinicians with respect to their individual preparedness for teaching in an outreach setting

Concern was expressed about feeling 'good enough' and they preferred to know the standard of their peers. A feeling of isolation at outreach was expressed by nearly all and most wanted to keep in touch with the main hospital by rotating through the various departments.

'We are quite isolated from the main hospital site. I know we are not teaching different things, but we are in a different setting. I do think it would be quite nice to have some kind of rolling programme to keep us in touch with the dental hospital more' (Int1. Q5).

The benefits of outreach teaching

The clinicians were in no doubt that outreach teaching offered additional advantages to the students (Box 5).

Discussion

This study considers the pooled perspectives of all the study participants and the specific perspectives of the outreach clinicians. The first aspect was addressed by the questionnaire and although the response rate was low, it did not affect the development of the interview guide, since the questionnaire was simply used to identify and develop themes. 'Clinical competency' was highly regarded by all groups and this mirrors other studies with respect to dentists,22,23students24 and student nurses.25 It is not surprising that 'serving as a role model' was highly regarded by the dentists.26 Attitudes are learnt through observation of seniors and thus teachers must be aware of the need to provide good role modelling in the presence of the student.27 One obvious difference between dentists and students was their opinion on 'reflective practice' which is considered to be an important step for learning.28 This was ranked much lower by the students. Maybe they felt that they did not have enough time to reflect29 and thus did not rank it as highly as their supervisors did.

Analysis of the interviews also revealed that outreach clinicians highly valued 'being very experienced' and 'being providers of a safe learning environment', but these were at variance to the overall rankings. A wealth of experience and qualifications was seen in the outreach cohort but experience alone is not an indicator of expertise.30 Immediacy of the triad of the patient, student and the supervisor might require staff to be very experienced, to be able to deal with any unexpected events in an outreach clinic. 'To be available, receptive and supportive'31 was also a valued attribute.

Based on the interviews, recommendations to improve and enhance the role of clinical teachers were made (Box 6).

Conclusion

This case study found that outreach clinicians could be better prepared for their teaching role. A full job description and a role profile along with comprehensive induction may help with individual preparation. Personal development plans, guided by the needs of the School, should include training as a teacher in addition to maintenance of clinical competency. With a range of professional profiles, this cohort of outreach clinicians collectively offered all the skills and attributes required in this 'community of practice'. Clinical education is increasingly delivered in primary care settings and further research of the demands on outreach clinical teachers is recommended.