First-year oral health and dentistry student perceptions of future professional work

Authors


Dr Vivienne Anderson
Faculty of Dentistry
PO Box 647
University of Otago
Dunedin 9054
New Zealand
Tel: +64 3 479 7114
Fax: +64 3 479 7113
e-mail: vivienne.anderson@otago.ac.nz

Abstract

Objectives:  To explore and compare how pre-doctoral dentistry (BDS) and oral health (BOH) students characterise their future professional work at the start and end of their first-year professional programme.

Materials and methods:  All BDS and BOH students were given an anonymous survey on the first and last days of their 2009 course. Start and end surveys (ES) were completed by 75% of BDS (51) and 83% of BOH students (33). This paper examines students’ responses to two questions asking them to identify a situation characterising their future professional work and a professional difficulty they would likely encounter. Student responses were analysed inductively to identify key themes and confirm each theme’s ‘weighting’ based on frequency of mention.

Results:  Students’ answers to both questions revealed eight characterisations of future professional work involving the following: restorative tasks, patient-related concerns, patient emotion and behaviour, population-level/public health concerns, disease prevention and monitoring, communication, teamwork and self-management. In ES responses, BDS students emphasised restorative tasks as central to a dentist’s work, and in both surveys perceived ‘dealing with patients’ as a central difficulty. In contrast, BOH students’ answers to both questions revealed a patient care emphasis, and in both surveys, BOH students emphasised patient-related concerns as a likely difficulty.

Conclusion:  Bachelor of Dentistry students characterised their work as primarily interventive, and BOH students, as primarily patient-centred, communicative, and preventive. Whilst BDS students apparently valued restorative capabilities, BOH students valued the ability to ensure patient well-being. Further research will examine students’ differing perceptions and how these change over time.

Introduction

Understandings of the ‘ideal professional’ underpin the development of formal curricula in oral health and dentistry pre-doctoral programmes. Dental education literature suggests that the ideal (oral health or dentistry) professional has the clinical and interpersonal skills necessary to practise competently (1); the capacity and willingness to access, evaluate and use research evidence (2); and the ability and willingness to self-evaluate and solve problems (3). Other ‘ideal professional’ attributes identified in research literature include the ability to practise appropriately within a specific healthcare/socio-cultural context (4, 5); the ability to work as a team member, including inter-professionally; and the ability to practise ethically (4, 6, 7). ‘Ethical practice’ is largely constructed as involving a sense of responsibility not only to relieve pain, but also to improve the oral health of whole communities through patient education, care for vulnerable citizens and advocacy (6, 8). Dental and oral health education are increasingly portrayed as not only involving the promotion of students’ skill development and knowledge acquisition, but also their professional ‘becoming’ (8, 9), or transformation from student to competent health professional.

Whilst formal curricula may play a crucial role in dental and oral health students’ transformation to competent professional, as Genn (10) suggests, ‘curriculum’ does not only include formalised course content, but everything that takes place within an educational context. For example, formal and informal staff-student and peer interactions can be seen as elements of the curriculum, as can the theories of knowing (epistemology) and being (ontology) that underpin what is taught and how it is taught (9, 11). In addition, dental school curricula may be shaped by factors external to the educational context, including economic imperatives affecting professional practice (6), societal notions of dentistry or oral health practice that students bring to their education (9, 12), and students’ ways of conceptualising course content (13).

This paper reports on the first year of a longitudinal study aimed at tracking Bachelor of Dentistry (BDS) and Bachelor of Oral Health (BOH) students’ emerging perceptions of their future professional work throughout their pre-doctoral programmes. The study builds on earlier work by Kieser et al. (8) involving a longitudinal examination of University of Otago beginning dentistry students’ perceptions of their professional work. This, in turn, drew on Dall’Alba’s (14) qualitative study of medical students’ understandings of professional practice. Our study differs from these earlier studies in its inclusion of students from two health professional programmes and its continuation throughout students’ course of study. Like Dall’Alba (14), our primary aim is to examine how students characterise their future professional work, and following Kieser et al. (8), we are also interested in how students’ characterisations shift over time. In addition, our study aims to consider similarities and differences in the ways students in the two respective programmes characterise their future professions (dentistry or oral health), in the broader professional understandings that their characterisations reveal, and in the possible links between these and programme curricula.

Materials and methods

The University of Otago BDS and BOH programmes

Kieser et al. (8) provide an overview of the University of Otago BDS programme. In brief, it involves 5 years of study, beginning with a high stakes health sciences first-year course from which students are selected for dentistry, medicine, physiotherapy and medical laboratory science programmes. Alternatively, students may gain graduate entry to the BDS programme if they have completed another degree and papers equivalent to the first-year health sciences course. The next 3 years of the programme (BDS 2, 3 and 4) involve a mixture of clinical, laboratory-based and didactic teaching and follow three broad streams: ‘The Dentist and the Patient’, ‘Biomedical Sciences’ and ‘The Dentist and the Community’. Although early clinical exposure is central to the programme, the focus on clinical work increases as the programme progresses. The final year is primarily clinical, with the three streams combined as ‘General Practice Dentistry’. The BDS programme includes some emphasis on sociological and ethical concerns, but is primarily informed by the physical sciences (Dentistry Otago Infosheet, http://dentistry.otago.ac.nz/study/dent.html).

In contrast with the University of Otago BDS programme, the 3-year BOH programme is explicitly underpinned by a social science emphasis, including elements of learning relating to New Zealand’s bicultural heritage (4). The programme is relatively new (accredited in 2006) and brings together what were previously separate dental therapy and dental hygiene programmes. Students can gain direct entry into the BOH programme from secondary school if they meet minimum university entrance requirements and have studied senior Biology and English. Alternatively, students can be selected for the programme if they have completed other university programmes or have health-related experience alongside equivalent (senior secondary school) qualifications in biology. Graduates of the BOH programme can register to work in New Zealand as dental hygienists, dental therapists or both. Both disciplines have an important educative, preventive and health promotion role, with dental therapists providing oral health assessment, treatment, management and prevention for children up to 18 years of age (4).

Coates et al. (4) provide a comprehensive account of the history and philosophy of the BOH programme. In brief, the programme aims ‘to produce graduates who are clinically competent oral health professionals, with a strong sociological perspective and the expertise required to engage in evidence-based professional development’ (p. 1005). Stated learning outcomes explicitly emphasise students’ professional ‘becoming’ (9), including their skill development, development of the knowledge and understanding necessary to approach and evaluate tasks, and understanding of what it means to approach tasks with professionalism (4). The rationale for the programme’s sociological emphasis is to foster students’ capacity for critically analysing structural and societal factors that can shape health promotion and disease prevention in a multicultural, socio-economically disparate context (4). Although the BDS and BOH programmes share facilities and some teaching staff, there is currently little interplay between them.

Examining students’ understandings of future professional work

In 2009, having gained ethical approval from the University of Otago Department of Oral Rehabilitation, we delivered a two-part survey to BDS and BOH students on the first and last day of their first (professional) year course. (This was in February and October, at the start and end of New Zealand’s academic year). The first part of the survey included two open-ended questions drawn from Kieser et al. (8) and Dall’Alba’s (14) earlier research with dentistry and medical students respectively. The questions were:

• Give an example of a concrete situation which illustrates what you think is central to the work of a dentist/dental therapist/hygienist; and

• Give an example of a concrete situation in a dentist or dental therapist/hygienist’s daily work which you think can be difficult to deal with.

Both questions reflect a phenomenographic approach (14): a focus on students’ conceptual, experiential, culturally learned and individually developed ways of making sense of their future professional work (13, 15). The second section of the survey will be discussed in a later paper. Although survey responses were anonymous, students were allocated a number for tracking purposes.

We used an inductive approach to analyse students’ responses to the two open-ended questions (16, 17). Our approach to analysis was loosely based on that described by Dall’Alba (14) and Kieser et al. (8). However, a point of difference was that in our study, the first stage of analysis was conducted primarily by the second author (MK) as part of her summer student project, and not by all three authors together. First, MK read and re-read students’ responses to the two questions together and noted down key ideas evident in these across all four questionnaires (BOH and BDS start and end of year questionnaires). After a further reading, independent parallel coding by the first author (17), and discussion as a group, we grouped these ‘key ideas’ into eight ways of characterising dentistry and oral health work, noting down questionnaire excerpts that illustrated the different ways in which students’ responses alluded to each characterisation. Through a further reading, MK developed descriptions of each characterisation and checked that no outstanding characterisations were evident. After then re-coding students’ questionnaire responses in relation to the eight characterisations, she produced a final ‘weighting’ table for each group based on frequency of mention. As in the previous two studies, the eight ways of characterising dentistry and oral health work were not predetermined but emerged from students’ questionnaire responses.

Unlike Dall’Alba (14) and Kieser et al. (8), the present study found that individual students did not necessarily characterise their future professional work in only one way. For example, at the end of 2009 in response to question one (provide an example of a situation central to your future professional work), a BDS student characterised his or her future work as involving both communication with the patient and disease prevention: ‘Explaining to a patient why they’re getting dental problems, making them understand the science behind it and let them know how to make sure they don’t need any more rehab for that problem’. In line with an inductive approach to data analysis, where students’ questionnaire responses revealed more than one way of characterising their future professional work, we counted each characterisation (17).

As is the case in all qualitative research, the influence of our own perceptions, experiences and frames of reference can be seen as both a strength and a limitation of the study (18). As a strength, we read students’ questionnaire responses from productively disparate perspectives: MK as a BDS student; LFP as an academic staff member and BDS two clinical course co-ordinator; and VA as an academic staff member with educational support responsibilities across the BOH and BDS programmes. This provided a check in terms of our coding clarity (17), resulting in many discussions about alternative ways of coding students’ responses; and possible interpretations of students’ responses in relation to BOH and BDS curricula, clinical teaching in the faculty, broader professional understandings, and public perceptions of dentistry and oral health practice in New Zealand. As a check against misreading students’ responses, we followed the same practices as Kieser et al. (8): focusing on what students’ responses suggested about their understanding of dental or oral health practice rather than prior hypotheses or previously derived categories; endeavouring to focus on students’ entire responses rather than sentences or words taken out of context; cross-checking our interpretations against other plausible interpretations; and allowing for multiple interpretations if necessary.

Results

Participants included 51 BDS and 33 BOH students enrolled during 2009 in their first professional year of study at the University of Otago Faculty of Dentistry, New Zealand. These included 75% of all BDS (51 of 68) and 83% of all BOH students (33 of 40), each of whom completed both the start (SS) and end of year (ES) surveys. Surveys were delivered on the first (SS) and last (ES) days of the academic year. More women than men completed the surveys (66% overall), and there were marked gender differences between the BOH and BDS groups. All BOH participants except one were women, whilst over half of the BDS group (19) were men. Participants’ ages ranged from 18 to 33 years with 92% of students aged between 18 and 22 years and nearly half of the students aged 19 years.

Eight ways of characterising oral health and dentistry work emerged in both BOH and BDS student responses. As in the earlier study by Kieser et al. (8) the same characterisations were largely apparent in students’ responses to both question one (anticipated professional role) and two (anticipated difficulties). The characterisations, their definitions and example quotations for each are outlined in Table 1.

Table 1.   Students’ characterisations of future professional work derived from question one (anticipated professional role) and two (anticipated difficulties) responses
CharacterisationDefinition (as applied to each question)Example
  1. BDS, Bachelor of Dentistry; BOH, Bachelor of Oral Health; ES, end survey; SS, start survey.

Restorative tasksQ1Undertaking technical procedures to improve function or restore a problem‘Caries…restore either by remineralisation or amalgam or composite’ (BDS ES, Q1)
Q2Dealing with complications or restrictions with such procedures‘What treatment to give when there is a compromise between cost and effectivity’ (BDS SS, Q2)
Patient-related concernsQ1Taking a patient-orientated approach and addressing patients’ concerns‘Educating…patient on the importance of maintaining and how to maintain oral health’ (BDS ES, Q1)
Q2Dealing with a lack of cooperation, complaints and patients’ specific needs‘Dealing with client’s specific needs, which should be culture etc’ (BOH SS, Q2)
Patient emotion and behaviourQ1Coping with patients’ emotions and associated behaviour‘Help patient feel safe’ (BOH SS, Q1)
Q2Dealing with patients’ negative emotions as they affect the patient-dentist relationship‘Unhappy patient’; ‘stressed patient’; ‘fear’; ‘lack of trust’ (BDS SS, Q2)
Population-level/public health considerationsQ1Providing education and promoting good oral health care at a population or community level‘Treating the community, providing oral health education to prevent future oral disease and treating the existing problem’ (BDS ES, Q1)
Q2(No difficulties identified)
Disease prevention/monitoringQ1Preventing and monitoring oral diseases through detection, examinations and oral health instruction‘Explaining to a patient why they’re getting dental problems… and letting them know how to make sure they don’t need any more rehab for that problem’ (BDS ES, Q1)
Q2Making borderline decisions between prevention and intervention‘Whether to cut a cavity prep or simply provide oral health instruction and remineralisation’ (BDS ES, Q2)
CommunicationQ1Communicating with colleagues and/or communicating with patients‘Notify [the patient] of the procedure, cost and what the treatment is forEnsure the patient is thoroughly informed before proceeding’ (BDS SS, Q1)
Q2Explaining technical terms or delivering tough diagnoses to patients. Negotiating linguistic or cultural barriers‘Children don’t have…[a] great knowledge of [the] dental area [and] thus it could be difficult for us, trying to explain to them carefully’ (BOH SS, Q2)
TeamworkQ1Working with other dental professionals‘Getting good support and opinions from your colleagues’ (BDS ES, Q1)
Q2Dealing with a lack of professional support, employer pressure, maintaining working relationships, and knowing when to refer cases‘Working relationships’ (BOH ES, Q2). ‘No dental assistant’ (BDS SS, Q2)
Self-managementQ1Maintaining and exhibiting desirable professional attributes and meeting professional expectations‘Restorative work is crucial. It is what people expect dentists to do well’ (BDS ES, Q1)
Q2Difficulties maintaining a ‘professional attitude’ or coping with physical and emotional demands‘Witnessing… people with extremely poor OH…This will…make us feel slightly helpless in the fight against dental caries’ (BOH ES, Q2)

BDS student perceptions of future professional work: changes over time

Overall, BDS students’ perception of a dentist’s central role and everyday difficulties shifted little from the start to the end of the year. The concrete situations discussed in response to question one and likely difficulties identified in response to question two primarily emphasised restorative tasks and patient-related concerns. Patient emotion and behaviour emerged as a secondary source of likely difficulty. Table 2 illustrates how students’ characterisations shifted or remained the same over their first professional year of study. Characterisations evident in student responses are listed in order of frequency, with the most frequent characterisation at the top of each list and the least frequent at the bottom.

Table 2.   BDS student characterisations of future professional work as evident in responses to questions 1 and 2 at the start and end of 2009
 Start survey (SS)End survey (ES)
  1. 1Number of student responses for Q1: 46 (SS), 47 (ES).

  2. 2Numbers in parentheses denote frequency of mention. As some responses revealed more than one characterisation, the number of mentions exceeds the number of student responses.

  3. 3Number of student responses for Q2: 50 (SS), 48 (ES). The following characterisations did not appear in students’ Q2 responses: population-level/public health considerations (SS, ES) and teamwork (ES).

Q11 (A concrete situation illustrative of future professional work)Patient-related concerns (31)2Restorative tasks (29)
Restorative tasks (24)Patient-related concerns (28)
Communication (16)Communication (19)
Self-management (13)Self-management (13)
Patient emotion and behaviour and population-level/public health considerations (7)Disease prevention/monitoring and population-level/public health considerations (10)
Teamwork (5)Patient emotion and behaviour (4)
Disease prevention/monitoring (3)Teamwork (1)
Q23 (An everyday situation that would be difficult to deal with)Patient-related concerns (44)Patient-related concerns (48)
Patient emotion and behaviour (23)Patient emotion and behaviour (14)
Restorative tasks (10)Restorative tasks (11)
Communication (7)Self-management (9)
Self-management (3)Communication (5)
Teamwork (2)Disease prevention/monitoring (1)
Disease prevention/monitoring (1) 

At both the start and the end of their first professional year, BDS students emphasised addressing patient-related concerns and undertaking restorative tasks as the primary roles of a dentist. Notably, the order of these two characterisations shifted throughout the year. Whilst in their SS responses, students emphasised patient-related concerns over restorative work; in ES responses, students emphasised undertaking restorative tasks slightly more than addressing patient-related concerns. Many ES responses showed a more detailed knowledge of restorative tasks, with students identifying a wide range of tasks (including history and examination, diagnosis, treatment planning and ‘drilling and filling’), mentioning specific materials and/or naming diseases being treated by restorative procedures. Similarly, the patient-related concerns highlighted in students’ ES responses showed greater detail than previously (for example, including factors such as cultural background and socio-economic status).

Students’ SS responses revealed more of a focus on the mouth and the patient in relation to restorative work, and less consideration of the broader clinic setting (communication and teamwork issues) or oneself in relation to the patient (self-management concerns). Self-management concerns mentioned included problem solving; personal skills such as efficiency and time management; technical skills such as dexterity (‘being good with my hands’); and having a ‘good attitude’. Question one responses relating to teamwork were limited to working with fellow dental professionals and others ‘whom you’ve never met before’. Throughout the year, there was a reduction in students’ emphasis on the dentist’s role in addressing patient emotion and behaviour. Although BDS students’ (relatively low) emphasis on population-level/public health considerations remained fairly constant throughout the year, they showed a marked increase in emphasis on the dentist’s role in preventing and monitoring disease.

With the exception that ‘teamwork’ did not appear in students’ ES responses, the ways in which BDS students characterised their future professional work in response to question two (likely difficulties) changed very little over the year. One small change in ES responses was a slightly greater emphasis on difficulties associated with self-management in clinical settings. In both SS and ES responses, students primarily emphasised patient-related concerns and (to a lesser extent) patients’ emotion and behaviour as the most likely sources of difficulty when engaged in dental practice. Difficulties associated with patient emotion and behaviour in both surveys included patients’‘fear’, ‘pain’ and ‘lack of trust’. However, there were subtle shifts in how students referred to difficulties associated with other patient-related concerns. In their SS responses, students’ descriptions of patient-related difficulties alluded to ‘uncooperative’ and ‘difficult’ patients, especially young patients. Although still largely negative, students’ ES response comments were more comprehensive, including the following: patients having ‘unrealistic expectations’, complaining about ‘high prices/costs’ or making ‘unreasonable complaints’. Similarly, in their ES responses, students identified more complex issues likely to cause difficulties in relation to restorative tasks, such as: ‘crowded teeth’ and accidents such as ‘drill[ing] [the] wrong tooth’ or ‘poor LA’.

BOH student perceptions of future professional work: changes over time

Bachelor of Oral Health students’ SS and ES responses to both questions one and two emphasised a patient-centred view of their future professional work (see Table 3). In both SS and ES responses, BOH students indicated a relatively strong awareness of their role in public health promotion. Notable shifts in question one responses included a reduced emphasis on restorative tasks between the start and end of year, and an increased emphasis on self-management. Difficulties identified indicated an increased concern with self-management after a year of study and a slightly increased emphasis on restorative tasks as a source of difficulty. Overall, BOH students’ question two responses revealed a consistently patient-focused awareness of tough everyday situations.

Table 3.   Bachelor of Oral Health student characterisations of future professional work as evident in responses to questions 1 and 2 at the start and end of 2009
 Start survey (SS)End survey (ES)
  1. 1Number of student responses for Q1: 31 (SS), 32 (ES).

  2. 2Numbers in parentheses denote frequency of mention. As some responses revealed more than one characterisation, the number of mentions exceeds the number of student responses.

  3. 3Number of student responses for Q2: 31 (SS), 32 (ES). The following characterisations did not appear in students’ Q2 responses: population-level/public health considerations (SS, ES), disease prevention/monitoring (SS, ES), and self-management (SS).

Q11 (A concrete situation illustrative of future professional work)Patient-related concerns (32)2Patient-related concerns (35)
Restorative tasks (26)Population-level/public health considerations (17)
Population-level/public health considerations (20)Restorative tasks (16)
Communication (19)Self-management (12)
Teamwork (5)Communication (11)
Patient emotion and behaviour (4)Patient emotion and behaviour (6)
Self-management (2)Teamwork (4)
Disease prevention/monitoring (1)Disease prevention/monitoring (3)
Q23 (An everyday situation that would be difficult to deal with)Patient-related concerns (39)Patient-related concerns (32)
Patient emotion and behaviour (19)Patient emotion and behaviour (14)
Communication (5)Restorative tasks and self-management (6)
Teamwork and restorative tasks (4)Teamwork and communication (1)

In both their SS and ES responses to questions one and two, BOH students revealed a comprehensive view of their future professional work that encompassed both ‘personal and clinical aspects of treatment’ (BOH ES, Q1). This included conducting restorative work, providing emotional support and educating people about oral health. Students’ responses also revealed an awareness of the implications of different kinds of environments for patient care, for example, by identifying the need to respond appropriately to specific groups of patients and the need to work as part of an oral health team. End-of-year responses to question two indicated students’ increased awareness of the kinds of issues that might be faced when relating to patients in clinical contexts. For example, SS responses emphasised issues relating to ‘difficult patients’, whilst ES responses referred to specific patient conditions, for example, ‘physical disabilities’, ‘children with attention deficit hyperactivity disorder’ and patients with allergies to latex or other materials.

Self-management only appeared in BOH students’ question two ES responses. Students’ concerns included meeting time constraints, maintaining professionalism, gaining personal satisfaction (‘may become bored’), maintaining physical well-being (back/wrist pain, etc.) and having an adequate level of knowledge. Some students’ question two self-management concerns also reflected a more general concern with patient well-being, for example: ‘A health practitioner may be put in distressing situations such as witnessing children and underprivileged people with extremely poor oral health; I can imagine this will be relatively upsetting and even make us feel slightly helpless in the fight against dental caries’.

Overall, there was a marked difference between the ways in which BDS and BOH student alluded to difficulties associated with patient emotion and behaviour. Whilst BDS students emphasised patient emotions and behaviour as something to be ‘managed’, BOH students’ responses were couched in more empathetic terms: for example, ‘help[ing] [the] patient feel safe’, ‘giv[ing] [the] patient confidence to talk’ and understanding ‘personal and clinical aspects of [the] treatment’. Also, an emphasis on teamwork featured slightly more in BOH than BDS student responses, and (in contrast with BDS students) BOH students revealed a view of teamwork as working with others beyond one’s own scope of practice. For example, one BOH student said ‘A patient that has never been to the dentist before may have problems with their gums and may need periodontal treatment and getting their gums in good condition before [the] dentist can restore [their] teeth’.

Discussion

In this study, we asked students enrolled in the 2009 University of Otago BOH and BDS first-year professional programmes to identify a situation that exemplifies their future professional work and a difficult situation that they would likely encounter (as dentists or oral health professionals). The specific ways in which students characterised their future professional work differed in some respects from those identified in the earlier research with University of Otago dentistry students (8). Differences in how specific groups of students characterise professional practice should be expected given that understandings of professional practice are highly context-specific (14, 20). Despite this, striking similarities also emerged. Echoing Kieser et al. (8), we found that beginning BDS students at the University of Otago largely characterised their future professional work in relation to diagnosis and treatment, with little focus on prevention. In contrast, BOH students revealed an apparently more patient-centred view of their future professional work, less focus on restorative tasks, and attention to population-level/public health considerations. The apparent differences in responses from the two groups of students warrant close investigation.

At both the start and the end of the year, BDS students emphasised restorative tasks as a key aspect of dentists’ work and dealing with patient-related concerns and more specifically, patient emotion and behaviour concerns as central difficulties. Although students’ apparent awareness of disease prevention and monitoring and population-level/public health considerations increased during their first professional year, a focus on restorative tasks remained primary, increasing in students’ ES responses. Students’ perceptions of likely difficulties also shifted little, although accounts of likely difficulties were more detailed in ES responses. In their question two responses to both surveys, BDS students cast patients in a mostly negative light.

In contrast, in both their SS and ES responses, BOH students portrayed the role of oral health professionals as explicitly patient-centred and as concerned with maintaining oral health both at an individual and at broader population levels. Although both BDS and BOH students emphasised difficulties associated with patient-related concerns generally and patient emotion and behaviour specifically, BOH student responses revealed more of an awareness of the professional’s role in mitigating difficulties or concerns (for example, by supporting patients who are fearful). When both groups highlighted patient emotion and behaviour as a source of difficulty, BOH student responses were generally compassionate and empathetic, whilst BDS students tended to portray patient emotion and behaviour as problematic or a difficulty to be ‘managed’.

How might students’ perceptions reflect or problematise current curriculum emphases across the two programmes? As students were surveyed on the first and last days of their 2009 course, formal course curricula can hardly be credited with students’ initial perceptions of their future professional work. Similarities in students’ SS responses include an emphasis on patient-related concerns and restorative tasks in response to question one, and patient-related concerns and patient emotion and behaviour in response to question two. Notable differences include the BOH students’ initial emphasis on population-level/public health considerations in their question one responses, and lesser emphasis on restorative tasks in response to question two. These different initial emphases in students’ characterisations of dentistry vs. oral health work suggest the importance of understanding ‘curriculum’ broadly (9, 14, 21), taking into consideration students’ (and teachers’) theories of knowing and being, and the understandings that students bring to their respective professional programmes. For example, BOH students’ ongoing concern with patient-focussed care vs. BDS students’ ES emphasis on restorative tasks could be seen as reflecting public attempts in New Zealand to differentiate oral health professionals (formerly, ‘school dental nurses’) from dentists, as caring, approachable and friendly rather than associated with fear and pain (22–24). Examining hidden curricula is crucial to developing and understanding the implications of formal curricula, because the ways in which students take up or ignore implicit or explicit programme elements may be shaped by their preconceptions, public discourse or teacher attitudes (25). In the light of this study (for example), moving BDS students towards a more preventive approach may require very explicit teaching around the rationale for and value of a preventive approach in dentistry.

The two groups’ relative focus (BOH) or lack of focus (BDS) on population-level/public health concerns throughout the year is of considerable interest. Either the respective curricula effectively reinforced students’ preconceived ideas or were relatively ineffective in challenging them. A close look at course structure is helpful in evaluating these two possibilities.

First, BDS students’ relative inattention to population-level/public health considerations was surprising, because a full-year paper dedicated to ‘the concepts and principles of population oral health’ is part of the first-year formal curriculum (BDS programme guide, 2009). This discusses the New Zealand dental care system, public health concepts and dental epidemiology. However, as students encounter patients for the first time in their first-year second semester, an overwhelming preoccupation with skills directly required for carrying out history and examinations, diagnosis, treatment planning and restorative work could be seen as an understandable priority. Novice dentists are likely to be more intent on developing technical competence than focusing on the ‘bigger picture’ of dentistry and oral health (26). A preoccupation with technical skill development may also explain students’ largely negative view of ‘difficult patients’ (as limiting possibilities for skill development), and lack of focus on teamwork as it relates to the practice of dentistry. In contrast, students’ increased focus on disease prevention/monitoring in question one and two ES responses seemed to parallel (formal) curriculum content, corresponding with an increased focus on the theory and practice of prevention across the first professional year.

In terms of BOH student responses, an initial and enduring emphasis on patient-focused care is perhaps not surprising given the programme’s explicit social science underpinnings. Such a programme may be more likely to attract students with an interest in people (not just the oral cavity), and in oral health as a social (rather than simply medical) practice. Also, the maintenance of this focus throughout the year is consistent with the formal BOH curriculum (4). An alternative (or second) explanation could be that a strong care ethic is often associated with professions that have historically been dominated by women (19, 27–29). Future research will examine whether BOH students maintain a strongly patient-centred view of their future professional work alongside shifts that occur in the student gender balance.

In contrast, BOH students’ initial and ongoing emphasis on population-level/public health considerations (relative to BDS students) is surprising, because ideas of oral health promotion (for example, in schools) and oral health education (for instance, providing dietary advice) are not explicitly included in the BOH curriculum until students’ second year. This may reflect BOH students’ background work experiences, interests or motivations. Alternatively, although not part of the formal curriculum, public health considerations may part of the BOH ‘hidden curriculum’ (25, 30): a consequence of course structure, assessment methods, teaching approaches and/or teacher attitudes.

Kieser et al. (8) ordered the characterisations that emerged in the earlier Otago study students from a narrow understanding of dentistry as ‘relieving pain’ to a broader understanding that encompasses public health considerations. Although the characterisations that emerged in our study are somewhat different, according to such a hierarchy, first-year BOH students in our study appear to have a much more comprehensive view of oral health practice than first-year BDS students. If the BOH programme’s social science underpinnings are a reason for this, our study results could be read as reinforcing the call to recognise dentistry as a social (not just a medical) science (18). However, hierarchical categorisation of students’ perceptions of their future professional work could also be seen as problematic. For example, on closer analysis, students’ comments revealed subtle nuances within each characterisation (for example, a more or less empathetic view of difficulties associated with patient emotion and behaviour, or a more or less complex understanding of restorative tasks). Equally, a so-called ‘narrow’ focus on restoration may reflect a novice’s preoccupation with technical skill development in the face of new and challenging procedures (26).

It is necessary to read this paper as reporting on situated research: a contextualised ‘snapshot’ of students’ notions of their future professional work across two different programmes. Our aim is to continue examining how BOH and BDS students’ perceptions of their future professional work change over time, in relation to or in spite of formal curricula. One outcome of the data reported here is the introduction of an explicitly preventive focus in the BDS first professional year programme. A survey of 2010 first professional year students will indicate whether this change is reflected in altered understandings of future professional work.

Although students’ responses to the two questions included in our study provide rich qualitative insights into their understandings of their future professional work, it is possible that students’ intended meaning may have differed from our interpretations. Also, we did not gather data on prior occupation, or previous experiences in relation to students’ respective programmes. To address these issues, in subsequent surveys we plan to include a question asking students to outline any previous work experience in health-related fields. We also hope to conduct focus group interviews with the students included in this study to clarify our interpretations and further examine factors shaping how students characterise their future professional work.

Conclusion

In start- and end-of-year responses to two open-ended survey questions during the first professional year of study, BDS students revealed an increased understanding of their future professional work as primarily interventive, and BOH students, as primarily preventive and patient-centred. The explanation for these differences may be curriculum-related, reflect students’ personal backgrounds or reflect broader societal understandings of dentistry vs. oral health work. Future research will examine how students’ characterisations continue to develop over time.

Acknowledgements

Funding for this project was provided by the Auckland Dental Association, a branch of the New Zealand Dental Association, in the form of a summer student scholarship. We are grateful for Professor Kieser’s encouragement, advice and willingness to share his earlier work in this area.

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