Educational Methodologies
Student Self-Assessment in Dental Hygiene
Education: A Cornerstone of Critical
Thinking and Problem-Solving
Michelle R. Mould, R.D.H., M.S.D.H., Ed.; Kimberly Krust Bray, R.D.H., M.S.;
Cynthia C. Gadbury-Amyot, M.S.D.H., Ed.D.
Abstract: Self-assessment is an integral component of learning and developing decision making and critical thinking skills in
the practice of dental hygiene. Dental hygienists must think critically and develop problem-solving strategies during their formal
education to ensure lifelong quality and ongoing development of their personal knowledge and skill as related to providing comprehensive, evidence-based patient care. The primary focus of this qualitative investigation was to obtain undergraduate dental
hygiene students’ perceptions of and experiences with self-assessment. The sample consisted of an intact undergraduate dental
hygiene class of seventeen students in their final semester of a two-year, entry-level dental hygiene program at a community
college in the southeast United States. Data for this research were obtained from three sources: 1) a program-designed self-assessment survey assignment, 2) in-depth interviews with four second-year dental hygiene students, and 3) program-designed clinical
competence evaluation forms. Inductive data analysis revealed that the majority of students perceived that they had no prior
experience with self-assessment in any prerequisite coursework and thus felt unprepared for its use in the dental hygiene program.
As they matriculated in the program, students began to see the advantages of self-assessment in clinical practice. Programmatic
orientation to self-assessment may therefore be beneficial due to the varying backgrounds of students entering dental hygiene
programs.
Prof. Mould is Assistant Professor of Dental Hygiene, Chattanooga State Community College; Prof. Bray is Professor and
Director, Division of Dental Hygiene, School of Dentistry, University of Missouri-Kansas City; and Dr. Gadbury-Amyot is
Professor and Director, Distance Education and Faculty Development, School of Dentistry, and Interim Associate Vice Provost
of Online Education, University of Missouri-Kansas City. Direct correspondence and requests for reprints to Prof. Michelle R.
Mould, Chattanooga State Community College, Dental Hygiene Program, 4501 Amnicola Highway, Chattanooga, TN 37406;
423-697-4713; 040895@epbfi.com.
Keywords: self-assessment, dental education, dental hygiene, critical thinking, problem-solving
Submitted for publication 9/26/10; accepted 1/8/11
U
pon graduation, dental hygienists become direct providers of patient care, and instructors
are no longer available to provide evaluation
and guidance. Learning to evaluate one’s own skills
and demonstrating competence in self-assessment
are therefore considered necessary for entry into the
dental hygiene profession. Effective self-assessment
is based on the ability to deconstruct an event and
make a judgment about it based on an individual’s
understanding of the situation. At the same time, the
individual must reflect on his or her understanding
of the situation and evaluate how to respond. The
ability to accurately self-assess is a cornerstone for
developing strong critical thinking and problemsolving skills.1-5
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Journal of Dental Education
It should not be assumed that, upon entry
into a professional program, students will possess
knowledge of the self-assessment process needed to
think critically and make sound decisions without
assistance. The process of learning through developing experiences requires instruction beyond the
presentation of defined bodies of knowledge. Growth,
especially in adult learning, involves both the assimilation and application of knowledge. Students must
be encouraged to develop and apply knowledge as
part of a decision making process.6 To help educators
better understand how to help their students develop
this ability, the primary focus of this qualitative
investigation was to acquire and assess a group of
undergraduate dental hygiene students’ perceptions
of and experiences with self-assessment.
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Self-Assessment in the
Dental Professions
In 2009, the American Dental Education Association Commission on Change and Innovation in
Dental Education (ADEA CCI) issued a collection
of commissioned articles developed over a five-year
period “to stimulate self-assessment and reflection on
the status of academic dentistry and to consider ways
to enhance the preparation of our next generation of
practitioners.”7 These articles, originally published in
the Journal of Dental Education from 2005 to 2009,
were combined in a single volume entitled Beyond the
Crossroads: Change and Innovation in Dental Education. These twenty-two articles were intended to
encourage new ways of thinking about curriculum development, teaching and learning strategies, student
assessment, educational leadership, and academic
environment and quality of faculty work-life in the
realm of dental education. Included in this national
initiative to explore the future directions of dental
education, the ADEA CCI has specifically addressed
the role of fostering skills in self-assessment, critical
thinking, and problem-solving in the development of
lifelong learners capable of providing evidence-based
oral health care.
The authors of one of these articles discuss critical components of what has been termed “the novice
to expert learning continuum” and how it relates to
the development of practitioners who exhibit critical
thinking, problem-solving, and self-directed learning
skills associated with lifelong learning.5 Application
of this learning continuum to dental education has
been well documented in the literature.5,8,9 According to this theory, learners progress through stages
from the novice, or true beginner, to the final stage
of expert: “An individual in training for a professional role evolves from a true neophyte . . . through
a series of stages where capacities are gradually and
progressively enhanced by trial and error learning
and successive approximation supported by timely
and corrective coaching” (p. 926).5 Dental and dental
hygiene students graduate from their programs as
entry-level practitioners midway across the continuum, at the stage identified as competent. While
individuals at the competent stage are deemed to
have the capacity to function independently without
instructor supervision, their knowledge will continue
to grow as lifelong learners moving toward the expert
end of the continuum.5
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Crucial to facilitating learning is recognizing
that all students enter the learning continuum with
varying degrees of cognitive ability. Much of the
self-assessment literature in medicine and dentistry
to date emphasizes measuring the accuracy of selfassessment and the challenges in doing so.10-14 However, it does not address what experience students
have with self-assessment prior to entering their
program. Some research has found that students
often have difficulty transitioning from secondary
education to a university or professional program.15,16
Occasionally, students may feel overwhelmed when
asked to perform such tasks as self-assessment
when they are expected to engage in accurate evaluation of themselves without adequate training during
prerequisite coursework.15,16 Fundamental issues
such as these must be addressed in dental hygiene
education as a component of developing long-term
competence in self-assessment and enhanced critical
thinking and problem-solving.
Self-assessment involves the process of collecting information about and reflecting on one’s
own performance. This is essential in the process
of developing problem-solving and critical thinking
abilities. Developing proficiency in critical thinking involves the use of metacognitive skills as well.
Metacognition refers to self-awareness of one’s own
thinking, or the ability to comprehend, analyze, and
reflect one’s own knowledge and learning.17-20
Self-assessment serves as a form of quality
assurance. Quality assurance programs focus on the
decision making process and on improving the overall
quality of care provided by health care practitioners.1,2
Health care providers unable to accurately self-assess
may be at risk of rendering less than optimal care for
their patients.13
While much of the literature details the benefit
of different aspects of self-assessment, questions
have been raised concerning the consistency of how
self-assessment is taught and evaluated in health care
education, and current research continues to show
variations regarding self-assessment training in medical and dental schools.10,13,21 Self-assessment research
in dental hygiene has centered more on the attitudes
and perceptions of practicing dental hygienists, rather
than undergraduate students’ self-assessment in
dental hygiene education and skill development.1,2,22
Competence in self-assessment begins with
training in the basic skills needed to develop and
evaluate personal goals and abilities. Health professions education programs are accountable for
Journal of Dental Education ■ Volume 75, Number 8
graduating competent clinicians. Thus, it is the responsibility of these institutions to teach students how
to identify goals and progress toward achievement of
those goals. Gordon’s 1992 review of self-assessment
literature from the 1970s through the early 1990s
reported inconsistencies in the formal teaching of
self-assessment skills within health professions
education.23 Gordon also found that programs that
successfully implemented self-assessment as part
of their curriculum reported improvements in students’ communication, motivation, knowledge, and
performance.
The Best Evidence Medical Education (BEME)
Collaboration published an in-depth systematic
review of self-assessment literature in 2007.24 Its
purpose was to determine the effectiveness of selfassessment in the identification of learner needs
and its impact on clinical practice. The authors of
that review found similar inconsistencies regarding
teaching and evaluating self-assessment in clinical
education to those reported by Gordon. The majority
of studies included in the BEME report focused on
the accuracy of self-assessment as compared with
external assessment such as the judgment of faculty
and peers or a criterion measure such as examinations
or guidelines. None attempted to measure changes
in perceptions of learning needs or reported on any
self-assessment interventions that promoted individual learning. Despite this, evidence in the review
did indicate that developing accurate self-assessment
practice might be enhanced by identifying previous
subject knowledge or skill, providing some level of
instruction about a skill, and utilizing video or verbal
feedback associated with execution of a skill.
The BEME review also explored the emerging philosophy of a need for more qualitative selfassessment research, noting that “self-assessment, no
matter how it is defined, is a complex concept which
does not lend itself to objective measurement.”24 The
authors made a point that self-assessment for ongoing
self-directed learning is a qualitative exercise, concerned with specific subjects in an individual context.
In this context, a descriptive approach to identifying
students’ clinical knowledge and skill would be the
preferable research method since such perceptions
are not quantifiable. They further acknowledged that
personalized assessment in development and practice
of self-assessment skills should be a target of future
research beyond the quantitative research paradigm.
The purpose of our qualitative investigation was
twofold. First, in 2000, the dental hygiene program
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under investigation received a Council on Dental
Accreditation (CODA) site visit recommendation related to Dental Hygiene Accreditation Standard 2-25:
“Graduates must be competent in the application of
self-assessment skills to prepare them for lifelong
learning.”25 To address the CODA recommendation,
efforts were made to implement self-assessment in
the curriculum. Our research study was an attempt to
develop an understanding of students’ perceptions of
and experiences with self-assessment in their education prior to entering the dental hygiene program.
First-hand observations by the principal investigator
beginning in 2004 while working as an instructor
in the two-year entry-level dental hygiene program
raised the question as to whether the 2000 selfassessment methods were truly effective in meeting
the CODA standard. Quite often, the general attitude
of students was “just tell me what I need to know to
pass the test.” Frequently, self-assessment was seen
as “busy work,” and students wrote the same thing
repeatedly just to be finished. The secondary goal of
this study was to gather program-specific information
that could be used to advance student self-assessment
as an integral part of authentic assessment in the
dental hygiene curriculum.
Methodology
This study utilized the qualitative methodology of phenomenological inquiry to explore the
perceptions of dental hygiene students with regard
to the use of self-assessment both prior to entry in
the dental hygiene program and in their clinical
experiences during program matriculation. Phenomenological studies offer detailed descriptions
about individual situations. The primary process of
collecting information involves in-depth interviews
of a few subjects, typically three to ten individuals.
With phenomenological inquiry, Creswell states,
“the important point is to describe the meaning of a
small number of individuals who have experienced
the phenomenon.”26 Often phenomenological inquiry
may not lend itself to direct generalization of findings
in the same way as quantitative research.26,27 However,
this methodology is appropriate for this setting, as
the examination of undergraduate student perceptions
of self-assessment has not been previously studied
in dental hygiene. While the findings of this investigation may not be generalizable, they can result
in hypothesis-generating research that may then be
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further studied. The research questions that guided
this investigation are shown in Table 1.
This research was conducted by the principal
investigator in fulfillment of the graduate requirements of the master’s of science degree in dental hygiene education at the University of Missouri-Kansas
City School of Dentistry. Permission to conduct the
research was given by the University of MissouriKansas City Social Services Institutional Review
Board. Additionally, the dental hygiene program under
investigation granted permission to access student
information for the purpose of this study.
The study participants were an intact secondyear dental hygiene class of students (n=17) completing their final semester in an associate of applied
science degree program in dental hygiene. At the time
of this investigation, various opportunities for student
self-assessment were included in all semesters of the
program under investigation. However, no formal explanation of the process was included in new student
orientations. Table 2 shows the demographics of the
study population upon program entry.
Data for this research were obtained from
three sources: 1) responses from a program-designed
self-assessment survey assignment given to all
seventeen second-year students at the beginning of
their final semester in the dental hygiene program;
2) in-depth interviews with four of the second-year
dental hygiene students in their final semester of
the program; and 3) self-assessment examples from
program-designed clinical competence evaluation
forms collected from all seventeen students in the
final semester of the program.
As a result of responding to the recommendation from CODA during the site visit in 2000, the
dental hygiene program implemented an assignment
given to students at the beginning of their final semester aimed at reviewing student utilization of clinical
self-assessment. This assignment was updated by the
program periodically, and the most recent version
(revised 2007) was in place at the time of this study.
Program-developed reflective open-ended questions
in survey format were designed to ascertain whether
students understood how and why self-assessment
was used in clinical dental hygiene practice in an attempt to determine whether additional review of the
process was needed prior to graduation. Responses
were kept anonymous to encourage students to be
frank and candid in answering all of the questions.
Assignment responses served as a first source of data.
Stratified purposeful sampling was utilized
to select four students for in-depth interviews with
the principal investigator to provide the second data
source. Stratification was based on two criteria: age
and grade point average (GPA) at time of program
entry. Research has shown that GPA may be used as
a predictor of success in dental and dental hygiene
education.28,29 Additionally, the literature suggests
that non-traditional college-aged students (age
twenty-five and older) may be more likely to develop
a deeper comprehension focus in their approach to
learning, whereas younger students might be more
apt to assume a surface-level assessment approach
to learning.19
The third source of data—clinical competence
evaluation forms obtained from the fourth-semester
clinic—included a self-assessment component that
students completed during each patient experience.
These forms are introduced to students at the beginning of their second semester as they begin providing
patient care in the dental hygiene clinic and are used
throughout the program to evaluate progress toward
clinical competence. Students set daily clinic objectives and are encouraged to self-assess their progress
toward meeting or learning from those objectives.
Prior to the year 2000, these forms did not contain
student self-assessment data. As a result of the 2000
CODA site visit, the form was revised to include the
self-assessment component. To obtain a comprehensive data sample, competence evaluation forms were
Table 1. Preliminary research question and sub-questions of study
Preliminary Research Question
Sub-Questions
1. How do undergraduate dental hygiene students
learn and perceive the process of self-assessment?
1. How do dental hygiene students define self-assessment?
2. What experiences have students had with self-assessment prior
to entering the dental hygiene program?
3. Do students feel adequately prepared to self-assess when
beginning the dental hygiene program?
4. What value do students place on the ability to self-assess?
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Journal of Dental Education ■ Volume 75, Number 8
evaluated from semester onset to midterm and from
midterm to end of semester.
Inductive data analysis, with emphasis on the
specific approach recommended for phenomenology, was used in this study. While it is impossible to
totally eliminate researcher bias, one strategy used
in qualitative research is to be conscious of one’s
biases while conducting the study in an attempt to
accurately represent the data. To ensure validity and
reproducibility of the data, all interviews were audiorecorded and professionally transcribed. Another
qualitative strategy, member checking, ensures that
the researcher is representing correctly the intent
of the individuals being interviewed. Student interviewees in this study were given a copy of their own
interview transcripts and the opportunity to provide
further clarification or make changes. Additionally,
prolonged engagement of the researcher with the
students in the clinical setting was used to minimize
bias and establish credibility. Prolonged engagement
refers to the time the researcher invests to sufficiently
understand the environment under study.30
Multiple methods of data collection allowed for
triangulation of the data. Analysis of the interview
transcriptions, course-required assignments, and examples of student clinical self-assessment provided
valuable insight into student perceptions of program
self-assessment. Due to potential bias as a result of
the principal investigator’s being a faculty member of
the program under investigation, data were examined
by the principal investigator and two external faculty
reviewers with significant knowledge in qualitative
research.
Results
Analysis of the interview data resulted in four
major coding categories: 1) educational preparation,
2) orientation, 3) awareness, and 4) value. Table
3 shows the emergent categories with representative themes of each. Triangulation of data from the
program-designed survey assignment and programdesigned clinical competence evaluation forms corroborated coding categories and themes.
Educational Preparation
Students participating in the interviews openly
described the unfamiliar nature of self-assessment,
with comments like these: “That’s [self-assessment]
something that’s been new to me in the dental hygiene
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Journal of Dental Education
Table 2. Demographic and educational information on
students in study (N=17)
Number (%)
Gender
Female
Male
17 (100%)
0
Age
18–22
23–28
29–35
36 and over
9 (52%)
3 (18%)
2 (12%)
3 (18%)
GPA
2.5–2.7
2.8–3.0
3.1–3.3
3.4–3.6
3.7–4.0
0
0
2 (12%)
3 (18%)
12 (70%)
Ethnicity
Caucasian
Hispanic
African American
17 (100%)
0
0
Self-reported experience with selfassessment prior to dental hygiene
education
None
Minimal
Life experience
9 (52%)
4 (24%)
4 (24%)
Table 3. Emergent categories of student perceptions
with representative themes
Educational Preparation
No past experience
Never been asked to do before
Lack of ownership
Orientation
Need direction
Not important
Waste of time
Awareness
Focus on negative
Not safe
Constructivism
Critical thinking and problem-solving
Value
Sense of accomplishment
Competence and validation
Value in profession
1065
program”; “I had never even heard of self-assessment
until I got into this program”; and “I have an associate
degree in general studies and I was in college for a
total of three or four years [prior to entering the dental
hygiene program] and I have never had any classes
that focused on self-assessment.”
Another student response indicated frustration
when asked to self-assess in clinic because she had
never been asked to self-assess prior to entering the
dental hygiene program:
[In clinic] we were given forms that said
self-assess, and as we discussed you’re not
taught that in any other program, in any
class and it’s like “What does that mean?”
or “What do I write?” At first I wrote, if
you look back at my papers I’ve written two
words: “Did fine,” or “Had a bad day”; you
know, I didn’t get into the depth of what I
could have if it [self-assessment] had been
explained to me.
Another student stated: “My personality was a selfassessor. I’ve always been a type A personality, so I
was always self-assessing myself, but I’d never been
asked to write down any thoughts about my performance in a subject or anything like that.”
Of the students citing “life experience” with
self-assessment, some seemed to have a very basic
understanding of the concept, as in this example:
I am 41 years old. I do have a degree related
to Medical Secretary. . . . [My] experience
with self-assessment is probably more
life experience . . . my previous jobs and
bookkeeping, and all that. You have to keep
constant check on yourself. At my work
we have a field trainer program and we
train new employees and try to help make
ourselves better at the same time. We also
do a mentoring program . . . you know, we
watch them and then they watch themselves.
And we’re like, “Where are you struggling,
and if so how do you think you can fix it?”
I just personally evaluate myself at the end
of each day and when difficult relationship
issues come up.
A lack of past experience in self-assessment
was also confirmed through document analysis of
students’ written self-assessment course assignment.
Nine of seventeen students reported absolutely no exposure to self-assessment in any previous coursework
1066
taken prior to entering the dental hygiene program.
Four of the students replied with “not much.” The
final four students described their exposure to selfassessment more as “life experience.”
An additional source of corroboration, the
program-developed course survey that was administered during students’ fourth semester, found the
same issues with students’ expressing frustration
about lack of experience with self-assessment skill
development prior to program entry, as in these
comments: “Sometimes it is hard to put things into
words, especially when an instructor reads it because
I would worry that they would disagree”; “I wasn’t
sure what to write”; “I don’t usually know what to
say”; and “I’ve only now learned what we were really
expected to write on the forms.”
Comments from the clinical competence forms
further demonstrated the challenge some students
faced when attempting to self-assess during patient
experiences. One student listed her daily clinical objective as “complete a child patient” and followed up
with “difficult to get x-rays” as her self-assessment.
The instructor working with her had to ask, “What
will your strategies be when treating a child next
time? How will you learn from this today?”
An interesting theme related to a sense of lack
of ownership emerged during analysis of all three
sources of data. Lack of ownership implies an attitude of not wanting to accept responsibility for one’s
part in his or her own education, which is in direct
contrast to becoming a self-directed learner since
“self-directed learning is the ability to direct one’s
own learning experience.”5 Multiple students in our
study wanted the instructor to complete the patient
assessment “for the grade” first and then go back
and make comments based on instructor remarks.
Some would just give up and ask the instructor to
“do the procedure” for them. Often students did not
even fill out the self-assessment component of the
clinical competence evaluation form at all. Interview
responses revealed similar thought processes: “I’ve
always thought of self-assessment as your grade. Your
grade shows how you did”; “I never know what to
write. I just do better from other people assessing
me”; and “I think if somebody would’ve just told us
that you wanted us to do it [self-assess during clinic],
how important it was . . . and just so many things are
going on in there [clinic] . . . but I don’t think any of
us really realized what you wanted us to do. I thought
it [the self-assessment component of the form] was
just the ‘I didn’t do this right today,’ end of story.”
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Orientation
At the time of this investigation, no formal
orientation to self-assessment was given to new
students entering the program. The need for specific
orientation to self-assessment at program onset was
an emergent category during analysis. General lack of
knowledge with regard to the purpose and process of
self-assessment became evident as a constant theme
throughout the interviews and the written survey assignments. When asked about using self-assessment
as measurement to follow one’s progression of skill
development, responses indicated that many students
did not feel adequately prepared to self-assess upon
entering the program. In contrast to educational preparation that dealt with experiences prior to entering
dental hygiene, this category dealt with the issue of
orientation once in the program. Comments included
the following: “I never actually thought about it
[self-assessment] before the program”; “I dread selfassessment”; “Having never done it [self-assessment]
before, I did not feel confident, so I didn’t do it”; and
“Sometimes it is kind of complicated for me.”
Interview responses indicated that some students would have appreciated more guidance with
the self-assessment process at the beginning of the
program: “Just explain it [self-assessment] a little
more . . . you’re not taught in any other program or
class . . . and you know, explain that it’s going to
feel awkward at first to do it, so that we would be a
little more open to it”; “Explain the importance and
the reason for it [self-assessment] at the beginning
of the program”; and “I think when we were in our
preclinical studying and you have us self-assess at
the end of the day after learning a new skill, I think
that was great. I liked it even though at the beginning I wasn’t sure about how to go about writing,
you know, just going through and then once I really
thought about what you [instructor] were aiming for,
it actually really improved things.”
Prior to midterm in their final semester, some
students were still unclear regarding the exact process
of self-assessment. In many cases instructors could
recognize that learning was occurring through student
evaluations, but assistance with completing the operator self-assessment component during the patient
experience was still necessary. The discord between
setting daily clinical objectives and self-assessing was
captured on some of clinical competence evaluation
forms collected in the months leading up to midterm.
Excerpts are shown in Table 4.
Several responses in the data revealed student
feelings that self-assessment was not important or
was simply a waste of time. These findings were
consistent with the overall sense that students felt a
lack of instruction as to why self-assessment was an
essential part of clinical skill development. Examples
include the following: “In the beginning, I didn’t
think it [self-assessment] was important”; “Sometimes it [self-assessment] seemed like a pain to do
. . . not something that was really important to me”;
“You would just fill in the box [on the clinical competence evaluation form] to fill in the box”; “At first
it was ‘What is this? What do they mean?’ It seemed
silly”; and “Honestly, I don’t think I will really use
this [self-assessment] after graduation.”
Awareness
Another category that emerged was that of
awareness. Analysis of interview data confirmed
that in many instances students made the shift from
unaware to aware as it related to the intention and
benefits of utilizing self-assessment. Initially, the
feeling of not being safe to put one’s thoughts out
in the open or that self-assessment focused on the
negative seemed to impair some students, as in these
comments: “It [self-assessment] is a hard thing for
me. . . . I tend to be very, very, hard on myself, so
I focus on the negative and not the positive. I’m
Table 4. Excerpts from daily clinical objectives and self-assessment taken from clinical competence evaluation forms
(prior to midterm of the final semester)
Daily Clinical Objectives
Improve time management; work on effective calculus
removal and patient/clinician communication.
Complete quadrant of calculus identification on medium
patient.
Take panoramic film without flattening the smile.
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Journal of Dental Education
Self-Assessment
Good overall experience; would still like to work faster.
Patient had lots of subgingival medium calculus. Had to
explain things to him with Spanish brochures and flip
charts. He doesn’t speak much English.
Make sure not to release button on pan machine too
soon; had to start all over.
1067
going to have to always follow the negative with a
positive, but it is very difficult for me”; “We’re all
used to critiquing ourselves in the negative way, but
sometimes when you do deserve a pat on the back and
you have to self-assess that you’ve done well, [that]
is an awkward thing for me”; and “At first it [selfassessment] was difficult because I have a tendency
to be hard on myself.”
An example from one student’s clinical competence evaluation form revealed self-assessing only
the negative aspect of her patient experience. The
patient had very heavy black line stain that she was
unable to remove completely on her own. While she
successfully accomplished all other aspects of her
treatment plan, her only focus during self-assessment
was the fact that she needed assistance removing the
black line stain. Her instructor commented, “Black
line stain is probably the most frustrating to remove,”
and even remarked that the student provided good
treatment and patient management.
While many students doubted their abilities
initially, data analysis did reveal a transition from
the perception of self-assessment as being negative
to appreciating that the process could be very beneficial. Constructivism is the ability to link previous
knowledge with new knowledge.31 As students began
recognizing their ability to link those two components
of knowledge, they began to feel that they could rely
more on their own decision making and less on that of
an instructor, and their perceptions of self-assessment
changed considerably. For example:
When coming into a situation, your previous
knowledge and now your current knowledge
and how you have applied it and how teachers [perceive] how you are applying your
skills . . . can help you better yourself. It is
[not used] to criticize, but it is something
that could help you.
Thinking about how we can change what we
are doing in there [clinic] to help ourselves
and that it is not a spot for teachers to tell
us how to fix it [a challenge]. It’s become
very useful.
It [self-assessment] could be a good thing for
those who take it seriously. . . . If you have
a group of people who really think outside
of the box and pay attention to how they go
through their actions when treating a patient
and write it down, it could be positive to have
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the instructors see what we see and that we
have tried.
A student taking radiographs on a partially
edentulous patient set a daily clinical objective on the
clinical competence evaluation form to “successfully
complete two periapical and two bite wing films on
partially edentulous patient.” Her self-assessment
was “very hard to take films on patient with so many
missing teeth. Used cotton rolls but still challenged.”
The instructor then commented, “Good try; you
might consider using the snap-a-ray [next time].”
Positive learning occurred during the interaction
between the student’s self-assessment and instructor’s
recommendation. After speaking with her instructor,
the student followed up her entry and noted that she
had not thought about the snap-a-ray but would try
it in the future.
Positive changes in student self-assessment
skills did begin to manifest as students progressed
through the program. The faculty discussed challenges with self-assessment after midterm conferences in the final semester, and a decision was made
to make a more concerted effort to help students
expand their knowledge of the self-assessment
process. Once the students were reassured, either by
faculty input or through repeated experiences with
a particular skill, they naturally began to change the
way they determined their daily clinical objectives
and resulting self-assessment. Comments reflecting
these changes may be seen in Table 5.
Interview transcriptions and assignment responses during the final semester of the program
revealed the development of student understanding
of how self-assessment incorporates into the process
of critical thinking and problem-solving, as in these
examples: “I did realize that I can figure things out for
myself and I don’t have to go ask a teacher ‘what am
I doing wrong?’ So, it [self-assessment] taught me to
be a little more independent in my thinking and fixing
my own problems”; and “I use it [self-assessment]
to evaluate whether I accomplished something; if I
didn’t, I say what do I need to do to get better, or if I
excelled at something, I can make a note to use my
time more efficiently in other areas instead of just
focusing on that same thing.”
Value
Toward the end of the program, students began
to perceive the value of being able to self-assess their
clinical skills and rely less on instructor input. In the
final weeks, students exhibited a certain amount of
Journal of Dental Education ■ Volume 75, Number 8
Table 5. Excerpts from daily clinical objectives and self-assessment taken from clinical competence evaluation forms
(post midterm to the end of the final semester)
Daily Clinical Objectives
Identify where subgingival calculus is located and remove it.
Thorough evaluation of existing restorations.
Complete half mouth quad scale.
Self-Assessment
Able to feel calculus. Very tenacious calculus. Sometimes
must go back with a hand instrument because ultrasonic
just won’t remove all of it.
Missed 2 Class III composites on #22 and #27; need to use
air and pay more attention to composites.
Realized I need to go more sub with instruments. Feel
like I am learning more about fine scaling and learning to
know what I am feeling for.
satisfaction and accomplishment as they were able
to make decisions on their own. They relied less
on instructor input and took more ownership for
their decision making. Comments included the following: “It [self-assessment] helps me know when
I’ve reached what I feel to be perfection”; “Using
self-assessment has helped me pinpoint areas I need
to work on professionally and personally”; “I like
self-assessment because it allows me to recognize
my own progress”; and “It gives you a sense of accomplishment to actually feel like you have learned
something . . . and to take the time to realize what
you’ve learned.”
During analysis of the interviews and written
assignment, many students expressed more willingness to trust in their own assessment and critical
thinking abilities, although some still wanted teacher
validation before they truly believed in themselves.
Comments included these examples: “I don’t mind
it [self-assessment] so much anymore. It forces you
to find strengths and puts your weaknesses into perspective”; “I see the importance because when I have
areas of difficulty, I now recognize what I might want
to have addressed by faculty if needed”; “I think it
[self-assessment] is helpful. I can look back now and
see areas that were challenges for me. . . . I can see
how I am improving”; “You know where you stand
on certain skills and levels of achievement, but ultimately the teachers are more knowledgeable”; and
“It’ll come naturally to me because ya’ll have taught
us for two years how to do it. . . . I will naturally be
able to assess whether I did my best on each patient
and it’ll always give me a goal . . . give me something
to work towards.”
Interestingly, only one student said she “honestly may not use this [self-assessment] after graduation”; yet she had declared, on more than one occasion, that “self-assessment helps me know where I
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Journal of Dental Education
need improvement. . . . I like doing it because if you
are really able to point out what you are doing wrong,
you know how to make it better.” These different
responses could be attributed to the student trying to
say what she thinks the teacher wants to hear. However, the majority of students with initial reservations
about the use of self-assessment were able to identify
personal benefits of the process in clinical decision
making after graduation, as in these comments: “I
will use self-assessment to remember my reasoning
for wanting to become a dental hygienist and to keep
my ethics strong”; “I’ll use it [self-assessment] to
keep from becoming complacent. I want to be active
and up-to-date and not settle into a routine”; “I will
be able to gauge how my clients respond to me and
to treatment . . . make changes based on those experiences”; and “I always want to feel that I am learning
and doing a service to the patient.”
Discussion
Current educational theory regards critical
thinking as foundational to teaching and learning.
As dental hygiene students matriculate through an
undergraduate program, it is essential that they move
from a position of relying on instructor judgments
of their performance to the position of becoming
realistic self-evaluators. A competency-based educational program grounded in promoting the use of
critical thinking develops self-directed, self-aware,
and self-corrective learners. Realistic self-evaluation
is a defining characteristic of the competent health
care professional.1,4,32
This exploration of dental hygiene students’
experience with self-assessment supports the observation that learner awareness and implementation of
self-assessment closely follow the stages of the com-
1069
petency learning continuum.8,9,16 Changes in learner
self-awareness of competence serve as important
transitional landmarks along the learning continuum
as described by Hendricson and Kleffner.9,16 Applying their interpretation of the novice-expert learning
continuum to the program under study, dental hygiene students entered the program as “unconscious
incompetents” with a lack of knowledge and skill
related to utilizing self-assessment—almost a prenovice stage of the continuum. Typically, individuals
at this early stage of development are enthusiastic
about entering their professional training but naïve
about difficulties of the learning tasks ahead.9,16 General lack of knowledge with regard to the purpose
and process of self-assessment in the dental hygiene
program became evident as a constant theme in the
interview transcriptions and survey assignments of
this study.
Reflective analysis of the data indicated that
a majority of the students did not feel adequately
prepared to self-assess upon entering the program
because they had not been exposed to self-assessment
in any prerequisite coursework. While it is unlikely
that students had not experienced some form of selfassessment in their prior education, it is more likely
that they did not transfer what they had experienced
previously to what they were being asked to do in
their new role as a student clinician. In other words,
they might have been more capable of self-assessing
their writing than their thought processes. This line
of thinking parallels findings in the BEME review,
which suggested that practical tasks lend themselves
to self-assessment more readily than cognitive tasks.24
Dental and dental hygiene programs across the
country utilize self-assessment as one of several components in evaluating clinical skill development.33-35
During the initial phase of learning, students benefit
from orientation to program objectives and competencies. At the time of this study, our program did
not include formal introduction to any specific curriculum competencies during orientation sessions
held prior to or at the start of the first semester. An
expectation existed that students entering the program
would do so fully equipped with the skill set needed
for higher levels of critical thinking. In dental hygiene
education, professional self-assessment is not inherent; rather it is a skill that must be learned. Specific
criteria against which to measure are necessary to
help students develop proficiency in the level of
self-assessment used as a practicing clinician. The
literature suggests that including formal training or an
evidence-based self-assessment educational module
1070
in a dental hygiene curriculum could enhance student
aptitude and perception of the process used during
clinical practice.22,36 Triangulation of data sources
demonstrates that the students in our study did advance in their practice of self-assessment, although
their perceptions would have been more positive had
formal instruction about how one was supposed to
self-assess and how self-assessment would be utilized
been given at the onset of the program.
As students advance along the continuum,
they move to the stage of “conscious incompetent,”
during which students become acutely aware of their
limitations. Often negative self-talk or undue focus on
perceived weaknesses hinders the learning process.
Students at this point may appear apathetic or defensive. They are so concrete in their thinking that they
become hesitant to let go of their reliance on direct
instructor input and take on a “just tell me what to
do” thought process. Evidence of this mindset was
clearly expressed in our study when students asked
instructors to complete the patient assessment form
“for the grade” first so the students could go back and
make their comments based on instructor remarks or
when they would just give up and ask the instructor
to do the procedure for them.
What appeared as an initial attitude of indifference may have been a respondent’s attempt to hide
her lack of knowledge in a specific area. Anticipation
regarding peer and instructor judgment or what is
often termed constructive criticism can undermine
a student’s progress or self-confidence. Thus, lack of
confidence in one’s abilities may hinder the motivation to self-assess.23 The all-female population sample
of this investigation presented a potential limitation
in the study’s results. According to the BEME report,
gender may factor into individual self-confidence
and self-assessment. Among the studies reviewed by
the BEME, some researchers concluded that female
students tended to underestimate their abilities more
often than do their male counterparts.24
Instructor feedback and reinforcement are
critical in helping students advance to the next stage
of the learning continuum. Through the reinforcing
effects of instructor guidance along with extensive
practice, trial and error, and increasingly encouraging results, students can advance to becoming a
“conscious competent.” Frequent opportunities to use
reflective judgment and analyze problems presented
during patient care facilitate the skill development
that allows the conscious competent to rely less on
instructor input and more on her own decision making abilities.
Journal of Dental Education ■ Volume 75, Number 8
Evidence in our data analysis indicates that as
students began to combine previous knowledge and
current knowledge, they were able to transition from
a state of instructor dependence to a state of self-reliance exhibited by entry-level autonomous clinicians.
Additionally, some students truly recognized their
own shortcomings with self-assessment, indicating
that they did come to learn how to self-assess. The
majority of students with initial reservations about
the use of self-assessment in the program were able
to identify personal and professional benefits of being
able to self-assess and how they would incorporate
those into clinical decision making after graduation.
However, self-assessment of practical dental hygiene
applications, such as biofilm and calculus removal,
was undoubtedly easier for most students when
compared to assessing their reasoning for treatment
decisions or strategies. Even students who were high
academic performers still doubted their abilities in
hands-on and cognitive tasks in the clinic setting up
to graduation.
Conclusion
The ability to accurately self-assess is considered a hallmark of clinical competence and is
therefore necessary for the development of competent graduates. Long-term outcomes of accurate
self-assessment instruction are critical for graduating
dental hygienists capable of sound critical thinking
and problem-solving. This qualitative study provides
data intended to contribute to the ongoing development of dental hygiene educational best practices.
Understanding what students bring to their professional program is part of identifying learning needs
and learning styles. While it is unlikely that students
have not experienced some form of self-assessment in
their prior education, it is more likely that they are not
transferring what they have previously experienced
to what they are being asked to do when entering a
professional program.
Teaching students how to self-assess is an
important step in preparing dental hygienists for
autonomous clinical practice and lifelong learning.
Oftentimes dental hygiene faculty expectations
may be misaligned with student perceptions when
entering a program. Findings from this study may
give direction to changes needed in orientation to
the process of self-assessment in the dental hygiene
curriculum to support the development of critical
thinking and problem-solving skills. Inclusion of a
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Journal of Dental Education
formal orientation to self-assessment as it will be
utilized is an essential component in facilitating student understanding of the true purpose in developing
competence in the process.
REFERENCES
1. Fried JL, Devore L, Dailey J. A study of Maryland dental
hygienists’ perceptions regarding self-assessment. J Dent
Hyg 2001;75(2):121–9.
2. Devore L, Fried JL, Dailey J, Qori CG. Dental hygiene
self-assessment: a key to quality care. J Dent Hyg
2000;74(4):271–9.
3. Price B. Self-assessment and reflection in nurse education.
Nurs Standard 2005;19(29):33–7.
4. Price A. Encouraging reflection and critical thinking in
practice. Nurs Standard 2004;18(47):46–54.
5. Hendricson WD, Andrieu SC, Chadwick DG, Chmar
JE, Cole JR, George MC, et al. Educational strategies associated with development of problem-solving,
critical thinking, and self-directed learning. J Dent Educ
2006;70(9):925–36.
6. Reinarz AG, White ER. New directions for teaching and
learning: beyond teaching to mentoring. Vol. 85. San
Francisco: Jossey-Bass, 2001.
7. American Dental Education Association Commission on
Change and Innovation in Dental Education. Beyond the
crossroads: change and innovation in dental education.
Washington, DC: American Dental Education Association,
2009.
8. Chambers DW, Glassman P. A primer on competencybased evaluation. J Dent Educ 1997;61(8):651–66.
9. Hendricson WD, Kleffner JH. Curricular and instructional
implications of competency-based dental education. J
Dent Educ 1998;62(2):183–96.
10. Barnsley L, Lyon PM, Ralston SJ, Hibbert EJ, Cunningham I, Gordon FC, Field MJ. Clinical skills in junior
medical officers: a comparison of self-reported confidence
and observed competence. Med Educ 2004;38:358–67.
11. Lindermann RA, Jedrychowski J. Self-assessed clinical
competence: a comparison between students in an advanced dental education elective and in the general clinic.
Eur J Dent Educ 2002;6:16–21.
12. Clark MC, Owen SV, Tholcken MA. Measuring student perceptions of clinical competence. J Nurs Educ
2004;43(12):548–54.
13. Fitzgerald JT, White CB, Gruppen LD. A longitudinal study of self-assessment accuracy. Med Educ
2003;37:645–9.
14. Fitzgerald JT, Gruppen LD, White CB. The influence of
task formats on the accuracy of medical students’ selfassessment. Acad Med 2000;75(7):737–41.
15. McMillan WJ. “We are not in the least bit used to these
ways of studying”: developing academic competence in
all students. J Dent Educ 2005;69(10):1123–32.
16. Hendricson WD, Kleffner JH. Assessing and helping challenging students: part one, why do some students have
difficulty learning? J Dent Educ 2002;66(1):43–61.
17. Chartier L. Use of metacognition in developing diagnostic reasoning skills of novice nurses. Nurs Diag
2001;12(2):55–60.
1071
18. Costa AL. Mediating the metacognitive. Educ Leadership
1984;42(3):57–62.
19. Justice EM, Dornan TM. Metacognitive differences
between traditional-age and nontraditional-age college
students. Adult Educ Quarterly 2001;51(3):236–49.
20. van Velzen JH. Assessing students’ self-reflective thinking
in the classroom: the self-reflective thinking questionnaire.
Psychol Rep 2004;95:1175–86.
21. Wanigasooriya N. Student self-assessment of essential
skills in dental surgery. Br Dent J 2004;197(Suppl):11–14.
22. Bowers JA, Wilson JE. Graduates’ perceptions of selfassessment training in clinical dental hygiene education.
J Dent Educ 2002;66(10):1146–53.
23. Gordon MJ. Self-assessment programs and their implications for health professions training. Acad Med
1992;67(10):672–9.
24. Best Evidence Medical Education Systematic Review. The
effectiveness of self-assessment on the identification of
learner needs, learner activity, and impact on clinical practice. At: www2.warwick.ac.uk/fac/med/beme/reviews/
published/mckinstry/review.pdf. Accessed: September
26, 2010.
25. Commission on Dental Education. Accreditation standards
for dental hygiene education programs. Chicago: American Dental Association, 2009.
26. Creswell JW. Qualitative inquiry and research design:
choosing among the five traditions. Thousand Oaks, CA:
Sage, 1998.
27. Meadows LM, Verdi AJ, Crabtree BF. Keeping up appearances: using qualitative research to enhance knowledge
of dental practice. J Dent Educ 2003;67(9):981–90.
1072
View publication stats
28. Ranney RR, Wilson MB, Bennett RB. Evaluation of applicants to predoctoral dental education programs: review
of the literature. J Dent Educ 2005;69(10):1095–106.
29. Downey MC, Collins MA, Browning WD. Predictors of
success in dental hygiene education: a six-year review. J
Dent Educ 2002;66(11):1269–73.
30. Lincoln YS, Guba EG. Naturalistic inquiry. Newbury Park,
CA: Sage, 1985.
31. Patton MQ. Qualitative research and evaluation methods.
3rd ed. Thousand Oaks, CA: Sage, 2002.
32. Lublin J. Lifelong learning and self-directed learning.
Centre for Teach Learning: Good Pract Teach Learning
2003:1–12.
33. Albino JEN, Young SK, Neumann LM, Kramer GA,
Andrieu SC, Henson L, et al. Assessing dental students’
competence: best practice recommendations in the
performance assessment literature and investigation of
current practices in predoctoral education. J Dent Educ
2008;72(12):1405–35.
34. Navickis MA, Bray KK, Overman PR, Emmons M,
Hessel RF, Cowman SE. Examining clinical assessment
practices in U.S. dental hygiene programs. J Dent Educ
2010;74(3):297–310.
35. Kramer GA, Albino JEN, Andrieu SC, Hendricson WD,
Henson L, Horn BD, et al. Dental student assessment
toolbox. J Dent Educ 2009;73(1):12–35.
36. Jackson SC, Bowen DM, Boyd LD. An evidence-based
self-assessment educational module for dental hygiene
curricula. J Dent Hyg 2007;4:109.
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