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Academics can enhance students' learning experiences and outcomes by addressing key aspects of the learning environment, for example, implementing activities characterised by clear expectations, assessment focussed on understanding, and ‘giving … and seeking … of information, within an intrinsically motivating context’ (, p40). This premise draws on student approaches to learning theory which characterises learning as involving three interacting components: student characteristics and their understanding of the learning environment; the approaches they use when learning; and the quality of their learning outcomes [2-4]. This model of learning is supported by analyses across all year levels, in humanities, science and commerce programmes , showing that students' perceptions of aspects of their learning environment, for example, teaching quality and levels of workload, have direct and indirect influences on the quality of their learning outcomes.
In defining a ‘learning environment’, it is necessary to consider ‘the social, psychological and pedagogical contexts in which learning occurs and which affect student achievement and attitudes’ (, p3). Therefore, an academic environment includes the people and approaches with whom students interact in a course, and the quality of teaching, assessment and expected workload . Similar agents act in a clinical environment, with the addition of patients. The learning environment in a simulated dental clinic for learning operative skills includes both academic and clinical environments where students are working with simulated oral cavities in manikins instead of patients.
To optimise students' learning in dental operative learning environments, it is clear that we need to clarify what the essential characteristics of this environment are, including students' perceptions of these characteristics, and how they relate to the quality of the outcomes achieved. However, there have been only a few publications that discuss the rationale and design of dental operative technique courses and related learning activities (e.g., [6, 7]). Current research into features of the learning environment for learning dental operative skills and related disciplines has focussed mainly on identifying characteristics of the elements that contribute to learning outcomes. For example, positive effects on outcomes after teachers provided augmented feedback related to task components  and modelling , and the arrangement of optimal task sequence for learning  have been noted. The findings from these studies provide insights into what students achieved during learning trials [8, 9] and performance on retention/transfer tests [8, 10]. However, the timing of retention tests was too short to confirm maintenance of the level of performance achieved after the learning trials , and when retention tests were delayed (4 months), maintenance of higher levels of performance, including time spent in completing the task, was not consistent [8, 11]. In addition, these results provide little information about students' actual experiences and perceptions of their operative technique learning environments and possible relationships of their perceptions with performance.
Generally, investigation of students' experiences and perceptions of their learning environments has involved cross-sectional analysis of the whole curriculum or programme [12-18] or a specific educational context, for example, clinical courses [19, 20]. However, there are relatively few qualitative analyses that explore students' perceptions of their learning experiences on multiple occasions, that is, at various times over both semesters of a course. As a result, we do not know if or how students' perceptions change over the duration of a course. Although recent qualitative research has indicated characteristics of learning environments that students perceived supported their learning in various classes (e.g., didactic, simulated clinic and clinic) across a dental programme  and in postgraduate specialist clinical environments , we do not know whether these characteristics are directly applicable in the specific context of an operative technique learning environment.
Therefore, the current study was conducted to: (i) explore students' experiences of their operative technique environment across a year-long course regarding what was effective for their learning and why and (ii) investigate whether there was a relationship between students' perceptions of effective learning experiences and their learning outcomes in the course. Specifically, the research questions were as follows: (i) what learning experiences did students perceive were effective or ineffective in supporting their learning of dental operative technique skills? and (ii) did students who identified effective learning experiences over the duration of a course achieve higher levels of performance? The findings should improve our understanding of students' perceptions of the current approaches used in our operative technique courses in dentistry. It should also provide useful information to inform the design of effective learning activities for enhancing skill learning and minimise ineffective learning experiences.
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As a key participant in any learning environment, students' voices are a crucial component when reviewing the quality of our educational approaches. The current study used students' voices to identify characteristics of a learning environment in an operative technique course that were effective and ineffective. Drawing on SAL theory, the study explored how students perceived their learning environment across a series of learning activities and investigated how those perceptions were reflected in students' learning outcomes. The findings in relation to perceptions of effective learning environments were similar to previous studies regarding characteristics of good teaching and supervision [1, 12, 18] and peer-assisted learning . Other components that influence perceived effectiveness of learning environments, for example, assessment methods or workload , were not a major feature in our students' perceptions of their operative dentistry learning environment. However, whilst many of our students perceived their learning experiences as supportive, it would appear the outcomes they achieved were not directly related to their perceptions. This may relate to our students not fully understanding what is required of them, and therefore, they were unable to achieve quality outcomes. This is consistent with their preference for discussions and demonstrations, indicating that review of our approaches to support their learning of ‘how to’ is needed.
Students emphasised various approaches of tutors that were associated with effective learning. These included group discussion, demonstrations, and prompt, focussed, and constructive feedback. Although students participated in interactive lectures and staff reviewed PowerPoint™ presentations about the subsequent exercises in each laboratory session, students valued the further input provided by tutors. So, whilst students might develop their declarative knowledge, that is, ‘know what’ from presentations, translating those graphics and movements into a real situation might be problematical. As a result, students needed clarification of the procedural knowledge, the required ‘know how’ to actually do the task, for example, learning by observing a demonstration by an expert. Students' perceptions of effective learning as involving observation of their tutors are consistent with social cognitive theory . Specifically, observation of models (tutors) performing relevant tasks with engagement of students through questioning, plus discussions and review of the task processes, followed by practice and feedback on progress, are all critical elements for learning . It is noteworthy that observational learning has underpinned the learning of other surgical skills . In relation to issues our students raised about the complexity of the tasks, particularly in the initial stages of learning, it is recommended that the modelled tasks be subdivided so important actions are learnt and not misunderstood . Subsequent opportunities for students to observe these modelled tasks are also recommended so they can refine what they have learnt in response to their practice with self-evaluation of the same tasks, supported by constructive feedback .
Other research has highlighted issues of managing information in learning a complex activity. Detailed verbal instruction in conjunction with observation might provide too much information for students to process as they have not developed adequate symbols, images or schema to make sense of the knowledge required, thereby hindering learning [34, 35]. For example, the effectiveness of observation with no verbal instructions for learning suturing skills in surgery has been demonstrated . Specifically, under cognitively demanding conditions, participants who learnt by observation alone (i.e., no verbal instructions) or by observation accompanied only by physical (i.e., not verbal) guidance performed significantly better than participants who learnt by observation with detailed verbal instructions.
These theories and related research are consistent with students' perceptions of the value of demonstrations by their tutors, as noted earlier, but might also explain the lack of association between perceptions of effective learning experiences and subsequent performance. Due to the high cognitive load associated with observing and listening to tutors' detailed instructions about how to complete the tasks and why, students' subsequent performance was not as effective as expected. The impact of high cognitive load is particularly important in the early stages of learning  when students develop symbols, images or schema for their operative technique tasks, that is, before these processes become automated through practice [33, 34].
From the students' perspective, feedback played a crucial role in developing their procedural knowledge. Theoretically, when learning a new task without observation, a learner initially uses trial-and-error approaches to achieve the goal of the task . The learner subsequently develops a reference derived from corrective feedback through self-evaluation and/or guidance from teachers, to decrease errors in performance . In fact, verbal feedback from experts enables students to learn new surgical skills better than self-accessed feedback . Considering the role of feedback in context of the DCP2 operative technique course, students used self-regulated or self-controlled feedback, that is, they learnt from errors detected during practice and refined their performance. With augmented feedback from tutors, students modified their movement or strategies to cut a cavity more precisely. Furthermore, as students in DCP2 practise cavity preparations on only a limited number of plastic teeth, it was necessary for tutors to point out the nature and cause of errors in the early stages of learning so that the correct movement and outcome could be developed by students with repeated practice. However, it is clear that provision of feedback during learning does not routinely translate into sustained improved performance, despite the level achieved after learning phases [41, 42]. Similar findings have been reported in relation to learning dental operative skills. For example, continuous computer-based feedback in relation to the outcome, during a simple cavity preparation, resulted in improved performance during learning compared with no feedback [8, 43]. However, this higher level of performance was not maintained in delayed retention tests (4 months later). The influence of feedback on subsequent performance may help explain the current finding of a lack of an association between perceptions of effective learning experiences and subsequent performance.
It was clear that students preferred to receive constructive feedback rather than non-specific or unhelpful feedback. These latter findings can also be explained in the context of social cognitive theory , where demonstration of learning following observation requires the motivation of students through feedback. The focus of feedback needs to be targeted at progress made, in contrast to shortcomings, such that learning environments that involve feedback with a focus on current achievement in turn result in a positive impact on self-efficacy, an important influence on academic achievement . In contrast, feedback focussed only on gaps or problems might cause students to be less motivated to complete a task, and this might result in a lower level of performance [44, 45]. Consistent with students' preference for helpful feedback, a recent study revealed that feedback received after a good performance enhanced learning of a new motor skill . Specifically, this latter study indicated that providing feedback about outcomes from the most effective trials resulted in better performance in retention tests than for participants who only received feedback on the outcomes from ineffective trials.
Students in the current study also identified that sharing learning experiences with their peers was effective for their learning. Whilst the learning environment in the DCP2 course did not include specific activities involving discussions amongst students, they identified that these types of interactions enabled them to learn from each other. For example, they perceived that discussing effective strategies with colleagues helped them improve their procedural knowledge, though this did not translate into improved performance. Comparing processes and outcomes with their colleagues, who had similar capabilities to themselves, and seeing them achieve their goals, is likely to have had a positive influence on their perceived self-efficacy, a key element for successful academic achievement . These results are consistent with previous findings that peer learning was a useful tool for developing self-evaluation skills through providing opportunities to identify inadequacies and to correct misunderstandings [47, 48]. However, these latter outcomes were achieved when senior students were involved in supervision as peer tutors of junior students under the supervision of lecturers. As our students were at similar levels of experience, inadequate knowledge of peers could explain the lack of an association of effective learning experiences and subsequent performance [32, 49].
It was expected that as the majority of participants identified positive learning experiences, an association with performance would be evident. Previous studies have shown a positive association between academic outcomes and students' perceptions of the learning environment that included similar features to those identified in the current study as being effective for learning, namely reciprocal interactions, demonstrations and constructive feedback [1, 50]. However, the findings of the current study indicate that students' perceptions did not directly translate into better performance in their operative technique course. Related to previous explanations for the lack of an association, another possible reason might be that students were still in the trial-and-error phase of learning cavity preparation skills, having had limited opportunities to observe the operative techniques. Therefore, skill acquisition was delayed as learners tested hypotheses related to what did/did not work, with resultant increased cognitive load, reduced development of models or schema and subsequent interruption of skill acquisition . Similarly, in terms of social cognitive theory, even though students perceived they learnt from observing tutor demonstrations, reviewing their errors, receiving constructive feedback, as well as being aware their peers were performing at similar levels, a number of factors may have constrained the influence of these experiences on students' subsequent performance. Examples of possible factors include periods of limited attention when observing tutor demonstrations, limited time or opportunities for review and cognitive processing of the information provided by tutors, lack of practice opportunities and/or feedback that was demotivating as it focussed on deficits or highlighted better performance by peers [33, 44].
Additionally, only limited analyses of the performance data were possible due to the categorical nature of these data. Other studies that have demonstrated associations between students' perceptions of the learning environment and performance have used grade point averages or scores on tests . The current study also only assessed outcomes in terms of achievement, that is, completion of a cavity preparation, and did not evaluate outcomes in terms of being able to provide descriptions or explanations of the procedures or their satisfaction with the course . It is possible that significant relationships were present between these latter outcomes and positive perceptions of their learning environment. Another limitation of the current study was that it was conducted in a normal class environment of a selected course, and therefore, the findings cannot be generalised to other operative technique learning contexts. However, the results provide a useful starting point for educators to take account of students' voices as major ‘partners’ in dental education.
Implications for practice
The findings of the current study in the context of the theories presented indicate that besides opportunities for students to have core techniques explained followed by opportunities to practise, our current approach needs to include:
- fostering of positive self-efficacy by breaking down complex operative tasks  beginning with simpler tasks, routinely providing opportunities to observe models so students can make progress, followed by tasks of increasing difficulty, and supporting students to set their own goals . As we know our tutors do not routinely provide these observational opportunities, despite emphasising this in tutor training, use of videos would ensure all students can access demonstrations. The videos would include only limited verbal description and present a sequence of simple to complex tasks [34, 36].
- subsequent observation of these videos of modelled tasks so that students can refine their skills in response to what they have achieved in their practice .
- feedback that highlights progress and achievement and does not include competitive comparison with others, to support the growth of self-efficacy .
- self-regulation including monitoring their performance in terms of expected standards and reciprocal interaction between peers, involving supportive activities of sharing achievements and strategies to support development of self-efficacy .
- tutor training regarding expectations for supporting student learning, including the rationale for this approach.