Context of the study
To analyze the student-aspect of clinical note-taking, during a clinical examination of the masticatory system including an analysis of the occlusal aspects is based on clinical protocols used in the undergraduate Study Programme in Dentistry (SPD). The clinical protocols were collected between January and March 2018 at the University Dental Clinic, Department of Dental Medicine, Karolinska Institutet (KI). The students involved in this study were in their third year of the SPD. Twenty-four clinical protocols (in total 120 pages), by 24 students working in pairs, were subject to a thematic analysis. The students who wished to volunteer and to contribute with clinical notes for analysis of note-taking were informed to first remove any kind of identifications (i.e. name) from the protocols and to give a verbal informed consent at two occasions, first to the principal investigator (NCh) and then to an external researcher (MCh). The students were instructed by the external researcher (MCh) to check that they had removed all possible identifications before handing over the protocols. After receiving the protocols, the external researcher (MCh) scanned all protocols pairwise and renamed them Protocol 1 to 12, in order to keep anonymity. Thus, no identifications were possible to track on the digital files since these files only had the credentials of the external researcher. The students were prepared for the clinical part of the course with in total eight lectures (45 minutes each) during two semesters, some of them during the preceding semester and the others during the same semester as the examination (for a specification of content, see (12)). The students were on their third year of the SPD at KI and participated in the module “Orofacial Pain and Jaw Function 2”, part of the course “Clinical Odontology 2” (https://utbildning.ki.se/course-syllabus/2TL016/24160). For further information of the structure of the SPD in relation to this study, this has been described in detail in Christidis and co-workers (2021). Prior to this module, the students have had training in communication with patients at basic level of dental education, e.g. in semesters 1 and 2 in the course “To become a dentist 1, 7.5 credits”. They have also had training in reading and writing patient records at basic level of dental education, e.g. in semesters 1 and 2 in the course “To become a dentist 1, 7.5 credits”, and in semesters 3 and 4 in the course “Clinical odontology 1, 24.5 credits” – especially in a) Module 1: Patient documentation and introduction to the clinic, 1.4 credits, but also in b) Module 3: Periodontology, 7.6 credits; c) Module 4 Cariology, 5.2 credits, and d) Module 6 Integrated clinical dentistry in adults, 1.2 credit.
Object of analysis
The object of analysis was the student’s written completion of: 1) a teacher constructed protocol regarding oral mucosa, the dental apparatus including pathology on tooth level, oral hygiene, i.e. this part of the protocol has been taught in previous courses, while the following part regarding analysis of the occlusion and jaw-relations was new to the students; 2) an international clinical examination protocol of the temporomandibular region (i.e. the masticatory system), for both clinicians and researchers, according to the Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) (13), followed by an evaluation of the use of an occlusal appliance (i.e. bite-splint) which also is teacher constructed, these were also new to the students. Preceding this clinical task, the students participated in two three-hour lectures as well as a clinical demonstration by two teachers (SLJ, NCh) regarding the analysis of the occlusion and jaw-relations and examination of the temporomandibular region.
For the teacher constructed protocol the students are expected to describe the oral mucosa, the pharynx and the teeth. If there are variations to normal mucosa or pathological findings in the oral mucosa including the hard palate, these should be described concerning shape, size, color, location; if there are impressions in the cheeks or tongue also the degree of keratinization should be described in addition to shape, size, color, and location. Regarding the pharynx they are asked to describe if there are any signs of inflammation or irritation both in the pharynx and the soft palate. When it comes to the teeth, the students are asked to describe the dentition, i.e., which teeth are present, if they have signs of caries, periodontal disease, which restorations are present including their quality, degree of tooth wear or if there are any deviations from normal, exemplified in Fig. 1. Finally, there is a part with an occlusal analysis (i.e., how the teeth are in contact when biting and moving the jaw), similar to the example in Fig. 1.
Regarding the clinical protocol according to DC/TMD, the students are just expected to assess the jaw opening, check the occlusion i.e., the relation between teeth upon biting, and to fill in boxes with “Yes” or “No” regarding pain upon movement and/or palpation of the joints, jaw- and neck muscles, Fig. 2. When it comes to the evaluation of the use and effect of the occlusal appliance, they are expected to describe the occlusal appliance, i.e., the degree of wear, fitting, and appliance hygiene. After that, they are expected to ask the patient, in this case their clinical partner, about their experience and summarize the patient experience in words, similar to the example in Fig. 1.
Theoretical Framework and Analysis
Since dental students’ notetaking is considered a social practice (14), New Literacy Studies (NLS) can be used as the framework for the analysis of this study (15, 16). NLS is the overarching theoretical framework, whereas we used a thematic analysis of data as a first step. This combination gave us access to patterns and helped us discern meaning, a summary, an interpretation that attempted to theorize the importance of the patterns, as well as their general meanings and inferences within a specific theoretical context, in our case NLS (17, 18).
Central for NLS is that literacy is considered as social practices, which means that what and how people read and write, as well as the purpose(s) for reading and writing differs between contexts. Entering a professional higher education programme means that students also enter new literacy practices. On the one hand, they are introduced to the academic dental literacy practice, on the other, they are also introduced to and gradually appropriate a dental professional literacy practice. During their studies, they are expected to be able to shift between these two literacy practices, depending on the purpose of the texts they read and write (19). Furthermore, such texts are written for communicative purposes – there is an assumption that the writer should match the need of a future reader, making communication possible over time and between contexts that results in a predictable interpretation of the text by the reader (1, 20).
In order to find patterns in data, different methods for identifying, analyzing and reporting patterns were used. In this material consisting of students’ clinical notetaking thematic analysis was chosen since this method supports interpretation concerning different aspects of the topic of study involving a rich description of data, and a minimal organization of data (18, 21). In this study, a theme is determined by what it captures in relation to clinical notetaking. Thus, based on the clinical notes from the 24 volunteering students, themes, relating to the data, were created. These themes are ultimately related to the study’s research questions and were created by a thorough, inclusive, and comprehensive coding process, including interpreted data and not data paraphrased or described. Each theme has been described in detail and given a nuanced account (17, 18, 21). Thus, the thematic analytical procedure involved noticing patterns of meaning and issues of potential interest in the data. Analysis also involved a relational reading, which in this case was a constant moving back and forth between the protocols and the analysis of data produced. The analytical steps performed in relation to clinical notes of 24 dental students were as follows (Braun & Clarke 2021, p. 331): 1) data familiarization and writing familiarizations notes; 2) systematic data coding for each student in relation to the following analytical question: what content is noted vs what is not expressed in the notes?; 3) generating initial themes from coded and collated data (step 2); 4) developing and reviewing themes in relation to the identified questions and to the entire data set. This control ensures that the set themes are internally coherent, consistent and distinctive; 5) refining, defining and naming themes. The themes were: (i) Familiar knowledge, (ii) New knowledge, and (iii) insufficient distinction between anamnesis and status; and 6) writing the report and selecting extract examples that illustrate the themes. Finally, the selected extracts were related back to the research question of the study to ensure coherence.