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Year : 2020  |  Volume : 38  |  Issue : 3  |  Page : 293-303

Reflective learning for behavioral guidance in pediatric dentistry

1 Department of Paediatric and Preventive Dentistry, King George's Medical University, Lucknow, Uttar Pradesh, India
2 Department of Periodontology, King George's Medical University, Lucknow, Uttar Pradesh, India

Date of Submission23-Jan-2020
Date of Decision28-Aug-2020
Date of Acceptance02-Sep-2020
Date of Web Publication29-Sep-2020

Correspondence Address:
Dr. Richa Khanna
DHC 204D Ansal Orchid Greens Apartments, Sector M, Ashiyana, Lucknow, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JISPPD.JISPPD_33_20

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Introduction: Basic behavioral guidance (BBG) skills help in delivery of quality health care in pediatric dentistry. The complex nature of these skills, warrants analyzing actions performed. An appropriate scientific way to do this is by “reflection.” Hence, the present study was designed to introduce “reflection of action” as means for learning BBG skills by undergraduates in pediatric dentistry. Materials and Methods: Participants (dental undergraduate) performed oral prophylaxis (two visits) in pediatric patients (age 3–7 years) with application of BBG skills, under video recording. They were instructed regarding “reflection on action.” The learners then reviewed own videos and wrote reflections. Reflections were assessed on Boud's 4R framework and feedback was given by the faculty. Reflective writing was repeated for a second visit. Knowledge of the learners in using reflections for learning was assessed by retrospective pretest posttest questionnaire. Video recordings were scored for BBG skills. Acceptability of the intervention was addressed by satisfaction questionnaire. Results: There was a significant improvement in the knowledge of participants in using reflections for learning these skills. All participants were able to “revisit” (R1 level under Boud's 4R framework) patient encounter in their written reflections. Sixteen participants exhibited shift toward higher levels in the next visit. Video scores of learners also improved significantly over both visits. Students were satisfied with the content, delivery, and relevance of the new educational intervention. Conclusion: The strong need of improving BBG skills in pediatric dentistry was met by “reflection on action.” There was improvement in the knowledge of students in using reflections for learning and application of behavior guidance skills and was well accepted.

Keywords: Behavioral guidance, reflection on action, reflective learning

How to cite this article:
Khanna R, Singh RK, Singhal R. Reflective learning for behavioral guidance in pediatric dentistry. J Indian Soc Pedod Prev Dent 2020;38:293-303

How to cite this URL:
Khanna R, Singh RK, Singhal R. Reflective learning for behavioral guidance in pediatric dentistry. J Indian Soc Pedod Prev Dent [serial online] 2020 [cited 2022 Aug 17];38:293-303. Available from: http://www.jisppd.com/text.asp?2020/38/3/293/296635

   Introduction Top

Behavior guidance (BG) skills are critical for modifying and managing uncooperative behavior of pediatric patients in dental office, especially with young children. Lack of these skills results in inadequate delivery of quality and effective oral health care. Basic behavioral guidance (BBG) includes a set of skills involving several techniques/procedures that are difficult to learn and assess objectively. Most of these skills are complex and subjective in nature and belong to the nonpharmacological category. These skills demand multitasking from any general dentist – tasks of performing dental procedures, understanding child psychology, and also providing behavioral therapy to their patients.[1] These skills have subjective component of reasoning and decision-making that may vary with individual experience and different clinical situations. Hence, these skills qualify the criteria of experiential learning through “reflection,” which is the most scientific and logical way of learning complex skills.

Reflection is a meta cognitive process that occurs before, during, and after situations with the purpose of developing greater understanding of both the self and the situation so that future encounters with the situation are informed from previous encounters.[2]

The role of reflection in skill building is very well explained by Kolb's cycle of experiential learning. The first phase of Kolb cycle is “experience,” followed by the second phase of integrating experience to the existing knowledge through “reflection.” In the third phase, the learner understands his/her actions through reflections, identifies new learning needs, and expands knowledge base (abstract conceptualization). Finally, in the fourth phase, there is application of new learning from the “experience.” The phases are cyclical and repeated, leading to new learning with every new experience.[3] One of the very common forms/types is “reflection on action,” which is considered adequate for novice professionals.[4]

Literature provides evidence of early exposure to reflection assignments/tasks for facilitating a smooth learning curve.[5],[6] Such assignments benefit the health-care professionals in developing a therapeutic patient relationship and professional expertise.[2] However, the associated lack of evidence of its impact on the practice of skills and most importantly how it affects patient outcomes (desirable learning outcomes for the learner), raises doubts on best practices for teaching, learning, and assessing reflections in health professions.[7] Hence, vigorous research is the need.

With this background, it has also been perceived that learners need to be guided for reflecting within individual tasks/experiences, rather than embedding it in whole curriculum in general.[7] This fragmentation helps in better communication of the task-specific purpose. However, it will also need a thorough need assessment and prioritization of areas specific to the incorporation of reflective learning.

Considering these potential gaps and scope from the literature, a formal need assessment with students and subject experts was performed for the pediatric dentistry undergraduate curriculum. It revealed gap in the translation of knowledge to application in terms of BBG at undergraduate level. The present study was hence designed to introduce “reflection on action” in the curriculum for pediatric dentistry at the undergraduate level.


Reflection-on-action as an experiential learning tool for Basic Behavior Guidance in pediatric dentistry at the undergraduate level will improve desirable learning outcomes.



The primary objective was to improve desirable learning outcomes in BBG for pediatric dental patients using “reflection-on-action” as an experiential learning tool at undergraduate level.


The secondary objectives were to:

  • To improve knowledge of dental undergraduates regarding the role and importance of “reflection-on-action” in experiential learning
  • To identify emerging themes from learners' reflections that can aid in improving learning of BBG in pediatric dentistry
  • To assess change in levels of written reflections of learners over the period of intervention
  • To assess learner acceptability for the new education intervention.

   Materials and Methods Top


Undergraduate pediatric dentistry clinic.


Dental undergraduates (learners) posted in rotation in the pediatric dentistry undergraduate clinic who have previously practiced or performed oral prophylaxis in an experiential setting.

Sample size


Description of methodology

The study was approved by the institutional ethics committee. Theory component of BBG skills in pediatric dental patients' was addressed by means of large group teachings (3 h) and observing video recorded/real encounters in postgraduate clinics, of different situations as per curriculum. Practical/skill undertaken in the clinical setting now had an additional element of experiential learning by reflective writing. The component of “nitrous oxide inhalation” of BBG was excluded for the present study as it required dedicated training and setup. All the rest of the BBG techniques were included.

The study design was planned to incorporate cyclical process of Kolb's experiential learning. Each learner was asked to perform oral prophylaxis over two encounters in the same pediatric dental patient in the age group of 3–7 years. The learners were instructed to apply BBG skills as needed during the clinical experience. Appropriate instructions were given Annexure 1.

The learners were introduced to “reflection on action,” by a brief verbal structured instruction and a written form [Annexure 2]. Examples of reflective writings were also provided. They performed the actual task of oral prophylaxis the next day.

Each clinical experience (encounter) was video recorded after consent from the learner and parents/guardians of patient. Feedback on performance was given by the faculty immediately after the encounter to provide an assessment of their performance and also to guide them in the reflective process.

At the end of the first visit, each learner reviewed his/her own video and wrote reflections based on feedback received on performance, video recording, and knowledge gained from the instructional session. Written reflections of the learners were assessed for the emerging themes under the four reflection categories of the “4 R reflective framework” given by Boud et al.[8] [Annexure 3]. A verbal feedback on the written reflections as related to BBG skills was given to the learners. It also included feedback on reflective writing skills of the learners. The learners were asked to go through reflections, look back at what needed to maintain/improvise/avoid etc., in further patient encounters, and use this new learning in future experiences. The videos of each learner were observed and scored using a preformed score sheet by the faculty [Annexure 4]. Desired learning outcomes for BBG skills were itemized as video score sheet items. Scores were given by the faculty on the basis of efforts of the students, as seen on the video recordings.

The process of reviewing video, writing reflection, and feedback after assessment was repeated in the second visit of the patient. During feedback, the learners were again guided for applying the learning from the first-visit experience to this second-visit experience and reflect on improvements/changes they felt.

At the end of tasks (completion of both patient visits and two reflective writings), a retrospective pretest posttest questionnaire was administered to the learners to assess the change in their knowledge regarding using reflective thinking as a learning tool for BBG skills [Annexure 5]. They were explained the scoring system and the purpose of the administration of questionnaire.

Feedback was also taken from each learner to know their perspective for newly introduced intervention of “reflection-on-action,” after giving brief instruction of scoring and purpose [Annexure 6]. Perspective was related to the acceptability and satisfaction of the intervention by the learners in terms of content, relevance, and delivery.

Because the data obtained from retrospective pretest posttest questionnaire and video scores were ordinal in nature and also skewed, it was preferred to analyze it through Wilcoxon signed-rank nonparametric test. Different levels of efforts demonstrated by learners were expressed as distribution in numbers.

Ordinal data in the form of levels of written reflections were analyzed for shift and distribution of learners with various degrees of shift. Ordinal data obtained from the feedback questionnaire were analyzed for distribution across different levels of satisfaction.

Qualitative data obtained in the form of written reflections were subjected to “thematic data analysis.” Data were reduced by structuring and organizing into broad categories or codes until point of saturation. Inductive coding style was used. Using the codes generated, building up of overarching themes from the data was done, till point of data saturation. Validation of themes generated was done using triangulation method by confirming from a random subset of participants. External validation was done by comparing the coding of a total of eight random reflective writings by two independent observers. Reliability of data generated was done by ensuring confidentiality and anonymity to the learners verbally and in consent forms.

   Results Top

A total of 31 participants completed the study, which included attending theory component of the module, instructional session on reflective writing, performing two treatment visits of oral prophylaxis in pediatric patient, video-recording both visits, reflective writing for both visits, and filling retrospective pretest posttest and satisfaction questionnaires. Out of these 32 participants, 12 were male and 20 were female.

The outcome measures observed in the study are as follows:

Change/improvement in the knowledge of the dental undergraduates in using reflective thinking for learning basic behavioral guidance skills for pediatric patients

The median posttest scores were found to be significantly higher than the median pretest scores for all individual items of retrospective posttest pretest questionnaire. The median posttest scores (median = 60) were also found to be statistically significantly higher than the median pretest scores (median = 23) for overall response (Z = 4.93, P < 0.0001).

Emerging themes from reflective writings

Qualitative data obtained from reflective writings were analyzed for emerging themes till data saturation. The major overarching themes that emerged during data analysis were assessed using Boud's 4R framework and were classified under all levels of the reflective framework. They are listed in [Table 1].
Table 1: Emerging themes from reflective writings of students under Boud's 4R framework

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Shift in learners' levels of reflection over both patient visits

Observations of qualitative data from the reflective writings revealed that at least all participants could recall/revisit (R1) details of patient interaction in their reflective writings [Table 2]. The number of participants at R3 level increased considerably from the first visit to the second visit (increase by 10). The reflections also reached higher level R2 and R4 for a greater number of participants in the second visit (increase by 8 and 4, respectively). A total of twenty learners demonstrated a shift toward higher levels of reflection in their reflective writings over the patient visits [Table 2].
Table 2: Reflective framework levels distribution and shift over two visits

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Assessment of learning outcomes for basic behavioral guidance skills of dental undergraduates

Desired learning outcomes for BBG skills were itemized as video score sheet items. The scores were given by faculty on the basis of efforts of students as seen on video recordings. Wilcoxon signed-rank test for overall video scores indicated that the median second visit video scores (median = 82) were statistically significantly higher than the median first visit video scores (median = 68) (Z = 4.93, P < 0.0001). Sum of negatively signed ranks was 0, indicating only positive change in scores.

Number of students demonstrating desirable learning outcomes within basic behavioral guidance skills

A considerable increase was observed in the number of students receiving scores 3/4/5 in half of the scoring criterion of video score sheets over two visits [Table 3].
Table 3: Assessment of desirable learning outcomes for basic behavioral guidance skills

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Assessment of learners' satisfaction in using “reflection–on-action” as a means of learning basic behavioral guidance skills in pediatric dentistry

A high percentage of learners were satisfied with the delivery, content, and relevance of the newly introduced educational intervention “reflection-on-action,” as a means of learning BG skills in pediatric dental office. It was observed that a median number of 17 and 11 learners responded to all questions with “strongly agree” and “agree,” respectively. A maximum of 24 learners and a minimum of 14 learners responded with “strongly agree” in all the questionnaire items administered.

   Discussion Top

Students who achieve well are more often students who are aware of the weaknesses and strengths in their own learning processes.[9]

The present study is an attempt to create this awareness by introducing “reflective practice” in dental curriculum. Reflective writing assignments in the present study were introduced at undergraduate level, thereby supporting the rationale of early exposure to reflection.[6] The nature of reflective writing task, hence, was chosen as reflection-on action. In addition, reflection tasks were kept limited to BBG for better understanding of task-specific purpose.[7]

There have been, however, concerns over teaching and assessing reflections. Wald and Reis[10] and Aronson et al.[11] have, however, provided evidence of approach to be followed. In the present study, planning of instruction for reflective writing has been done using the approach explained by Aronson.[12] Pedagogical methods that have found recognition in literature are journal writing, critical incident essays, and reviews of audio/videotape recordings of one's self actions. Zick et al.[13] found that videotaped clinical encounters help learners to review their own performance. Videotaped feedback has also been reported to modify behavioral patterns of dental undergraduates within clinically relevant skills.[14] Video-captured performance as a component of learning program has many reported benefits in literature.[15] It allows self-assessment, triggers for reflections, and verification for elements of reflection.[16] Video recordings in the present study similarly served for self-assessment, objective assessment of skills, and also a correlation with self-assessment through reflective writings.

The authors preferred Boud's framework for structure of written reflection, due to its simplicity and cumulative nature.[17] Guiding questions for reflective writing were planned to provide a structure for writing that conforms to this framework.

BBG skills were chosen for reflective assignments because besides being eligible for experiential learning and associated need of improvement, they are the foremost skills needed to manage a pediatric dental patient and can elicit improved behavioral response in subsequent patient visits.[18] Within the clinical procedures, oral prophylaxis was considered as it is minimally invasive. Furthermore, only those learners were enrolled who had previous exposure of performing oral prophylaxis in patients. This ensured that focus of learning remains at BBG and not on the procedure.

Flow of learning experience in the study was woven according to Kolb's cycle.[3] Learners gained knowledge and went through “patient experience” ( first phase), followed by a second phase of reflective writing where the learner interpreted experience to knowledge. With reflective writings, the learners got an opportunity to understand actions, identify new learning needs, and expand knowledge base (third phase). Finally, they could apply new learning in the second patient visit (fourth phase).

Reported baseline knowledge of learners with respect to term reflection and using reflection for learning skills in dentistry was found to be low in the study. This indicated lack of sensitization to reflective writings. Posttest scores, however, demonstrated positive change for all questionnaire items, especially for using reflection for learning. It was preferred to administer a retrospective pre-test post-test self-assessment questionnaire as change was being measured over a very short period of time.[19] The purpose was to gauge perceptions of change as a result of program participation and also to reduce “response shift bias.“[20],[21]

Thematic analysis of qualitative data from written reflections was preferred to content analysis; interest was more in the emerging themes rather than frequency of codes generated.[22] This is because the learners may not have reported in writing all themes pertinent to them, even if they thought in mind. Observations of themes generated demonstrate that recalling patient particulars, patient behavior, patient interaction, and the BG strategies that learner adopted were quite nicely reported in reflective writings. It indicates that learners were able to reproduce clinical encounter experience in their writings. This revisiting helps learners to move higher up in reflection in future and also prepares them for further patient interactions.

A multitude of reactions were reported in reflective writings by learners. These reaction themes may guide the facilitators in planning their sessions and also guiding their learners to handle different reactions. For example, a learner with “anxiety of managing a hyperactive patient” may be guided to observe faculty/residents performing and mentally rehearse what steps he/she can take. Learners may also be guided to anticipate different patient behaviors and what can be done in different situations. They could be encouraged to look back into their reflective writings to see how they managed previously. Actions reported by other learners can further add to their experience.

Thematic analysis also revealed that the learners could relate their performance to their strengths and limitations and could identify reasons for both. This higher level of reflection is very important in decision-making for any health professional and it brings in critical thinking attributes to reflection. Finally, response of the learners to their strengths or limitations demonstrates that even a small sensitizing activity of reflection for a small subtask can guide young learners to highest level of reflection, where they act after critically appraising their performance.

Levels of reflection exhibited by participant learners varied considerably in the observations of the present study. Similar low levels and variability are reported in literature.[23],[24],[25] A study also observed a shift of at least one level in 16 (50%) of participants, though it was observed over a short duration of time.

One of the limitations of the study was limited period of intervention across which change in levels of reflection was observed, that is over 1 week of clinical procedure only. Such changes, if positive, are more appreciable when observed over long periods and more likely to sustain.

Emerging themes from learner's reflections indicated improvement in self-identified skills by learners. It also indicated that knowledge gained was operationalized in a real setting. Salient features of this qualitative data can be used for planning teaching–learning sessions. In addition, reflective assignments alone are a kind of self-reported improvement in learning. Hence, video observations of performance were added to generate evidence for learning outcomes.

The present study focused on one of the most essentially required competencies for dental undergraduates in pediatric dentistry-BBG skills. These skills were assessed using a preformed and validated checklist for video-recorded patient encounters. Scores of learners assessed by this checklist improved significantly over two patient visits. The checklist had an incorporation of elements to take care of baseline behavior presented by patients during encounter. The video gave the opportunity for a “second look” on actions, leading to learning of “how to do it” and also why it should be done.[26]

One of the most important attributes of BBG skill scoring emphasized in the study was observation of learning outcomes for chosen competencies. Observation of change in terms of skills concerned (i.e., desirable learning outcomes) is a requirement for any health-care education teaching–learning program. In the present study, it was observed that desirable learning outcomes improved over both patient visits in terms of video scores (performance) and also percentage of learners demonstrating efforts for at least 50% of desirable criteria within the skills. Hence, the hypothesis stated was deduced. It also provides a future direction for standardized delivery of education and patient care.

Majority of the participants exhibited satisfaction/acceptance to relevance, content, quality, and delivery of intervention in the study. There has been reported evidence of similar satisfaction by students for reflective process in clinical learning.[27]

   Conclusion Top

“Reflection-on-action” as an experiential learning tool for “BBG” in pediatric dentistry by dental undergraduates, highlights reflective learning of skills, selection of appropriate skills to be learned through reflection, fragmentation of learning tasks through reflection, and most importantly change in learning outcomes through reflections.


We acknowledge the guidance and help provided by the:

  • CMC Ludhiana FAIMER faculty, faculty advisors, and fellows
  • All learners for their co-operation.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   Annexures Top

   Annexure 1: Task 1 Top

Dear student,

As now you have learned basic behavioral guidance techniques (BBG) of pediatric dental patients, the task assigned to you is to perform oral prophylaxis in a patient between aged 3–7 years in a dental office setting. The procedure needs to be completed in two visits (two quadrants each per visit) using BBG techniques you know but without nitrous oxide inhalation.

Let us revise what you must take care of/incorporate while guiding the behavior of the patient to complete this task.

  • Always greet the patient
  • Consider use of good communication skills throughout the interaction
  • Observe carefully
  • Gather data/history as needed.
  • Try not to expose patient to anxiety producing stimuli in the very first interaction
  • Try counseling guardian/parents to reduce their anxiety
  • Use of euphemisms (substitute words)
  • Use of tell-show-do, ask -tell-ask
  • Use of distraction/involvement
  • Try structuring the situation as and when needed
  • Reinforcement use as needed
  • Be empathetic
  • You can use your authority with flexibility
  • End the appointment on a healthy note – giving some educational instructions/motivation.

Your interaction with the patient shall be video recorded if you give consent for that.

After video recording of your patient interaction, faculty would observe how well you performed the procedure. You will receive feedback. Grading of the performance will be done by the faculty to give you feedback. This shall not contribute to your internal assessments.

   Annexure 2: Task 2 Top

Your task now is to review your own video after the patient is sent, and observe for yourself, the basic behavioral guidance you performed. (treatment procedure skills need not to be focused)

The objective behind this task is manifold:

- You will be able to see how you performed

- You will be able to look for your positive points

- You will be able to see what you missed/or what went wrong

- You will identify where you needed improvements

- You will learn from your mistakes

- You will strengthen your positive points

- You can discuss positive and negative points with peers/faculty if you want

- You can assess yourself.

- You will assess what choices you made

- You will assess what decisions you made.

Once you review your video, you may write what you observed/experienced in the following format. We? would prefer if you can write in paragraphs. You can write in the simplest English language in which you are comfortable. You are requested to write in your own words. You are not going to be assessed on how you write. It is for your own learning.

We just want to know the story of your learning.

So tell us your own experience (patient behavioral guidance) in your own words:

  1. What went well:
  2. What did not went well:
  3. Why did this happen? Evaluate and justify the choices/decisions you made during encounter?
  4. How will you try to improve next time?
  5. What you still need to understand/improve on:

“We can help you more if you are still not clear“

For point

  1. You may describe your strengths, capacities, your overcoming capabilities, how you managed the patient well.
  2. You may describe your limitations, what were your fears, weaknesses, that did not allow the patient encounter to go well?
  3. Think and write how and why things were well or not well. How your decisions affected the management?
  4. Suggest alternative actions you might have taken (or might take next time) to improve the activity/visit and make it a better experience
  5. Plan for yourself how you can make this experience better in future.

Scoring criteria to be used by the faculty:

1 = No efforts at all

2 = Made negligible attempt in preventing/managing disruptive behavior

3 = Made effort that was not effective in preventing/managing disruptive behavior

4 = Made effort that was partially effective in preventing/managing disruptive behavior

5 = Made effort that was completely effective in preventing/managing disruptive behavior.

   Annexure 5: Pretest posttest questionnaire Top

Dear Learner,

Please provide your input for the following set of questions for both after the teaching session and before the session conducted on learning “reflection.“

   Annexure 6: Students' Satisfaction Questionnaire Top

Dear student,

Recently, you have gone through practice of written reflection after observing your own encounter with the pediatric dental patient. Kindly give your feedback regarding the introduction of “reflection“ writing for learning and practicing “basic behavior guidance skills“ via observation of video-recorded patient encounters. This will help us to make further improvements. Please mark only one option for each question of the feedback on the scale given

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  [Table 1], [Table 2], [Table 3]


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