• simulation clinic;
  • dental student experiences;
  • qualitative research;
  • critical incident


  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. Acknowledgements
  9. References


Students' perceptions of their learning environment influence the quality of outcomes they achieve. Learning dental operative techniques in a simulated clinic environment is characterised by reciprocal interactions between skills training, staff- and student-related factors. However, few studies have examined how students perceive their operative learning environments and whether there is a relationship between their perceptions and subsequent performance. Therefore, this study aimed to clarify which learning activities and interactions students perceived as supporting their operative skills learning and to examine relationships with their outcomes.


Longitudinal data about examples of operative laboratory sessions that were perceived as effective or ineffective for learning were collected twice a semester, using written critical incidents and interviews. Emergent themes from these data were identified using thematic analysis. Associations between perceptions of learning effectiveness and performance were analysed using chi-square tests.


Students indicated that an effective learning environment involved interactions with tutors and peers. This included tutors arranging group discussions to clarify processes and outcomes, providing demonstrations and constructive feedback. Feedback focused on mistakes, and not improvement, was reported as being ineffective for learning. However, there was no significant association between students' perceptions of the effectiveness of their learning experiences and subsequent performance.


It was clear that learning in an operative technique setting involved various factors related not only to social interactions and observational aspects of learning but also to cognitive, motivational and affective processes. Consistent with studies that have demonstrated complex interactions between students, their learning environment and outcomes, other factors need investigation.


  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. Acknowledgements
  9. References

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’ ([1], 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 [1], 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’ ([5], 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 [1]. 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 [8] and modelling [9], and the arrangement of optimal task sequence for learning [10] 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 [10], 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 [18] and in postgraduate specialist clinical environments [21], 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.


  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. Acknowledgements
  9. References

Curriculum and research contexts

The Dental Clinical Practice 2 (DCP2) course in the Adelaide School of Dentistry aimed to integrate knowledge and skills in preventive and simple restorative care and therefore provided a range of activities to support learning of operative technique skills. These included a series of interactive lectures that reviewed knowledge related to subsequent laboratory sessions, operative laboratory sessions and student/tutor feedback sessions. PowerPoint presentations about the procedures and required outcomes of laboratory exercises were provided online in advance and were reviewed at the commencement of each laboratory session. Students completed a range of operative dentistry exercises, for example, cutting different cavities in plastic teeth for different restorative materials. Groups of ten students were supervised by the same tutor over the 24-week course. During each session, tutors provided formative feedback, and for each activity, students self-evaluated their performance and reviewed this with their tutor. The assessment criteria were the same as for clinical assessment across all year levels of DCP, namely knowledge base, skills, patient management and professional behaviour [22].

As this study aimed to explore students' experiences of learning, a phenomenological approach was appropriate as this methodology focuses on how participants' experience specific events or aspects of their lives and how they interpret them [23]. In terms of the relationship of the researchers and setting [24, 25], our core belief related to understanding the effectiveness of dental operative skills learning is that good teaching involves reciprocal interactions between students and tutors, with assessment focused on understanding, as elaborated in previous studies [1]. We acknowledge that to inform our understanding of how and why learning happens (or does not), we need to hear from our students about their experiences and what impact these experiences have on them and their learning. Therefore, written (i.e., critical incident report) and interview data were collected from students (see below: 'Data collection').

The first author (NS) was an international postgraduate student at the School of Dentistry in 2008. She was in the second year of her PhD investigating operative technique skills learning in a simulation clinic. The remaining authors are staff involved in teaching and assessment, mostly in the first 3 years of the curriculum. However, NS and TW had no role in the design of any tutoring or assessment roles in DCP2. NS completed all participant consent, data collection and analyses, with input as noted below from other authors, after data were de-identified. Whilst NS's outsider position might influence some students' willingness to discuss their learning experiences, it was considered students would be more frank with NS than with academic staff due to differences in perceived authority and because she too was a student. By the time the critical incidents and interviews were completed, all students were familiar with NS as she had been observing students during their operative technique classes as part of her data collection. In her home university, NS had tutored in a course with some content overlap with DCP2 related to ergonomics and control of hand movements using high-speed handpieces and mouth mirrors. Therefore, her personal preconceptions regarding operative technique skills learning were based on her previous experience in a different learning context and the literature. As she had nothing invested in the DCP2 course, she worked on minimising the impact of her preconceptions during data collection/analysis [26] by focusing on the students' experiences of learning in the DCP2 setting and the key elements of this experience from the students' view.


Participants were second-year students who were enrolled in the DCP2 in 2008 at the Adelaide School of Dentistry and had consented to participate in the study (n = 52, 68% consent rate, 27 females and 25 males; Human Research Ethics No. H154-2006). In a class attended by all students at the beginning of the academic year, TW introduced the students to the project and to NS, who then invited the students to participate. De-identified data were analysed only for those students who had completed all relevant DCP2 exercises. Specifically, these exercises were as follows:

  • Critical incident reports in four laboratory sessions (see details below: Data collection)
  • Cavity preparations on a lower left first permanent molar (tooth 36) completed in semesters 1 and 2.

Students were excluded if they had not consented to participate in this study, were absent from any of the scheduled sessions where data were collected or did not complete all exercises and/or were repeating the Adelaide dental program. According to these criteria, 11 records were removed from further data analyses due to missing data for the critical incident reports. Therefore, a total of 164 reports from 41 students (22 females and 19 males), plus their cavity preparations from semesters 1 and 2, were included for data analyses.

Data collection

Data about students' perceptions of their learning experiences in DCP2 were collected using written critical incident reports and follow-up interviews (see below). Data related to students' learning outcomes were obtained in week 11 of both semesters 1 and 2 and involved completing a cavity preparation on a tooth 36, based on a patient scenario [27] (see Table 1). The accompanying patient's radiograph demonstrated caries on the occlusal and both proximal surfaces of tooth 36 which required restoration.

Table 1. Timing for completion of critical incident reports, associated learning exercises and outcomes of students' learning
WeekLaboratory topicActivities
  1. a

    semester 1, data in both semesters were collected in the first of two laboratory sessions that students participated in each week

  2. b

    semester 2

  3. c

    critical incident collected

  4. d

    Tooth numbering system: 36 = lower left first permanent molar, 37 = lower left second permanent molar, 46 = lower right first permanent molar, 47 = lower right second permanent molar, 48 = lower right third permanent molar

  5. e

    exercises used to assess students' performance

5 a , c Occlusal preparation (composite resin)Toothd 46, 47, 48 O
10 a , c Slot with occlusal preparation (amalgam)36 MO, 37 MOD
11 a Cavity preparation exercise36 MODe
 Exams/mid-year semester break (6 weeks) 
8 b , c Slot with occlusal preparation (composite resin)46 MOD
11 b , c Cavity preparation exercise, self-directed activities36 MODe
46 MOD

A written critical incident report was used to explore a broad range of learning experiences and to sample larger groups of students than is possible with individual interviews. This report included questions modified from a previous study [18]. The questions explored learning activities that students perceived to be effective or ineffective in supporting their learning in the laboratory sessions, discussion they had with their tutor and factors that influenced the quality of their preparations. The reports were completed at the conclusion of selected laboratory sessions in DCP2 (see Table 1). To check that the students understood the focus of the critical incident report, a pilot was completed by second-year volunteers (n = 10) who formed part of the study sample. This pilot report was collected after a laboratory session that did not generate data for this study. After discussion with the students, the format and the content of questions were modified. For instance, the amount of information provided in the instruction section was reduced, and the question format was adjusted to present a list of short statements.

The selected sessions for the critical incident reports were based on increasing complexity of exercises and cavity preparation skills that were needed for a MOD cavity preparation on tooth 36 (Table 1). For example, in week 6, semester 1, students had completed several cavity preparation exercises involving an occlusal surface. In week 10, semester 1, students had accomplished more complicated exercises, requiring new procedural knowledge, that is, cavity preparations involving both occlusal and proximal surfaces. In week 8, semester 2, students had completed several exercises based on patient scenarios, including radiographic images showing the extent of caries.

The interview component was conducted to obtain further in-depth data related to students' learning experiences using open-ended questions, for example, clarifying the effectiveness of the experience, what key features made the learning experience effective or not and the type and timing of interactions. Initially, 8–12 students were selected based on their critical incident reports that particularly focussed on the processes they found effective/ineffective for learning or quality of their outcomes. Sampling of further students followed, until no new ideas arose from the interviews, that is, saturation was achieved [28]. The 20-min interviews were conducted within 1 week of completion of the critical incident reports, with subsequent transcription by a professional transcriber.

Data analyses

Data for analysis included textual accounts of students' perceptions from the critical incident reports and interviews, and cavity preparations in plastic teeth. Textual data were analysed using thematic analysis [29]. Initially, each report and transcript from all time periods were explored to identify units of meaning, for example, who was involved, what happened and the related context [24]. Second, key terms or phrases were highlighted and then compared to determine a primary pattern in the data. Third, data were categorised into themes and subthemes. All effective and ineffective experiences were analysed together. By identifying the word ‘effective’ and ‘ineffective’ in response to the first question of the critical incident report, data were categorised into two groups. If students did not report these specific words, then the first author read the full transcripts and categorised students' perceptions based on what they reported. Positive experiences were coded to be effective and negative experiences were coded as ineffective and were cross-checked with the interview data. The third step was completed when no new information about effective and ineffective learning experiences emerged from the data. Finally, the results were reviewed by the last author (TW) to ensure their credibility.

Cavity preparation exercises on plastic teeth completed at the end of each semester were coded so that examiners (n = 3) were unaware of students' identities and the timing of completion of the exercise. Criteria for grading students' performance on the cavity preparation exercises were based on clinical acceptability, using the following grades: unsatisfactory (U); unsatisfactory but redeemable (UR), that is, cavity preparation was larger than carious lesion or tooth structure was compromised, but the preparation could be adjusted to be clinically acceptable; satisfactory (S); and good (G) [30]. Kappa statistics for interexaminer reliability were 0.41–0.47 and for intra-examiner reliability were 0.35. These indicated moderate and fair agreement, respectively [31], and therefore, final grades were assigned after review and agreement by all three examiners.

To identify the relationship between students' perceptions of their learning environment and their learning outcomes, students were grouped according to their perceptions of the effectiveness of each selected learning session and performance achieved. Specifically, groups were those who reported effective learning experiences in one/two sessions or in three/four sessions, and students who had a U grade in either semester or had a minimum of an UR grade in both semesters. Data were then tabulated and relationships analysed using chi-square tests, with a significance level set at P < 0.05.


  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. Acknowledgements
  9. References

Approximately 56% of written critical incident reports and 70% of interview transcripts identified experiences that supported learning. Several themes were derived from the reports and interviews, that is, roles of tutors in enhancing skill learning and roles of peers in self-evaluation. These themes are presented in sequence, according to the most frequently reported statements. The quotes are presented with the students' identifiers in parentheses, namely student code, time of data collection (week and semester, e.g., week 4 s1) and source of information (i.e., derived from the critical incident reports (CI) or interview). Despite the variation in types and complexity of tasks in the different weeks in which data were collected, students' perceptions about effective and ineffective learning experiences over the length of the course were generally consistent, for example, the roles of the tutor in giving useful feedback and learning from mistakes were reported as being significant for learning at each time period. As students' skills developed across the semesters, there was a decrease in focus on specifics of operative techniques that were perceived to influence their outcomes, for example, bur control, instrument angulation and indirect vision.

Roles of tutors: arranging group discussion to clarify ‘steps’ of a task and ‘what is expected’

Consistent across all critical incident reports, students noted that having their tutor setup discussions in their group helped to clarify ‘what are (the) “steps”’ in the subsequent exercise. For example, in the initial few weeks of the DCP2 course, students were confused about bur selection, how to use the instruments, and use of dental materials. Students noted that it was useful having a discussion with their tutor at the beginning of laboratory sessions about the expected outcomes and how to achieve them. This activity was perceived by students to be necessary to clarify the theoretical knowledge to be applied to the practical exercise. For instance, the following students cited experiences near the beginning and end of the course that addressed steps and/or expectations.

‘… my tutor showed me other people's stuff, like how smooth a cavity should be and he did one as an example on another tooth, like one was smooth and one was not smooth to sort of compare……which one is good and which one is bad, and this is where you work from…and it is effective.' (S194, week 6 s1, interview)

‘[Tutor's name] showed us how to create [a] cavity and restore cusp protection. It was effective for learning because [the tutor] explained the reasons behind each step and got me thinking… never tried this procedure before so I stopped every stage and tell [the tutor] what I think could be done next and ask [the tutor] for opinion. [The tutor] checked every stage of my procedure. [The tutor] gave me suggestions and told me what to do next and the reasons behind it.' (S317, week 11 s2, CI)

The perceptions of a lack of information or need for clarification of expectations were considered to be ineffective learning experiences as illustrated by another student:

‘I just guessed what I should do and I did it badly with the wrong instrument. I felt quite frustrated that I'm so lost and don't know exactly what's expected, what instrument is best to use…My main problem is I don't know what the end product should look like and what tools I can use to achieve that. I kept being told the cavity wasn't good enough. I felt very frustrated after the session because [I] don't know where to get information'. (S914, week 5 s1, CI)

Roles of tutors: live demonstration: ‘show how to do’ approach

In the first few weeks of the course, students were required to learn about how to use new instruments and materials. They had already gained some knowledge related to the exercises, that is, what and when to do, but they had no experience of ‘how to do’ these activities. For example, how much pressure was needed to cut a cavity in a plastic tooth without burning it, how to create smooth floors or taper the walls without destroying other parts of the tooth or where to place the mirror to avoid the water spray from the high-speed handpiece.

Students identified that having demonstrations with verbal instructions helped them to develop well-defined goals for the subsequent exercise. Although they were shown the procedures they needed to complete as static images using PowerPoint, they noted that demonstrations of ‘how to do’ the whole activity were instructive. Half of the students stated that they learnt more effectively when their tutor showed them how to solve a problem that they were struggling with, for example, how to use an instrument appropriately to create a desired outcome and how to control the rotary cutting instrument. Examples of such learning experiences included the following:

‘I had trouble with smoothing the floors and walls of the cavity and my tutor just showed me “maybe it's just how you're handling it and how you're positioning your hands on the mouth of the ‘tooth model’”. She just showed me and demonstrated and that just really helped with that. I usually learn by just observing first so that really helped me'. (S820, week 4 s1, interview)

‘…[The tutor] showed me how to manipulate the bur….made me practice, saw what I was doing and then explained the exact movements I was making with the bur that were causing the problems. It really improved my cavity preps. They were conservative, more defined, smooth walls and floors’. (S737, week 13 s1, CI)

Roles of tutors: providing feedback

Almost half of the students identified learning experiences involving feedback from their tutor as having an impact on their learning. Helpful feedback with practical tips to solve problems was noted to result in effective learning experiences. For instance, students who made mistakes and/or repeated errors in an exercise were potentially motivated to improve their performance by useful feedback which focused on the cause of the errors and techniques, or ‘tips’, to fix the errors:

‘The task involved drilling artificial caries from an acrylic maxillary arch. Initially my cavities had rough pulpal floors and walls, but with the tutor's tips for improvement during the session and continued acknowledgement of an improvement – the cavities ultimately had a better shape and were smoother’. (S184, week 2 s1, CI)

In addition, discussing satisfactory and unsatisfactory aspects of an outcome with the tutor was considered to be informative. For example:

‘[Tutor said] Do you realise your floor isn't flat?” and I said “sort of” and then she drew a diagram on the piece of paper of basically what my floor looked like and what a floor should actually look like…. then she said “yeah it seems to be only where you have tapered” and then she basically used the diagram to show how I should be angling the bur….. that helped explain one of the techniques used and then also she said to measure the length of the bur and so I have an idea of how deep I'm going against the cusp, and… I think that was probably the session where I got taught the most’ (S794, week 6 s1, interview)

A few students reported ineffective learning experiences in relation to feedback received from their tutor. These included non-specific feedback and feedback that focused on mistakes but not on how to improve. Students indicated preferences for specific feedback that included information about errors but also discussion of strategies to avoid the same error in subsequent exercises. For instance, in week 5, semester 1, a student was struggling with their preparation and sought feedback from their tutor. The tutor pointed out the error but did not suggest strategies for improvement. The student had felt confident with their knowledge before the task but later in the session felt frustrated:

‘I found this session unpleasant because [I was] frustrated at [my] tutor as [my tutor] was not answering my questions or offering strategies for improvement. [I] felt [my tutor] was not appreciating improvement’. (S603, week 5 s1, CI)

Other sources of feedback: learning from their own mistakes

By the second critical incident report, about 60% of students commented on learning experiences that related to errors they had produced during their cavity preparation exercises. The errors included unsatisfactory aspects of the cavity they had produced, for example, dimensions of the cavity, including width, depth, taper and smoothness as well as damage to tooth structure. Students reflected on effective learning experiences as a result of these mistakes that occurred during completion of these exercises, for example:

‘… drilled adjacent tooth when doing a proximal slot. Now [I] remember to use matrix bands, learned to leave sliver of enamel and remove with hatchet and used soft touches with the bur. Yes it was effective to learn from this mistake and understood how easy it is to damage the adjacent tooth’. (S496, week 8 s1, CI)

‘It's more I think about the mistakes I did before. Not just the mistakes but what caused the mistakes, because I would have discussed that with my tutor….. wasn't too bad if I did the exact same exercise or one very similar the next week or immediately after, because I had actually learnt slightly from my mistakes before. I mean they weren't perfect, but I tended not to make the same mistakes again’. (S435, week 8 s2, interview)

Other sources of feedback: roles of peers in self-evaluation

Effective learning experiences were acknowledged by students when they discussed their experiences with their peers. As students often encountered similar problems during exercises, they often shared their experiences and effective strategies they had learned from their peers:

‘Comparing your work with other students. This allowed comparison of what each was finding hard and sharing tips’. (S339, week 4 s1, CI)

‘I found that I was experiencing trouble producing flat floors with the high speed and rounded slow speed burs, but when a fellow student told me to use the flat fissure bur, I found that I improved immensely’. (S688, week 5 s1, CI)

Associations between students' perceptions and their performance

The majority of students described effective learning sessions in three or four of the weeks in which data were collected (Table 2). However, there was no significant association between students' perceptions of the effectiveness of the sessions and their grades, χ2 (1, N = 41) = 0.02, P = 0.89. This means that students' perceptions of effective learning experiences were not directly linked with the quality of their performance.

Table 2. Number of students who had different perceptions of the effectiveness of their learning environment and grades for cavity preparation exercises across semesters
Perception of learning environmentaGradesb
  1. a

    Based on critical incident reports collected in weeks 5 and 9, semester 1 and weeks 8 and 11, semester 2; χ2 (1, N = 41) = 0.02, P = 0.89

  2. b

    Performance on cavity preparations was graded as U = unsatisfactory, UR = unsatisfactory redeemable (cavity preparation was too deep/too wide/tooth structure is compromised but can be corrected to be clinically acceptable), S = satisfactory, G = good

  3. c

    U in either semester

  4. d

    grade of UR or higher in both semesters

Effective in 1 or 2 weeks8614
Effective in 3 or 4 weeks161127


  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. Acknowledgements
  9. References

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 [32]. Other components that influence perceived effectiveness of learning environments, for example, assessment methods or workload [1], 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 [33]. 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 [33]. It is noteworthy that observational learning has underpinned the learning of other surgical skills [9]. 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 [33]. 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 [33].

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 [36]. 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 [37] 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 [38]. The learner subsequently develops a reference derived from corrective feedback through self-evaluation and/or guidance from teachers, to decrease errors in performance [39]. In fact, verbal feedback from experts enables students to learn new surgical skills better than self-accessed feedback [40]. 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 [33], 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 [44]. 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 [46]. 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 [33]. 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 [51]. 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 [1]. 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 [1]. 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 [34] 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 [33]. 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 [33].
  • feedback that highlights progress and achievement and does not include competitive comparison with others, to support the growth of self-efficacy [44].
  • 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 [33].
  • tutor training regarding expectations for supporting student learning, including the rationale for this approach.


  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. Acknowledgements
  9. References

The present study accessed students' voices to reveal their learning experiences, one of the key components to understand an educational setting. In summary, students noted both effective and ineffective learning experiences during the DCP2 operative technique course. The role of the laboratory tutors was found to be important in creating an effective learning environment. Students perceived that they learnt effectively when their tutor set up a group discussion prior to commencing activities and demonstrated ‘how to do’ the activities, helping them to better understand the procedural knowledge. Constructive feedback about their performance was also considered to be effective for their learning. In contrast, feedback that focused on gaps or mistakes and not on how to improve was reported to result in ineffective learning experiences. Students who detected errors in their own performance noted that this helped them to improve. Interestingly, students commented on the positive role of their peers in evaluating their own performance. Whilst the results of this study revealed no significant relationship between students' perceptions of their learning environment and performance, various factors are likely to have contributed to this finding, related to supporting students to manage and integrate complex information and development of self-efficacy. It was clear that learning in an operative technique setting involved a range of factors related not only to social interactions and observational aspects of learning but also to cognitive, motivational and affective processes needed to perform complex dental operative technique skills. The current study provides an understanding of students' perceptions in relation to the dental operative learning environment and also some suggestions about how these can be translated into practice. Further research into the relationship of supervision to student self-efficacy is needed to clarify the impact of different supervisory approaches on students' operative learning outcomes. Analyses of different theories relevant to learning complex dental operative skills are needed to ensure we better understand our students' learning experiences so we can optimise their learning.


  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. Acknowledgements
  9. References

The authors would like to acknowledge the following for their contributions: Dr John Kibble for grading assistance; Dr Vicki Skinner and Assoc Prof Frances Greenwood for their constructive comments on an earlier version of this manuscript; the Australian Dental Research Foundation; School of Dentistry, The University of Adelaide; and Education Research Group, International Association of Dental Research for financial support.


  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. Acknowledgements
  9. References
  • 1
    Lizzio A, Wilson K, Simons R. University students' perceptions of the learning environment and academic outcomes: implications for theory and practice. Stud High Educ 2002: 27: 2752.
  • 2
    Ramsden P. Learning to teach in higher education. London: Routledge Falmer, 2003.
  • 3
    Prosser M, Trigwell K. Understanding learning and teaching: the experience in higher education. Philadelphia: Open University Press, 1998.
  • 4
    Biggs J. Teaching for quality learning at university. Buckingham: SRHE and Open University Press, 2003.
  • 5
    Fraser BJ. The birth of a new journal: editor's introduction. Learning Environ Res 1998: 1: 15.
  • 6
    Knight G, Guenzel P, Feil P. Using questions to facilitate motor skill acquisition. J Dent Educ 1997: 61: 5665.
  • 7
    Feil PH, Guenzel PJ, Knight GW, Geistfeld R. Designing preclinical instruction for psychomotor skills (I)–theoretical foundations of motor skill performance and their applications to dental education. J Dent Educ 1994: 58: 806812.
  • 8
    Wierinck E, Puttemans V, van Steenberghe D. Effect of tutorial input in addition to augmented feedback on manual dexterity training and its retention. Eur J Dent Educ 2006: 10: 2431.
  • 9
    Custers EJ, Regehr G, McCulloch W, Peniston C, Reznick R. The effects of modeling on learning a simple surgical procedure: see one, do one or see many, do one? Adv Health Sci Educ Theory Pract 1999: 4: 123143.
  • 10
    Dubrowski A, Backstein D, Abughaduma R, Leidl D, Carnahan H. The influence of practice schedules in the learning of a complex bone-plating surgical task. Am J Surg 2005: 190: 359363.
  • 11
    Wierinck E, Puttemans V, van Steenberghe D. Effect of reducing frequency of augmented feedback on manual dexterity training and its retention. J Dent 2006: 34: 641647.
  • 12
    Abraham R, Ramnarayan K, Vinod P, Torke S. Students' perceptions of learning environment in an Indian medical school. BMC Med Educ 2008: 8: 20.
  • 13
    Dunne F, McAleer S, Roff S. Assessment of the undergraduate medical education environment in a large UK medical school. Health Educ J 2006: 65: 149158.
  • 14
    Henzi D, Davis E, Jasinevicius R, Hendricson W, Cintron L, Isaacs M. Appraisal of the dental school learning environment: the students' view. J Dent Educ 2005: 69: 11371147.
  • 15
    Kossioni AE, Varela R, Ekonomu I, Lyrakos G, Dimoliatis ID. Students' perceptions of the educational environment in a Greek dental school, as measured by DREEM. Eur J Dent Educ 2012: 16: e73e78.
  • 16
    Ostapczuk MS, Hugger A, de Bruin J, Ritz-Timme S, Rotthoff T. DREEM on, dentists! Students' perceptions of the educational environment in a German dental school as measured by the Dundee Ready Education Environment Measure. Eur J Dent Educ 2012: 16: 6777.
  • 17
    Veerapen K, McAleer S. Students' perception of the learning environment in a distributed medical programme. Med Educ Online 2010: 15. doi: 10.3402/meo.v15i0.5168.
  • 18
    Victoroff KZ, Hogan S. Students' perceptions of effective learning experiences in dental school: a qualitative study using a critical incident technique. J Dent Educ 2006: 70: 124132.
  • 19
    Henzi D, Davis E, Jasinevicius R, Hendricson W. North American dental students' perspectives about their clinical education. J Dent Educ 2006: 70: 361377.
  • 20
    Papp I, Markkanen M, von Bonsdorff M. Clinical environment as a learning environment: student nurses' perceptions concerning clinical learning experiences. Nurse Educ Today 2003: 23: 262268.
  • 21
    Subramanian J, Anderson VR, Morgaine KC, Thomson WM. Effective and ineffective supervision in postgraduate dental education: a qualitative study. Eur J Dent Educ 2013: 17: e142e150.
  • 22
    Wetherell J, Mullins G, Hirsch R. Self-assessment in a problem-based learning curriculum in dentistry. Eur J Dent Educ 1999: 3: 97105.
  • 23
    Lawler J. Choosing a research approach: matching research questions with methodologies. In: Higgs J, Cant R, eds. Writing qualitative research. Sydney: Hampden Press, 1998.
  • 24
    Côté L, Turgeon J. Appraising qualitative research articles in medicine and medical education. Med Teach 2005: 27: 7175.
  • 25
    Kitto SC, Chesters J, Grbich C. Quality in qualitative research. Criteria for authors and assessors in the submission and assessment of qualitative research articles for the Medical Journal of Australia. Med J Aust 2008: 188: 243246.
  • 26
    Crotty M. The foundations of social research: meaning and perspective of the research process. NSW: Allen & Unwin, 1998.
  • 27
    Suksudaj N. What factors influence learning of psychomotor skills by dental students? [dissertation on the Internet]. Adelaide, AU: University of Adelaide, 2010. [cited 2013 Nov 09]. Available from:
  • 28
    Rice P, Ezzy D. Qualitative research methods: a health focus. Melbourne: Oxford University Press, 1999.
  • 29
    Patton MQ. Qualitative research & evaluation methods. 3rd edn. California: Sage Publications Inc, 2002.
  • 30
    Suksudaj N, Townsend GC, Kaidonis J, Lekkas D, Winning TA. Acquiring psychomotor skills in operative dentistry: do innate ability and motivation matter? Eur J Dent Educ 2012: 16: e187e194.
  • 31
    Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics 1977: 33: 159174.
  • 32
    Loke AJ, Chow FL. Learning partnership–the experience of peer tutoring among nursing students: a qualitative study. Int J Nurs Stud 2007: 44: 237244.
  • 33
    Bandura A. Social foundations of thought and action: a social cognitive theory. New Jersey: Prentice Hall, 1986.
  • 34
    Van Merriënboer JJ, Sweller J. Cognitive load theory in health professional education: design principles and strategies. Med Educ 2010: 44: 8593.
  • 35
    Pollock E, Chandler P, Sweller J. Assimilating complex information. Learn Instruct 2002: 12: 6186.
  • 36
    Masters RS, Lo CY, Maxwell JP, Patil NG. Implicit motor learning in surgery: implications for multi-tasking. Surgery 2008: 143: 140145.
  • 37
    Dubrowski A, Brydges R, Satterthwaite L, Xeroulis G, Classen R. Do not teach me while I am working! Am J Surg 2012: 203: 253257.
  • 38
    Fitts PM, Posner MI. Human performance. California: Brooks/Cole Publishing Company, 1967.
  • 39
    Schmidt RA, Lee T. Motor control and learning: a behavioral emphasis. 4th edn. Illinois: Human Kinetics, 2005.
  • 40
    Porte MC, Xeroulis G, Reznick RK, Dubrowski A. Verbal feedback from an expert is more effective than self-accessed feedback about motion efficiency in learning new surgical skills. Am J Surg 2007: 193: 105110.
  • 41
    Vander Linden DW, Cauraugh JH, Greene TA. The effect of frequency of kinetic feedback on learning an isometric force production task in nondisabled subjects. Phys Ther 1993: 73: 7987.
  • 42
    Schmidt RA, Wulf G. Continuous concurrent feedback degrades skill learning: implications for training and simulation. Hum Factors 1997: 39: 509525.
  • 43
    Wierinck E, Puttemans V, Swinnen S, Steenberghe D. Effect of augmented visual feedback from a virtual reality simulation system on manual dexterity training. Eur J Dent Educ 2005: 9: 1016.
  • 44
    Bandura A. Perceived self-efficacy in cognitive development and functioning. Educ Psychol 1993: 28: 117148.
  • 45
    Langan-Fox J, Armstrong K, Balvin N, Anglim J. Process in skill acquisition: motivation, interruptions, memory, affective states, and metacognition. Aust Psychol 2002: 37: 104117.
  • 46
    Chiviacowsky S, Wulf G. Feedback after good trials enhances learning. Res Q Exerc Sport 2007: 78: 4048.
  • 47
    Goldsmith M, Stewart L, Ferguson L. Peer learning partnership: an innovative strategy to enhance skill acquisition in nursing students. Nurse Educ Today 2006: 26: 123130.
  • 48
    Nikendei C, Kohl-Hackert N, Junger J. Peer-assisted learning: a planning and implementation framework. Guide supplement 30.3–practical application. Med Teach 2008: 30: 442443.
  • 49
    Weyrich P, Schrauth M, Kraus B, et al. Undergraduate technical skills training guided by student tutors–analysis of tutors' attitudes, tutees' acceptance and learning progress in an innovative teaching model. BMC Med Educ 2008: 8: 19.
  • 50
    Pimparyon P, Caleer SM, Pemba S, Roff S. Educational environment, student approaches to learning and academic achievement in a Thai nursing school. Med Teach 2000: 22: 359364.
  • 51
    Maxwell JP, Masters RS, Kerr E, Weedon E. The implicit benefit of learning without errors. Q J Exp Psychol 2001: 54: 10491068.