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 Table of Contents  
REVIEW ARTICLE
Year : 2016  |  Volume : 3  |  Issue : 1  |  Page : 10-14

The critical incident technique in dental research: A review


1 Department of Public Health Dentistry, People's Dental Academy, People's University, Bhopal, Madhya Pradesh, India
2 Department of Public Health Dentistry, People's College of Dental Sciences, People's University, Bhopal, Madhya Pradesh, India
3 Department of Pedodontics and Preventive Dentistry, People's Dental Academy, People's University, Bhopal, Madhya Pradesh, India

Date of Web Publication22-Dec-2015

Correspondence Address:
Binu Santha
Department of Public Health Dentistry, People's Dental Academy, People's University, Bhopal, Madhya Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2348-3334.172406

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  Abstract 

Research is a scientific quest to find answers to certain questions. It makes us think with curiosity and wonderment about how to make something better. Research contributes in a major way to the development and maintenance of health and health care systems. Qualitative research is concerned with qualitative phenomena and includes subjective assessment of attitudes, opinions, and behavior. It is especially important in the behavioral sciences where the aim is to discover the underlying motives of human behavior. The critical incident technique (CIT) is a well-established qualitative research tool used in many areas of health sciences including nursing, medicine, dentistry, and their respective education systems. This technique is described as consisting of “a set of procedures for collecting direct observations of human behavior in such a way as to facilitate their potential usefulness in solving practical problems.” This review gives a gist of CIT and its application in different aspects of dental research.

Keywords: Behavioral science, critical incident technique, qualitative research


How to cite this article:
Santha B, Saxena V, Jain M, Tiwari V, Singh A, Tiwari U. The critical incident technique in dental research: A review. CHRISMED J Health Res 2016;3:10-4

How to cite this URL:
Santha B, Saxena V, Jain M, Tiwari V, Singh A, Tiwari U. The critical incident technique in dental research: A review. CHRISMED J Health Res [serial online] 2016 [cited 2019 Dec 8];3:10-4. Available from: http://www.cjhr.org/text.asp?2016/3/1/10/172406


  Introduction Top


Research is a scientific quest to find answers to certain questions. It makes us think with curiosity and wonderment about how to make something better. One can define research as a scientific and systematic search for pertinent information on a specific topic. It is an art of scientific investigation to attain truth. It is an original contribution to the existing stock of knowledge making for its advancement.

Research contributes in a major way to the development and maintenance of health and health care systems. It plays a role in bringing modern health technology to people by encouraging innovations related to diagnostics; treatment methods as well as prevention; translating the innovations into processes by facilitating evaluation; and introducing these innovations into public health service through health systems research.[1]

Qualitative research is concerned with qualitative phenomena and includes subjective assessment of attitudes, opinions, and behavior. It is especially important in the behavioral sciences where the aim is to discover the underlying motives of human behavior.[2] Because qualitative research provides a level of descriptive detail and depth that is impossible to achieve with other types of research, it is the best form of research for studying how and why individuals interact within social contexts.[3]

First described by John C. Flanagan in 1954, the critical incident technique (CIT) is a well-established qualitative research tool used in many areas of the health sciences including nursing, medicine, dentistry, and their respective education systems. This technique is described as consisting of “a set of procedures for collecting direct observations of human behavior in such a way as to facilitate their potential usefulness in solving practical problems.”[4]


  Critical Incident Technique Top


The CIT began its life as an offshoot of the Aviation Psychology Program of the United States Army Air Forces in World War II. The new program focused on factual reports given by competent observers to produce an objective definition of effective or ineffective behaviors.

Extension and development of the technique by Flanagan and his students at the University of Pittsburgh's Department of Psychology in the late 1940s and early 1950s led to the use of the CIT in other occupational groups and activities. In 1954, Flanagan published a scholarly article on the CIT, describing the origins of the procedure, its present form, and its uses. This article outlined “a flexible set of principles which must be modified and adapted to meet the specific situation at hand."[4]

Five basic steps of CIT are:

  • Identifying general aims
  • Planning
  • Collecting the data
  • Analyzing the data
  • Interpreting and reporting the results.


Step 1: Identifying general aims

Pertinent research questions must be identified prior to undertaking any type of research. Examples of research questions have included such diverse issues as the following:

  • Gaining a greater understanding of how employee socialization and organizational adaptability influence workplace learning within office settings
  • Analyzing the needs of travellers based on a study of their tasks and activities.


Step 2: Planning

The following areas must be addressed at the planning stage:

  • The situations to be observed. Their relevance and effect on the general aim are crucial. The “incidents” may be positive and/or negative events that impact on the general aim. The researcher will decide what would be valuable to the investigation
  • The observers. Some familiarity with the situation is usually beneficial. This way the observers can be considered “experts” regarding the situation observed
  • The method of data collection
  • The method of data analysis
  • Institutional Review Board requirements and guidelines.


Step 3: Collecting the data

With good planning, the data collection is simplified. Observed incidents are reported and recorded for later analysis. The observations should be recorded as close as possible to the time when they occurred. Memory is improved if the observers know in advance that they will need to make the reports. If full and precise details are given, the report can be assumed to be accurate. Central to the CIT is the trust placed in the observer to make accurate reports. This trust should work both ways, and a guarantee of anonymity for the observers is usually required.

Reports can be made through individual or group interviews, through questionnaires, or through record forms. The choice of collection method will depend on the situation to be observed, time available, and other logistical factors. In many situations, the best option will be the standardized individual interview, which will allow for best explanation of the aims of the study and clarification of ambiguities in the reports. Audio or video recording of the interviews allows for analysis to occur later.

The size of the sample is difficult to determine in advance. Theoretically, sampling should continue until saturation is reached, that is, a point at which the addition of new incidents contributes no new information for the analysis. However, time and logistical constraints may require that a predetermined number of incidents are collected. Over 100 incidents are generally accepted to be a reasonable figure for analysis.

Step 4: Analyzing the data

The purpose of analyzing the data is to summarize and describe the data to allow it to be used for practical purposes. The aim is to increase the usefulness of the data without sacrificing comprehensiveness, specificity, or detail. The steps are as follows:

  • Selecting a frame of reference that will be related to how the data will be used
  • Developing a set of major area and subarea categories. This process is informed by guidelines from qualitative research methods – in particular, methods such as grounded theory 21. The process is “inductive,” that is, it uses an approach that allows the categories to be informed by the data. In this way, a predetermined (a priori) category system is not imposed, but rather the categories emerge from the data. Collaboration on the formulation of data categories is said to improve validity
  • Placing the incidents into the categories as they are reviewed, and making a simple count. Again, collaboration will improve validity. Redefinition and development of new categories may occur at this stage. Larger categories may be divided, or the smaller categories combined. This will improve the clarity of the results. Flanagan gives a list of considerations for establishing and naming categories.


Step 5: Interpreting and reporting

Any potential for bias in the first four steps should be reviewed at this stage, and limitations of the research should be identified. However, the researcher should not dodge his or her responsibility in evaluating the results. The original researcher is the best poised to reconsider the original research aims, make the necessary evaluations of the data, and report the value of the results.

In reporting the research, the methods of data collection and analysis must be completely transparent and clearly described. This is the only way that a reader will be able to judge whether or not the conclusions are supported by the data.[4]


  Critical Incident Technique in Health Care Research Top


Health care professionals within nursing, medicine, and dentistry use CIT that illustrates its flexibility.

Nursing and medicine

In a review of the CIT in nursing research, Kemppainen identified several reports that used the CIT to examine patients' experiences in health care settings, nurse-patient interactions, and patient responses to illness and health care treatment.

In medicine, Altmaier et al., used the CIT to identify effective and ineffective behaviors and develop categories of noncognitive characteristics to aid selection of anesthesiology residents. Effective teaching behaviors of family medicine preceptors were examined by Goertzen et al. and contribute to an evidence-based approach to teaching.[4]


  Dentistry Top


Dentists were one of the first occupational groups to be evaluated using the CIT. In the study reported by Flanagan et al., critical incidents were obtained from three sources such as patients, dentists, and dental school instructors. The incidents were analyzed and classified into four main aspects of the dentist's job: (a) Demonstrating technical proficiency, (b) handling patient relationships, (c) accepting professional responsibility, and (d) accepting personal responsibility. This research pertaining to the critical requirements for professional competence for dentists was put into action by the university, and a battery of selection and proficiency tests were developed by the university's School of Dentistry.[5]

More recently, Victoroff and Hogan's (2006) report of students' perceptions of effective learning experiences in dental school used the CIT as part of a multifaceted curriculum assessment strategy. Their investigation aimed to approach curriculum change from a positive perspective, by building on the strengths of the established predoctoral dental curriculum at Case Western University. The learning incidents of dental students collected through one-on-one interviews were analyzed, and a list of themes developed. The results identified three key areas related to effective learning experiences. These themes were instructor characteristics, characteristics of the learning process, and learning environment. Subcategories were identified within the three themes. The results are presented using quotes from the interviews, which bring life to the results and give a voice to the students' experiences. In their discussion, the authors note that the CIT is a useful method of gathering feedback from students for purposes of curriculum evaluation but do not propose any other uses for the technique in the field of dental education.

At the University of North Carolina, students were required to complete two community-based rotations and write a “reflection essay” upon completion of the rotations. The students were asked to describe a specific event (the critical incident) and reflect on the personal and professional implications that flowed from it. The resulting essays were analyzed using content analysis to summarize, code, categorize, and interpret the data. Three major themes emerged were personal and professional growth, enhanced awareness, and commitment to service. As with Victoroff and Hogan's data, subcategories were identified within the major themes. Again, the results are illustrated using direct quotes from the essays. This use of the raw data to give meaning to the results is common in qualitative research. It enables the reader to see the breadth and depth of the results obtained and makes for engaging reading.[4]


  Use of the Cit in Dental Education Research Top


The CIT allows for flexibility within the five basic steps. This allows researchers to tailor the technique according to their needs and the situation to be explored. The researcher establishes the situations to be observed and the identity of the observers based on the needs and aims of the investigation. Then, a choice is made regarding the method of data collection. The gold standard for data collection is the one-on-one interview conducted soon after the incidents occur. Group interviews are a time-efficient method, and questionnaires and record forms even more so. Obviously, the depth of data collected may vary from method to method.

There are a variety of uses for the incidents/events/episodes once they have been collected. Many are analyzed, and results are produced that can be further developed and interpreted so that they can be used for practical purposes. In other situations, the incidents are not analyzed so rigorously but instead used as the basis for further discussions in a more ad hoc manner. One example of this is an investigation into learning experiences that used incidents provided in written form by dental students as the basis for group discussions, while medical students at the same university were given individual feedback on their written reports. As a flexible set of principles, the CIT is a suitable research method in many aspects of health care and health care education.[5]

Allery et al. described the complete range of factors that doctors recognize as changing their clinical practice and provide a measure of how often education is involved in change. The design included interviews using CIT. Main outcome measures were categories of reasons for change in clinical practice. Results were that doctors described multiple changes in clinical practice with an average of 3.0 reasons per change. The three most frequently mentioned reasons were organizational factors, education, and contact with professionals, together accounting for almost half of the total number of reasons for change. Education was accounted for one-sixth of the reasons for change and was involved in one-third of the changes. Education was seldom mentioned as a reason for change in referral practice but was more often mentioned in management and prescribing changes. Consultants were influenced by medical journals and scientific conferences while general practitioners were more influenced by medical newspapers and postgraduate meetings. It was concluded that education is involved in about a third of changes in clinical practice. The wide range of other factors affecting changes in practice need to be taken into account in providing and evaluating education. The role of education in the numerous changes in clinical practice that currently have no educational component should also be considered.[6]

FitzGerald et al., were of the view that the CIT is a well-established qualitative research tool used in many areas of the health sciences including nursing, medicine, dentistry, and their respective education systems. It is a flexible set of principles that can be modified and adapted to meet the specific situation at hand. By gathering factual reports made by observers, researchers can build a picture of the situation under study. The CIT maximizes the positive and minimizes the negative attributes of anecdotes, effectively turning anecdotes into data. In this study, the first of two companion articles, the origins and current state of the CIT and its potential applications in dentistry and dental education are described.[7]

Victoroff and Hogan suggested that students' views of their educational experience could be an important source of information for curriculum assessment. They explored the characteristics of effective learning experiences in dental school using a qualitative method. Students were interviewed about specific, particularly effective learning incident that he or she had experienced in dental school and a specific, particularly ineffective learning incident, for comparison. Data analysis resulted in identification of key themes in the data describing characteristics of effective learning experiences. The following characteristics of effective learning experiences were identified: (1) Instructor characteristics (personal qualities, “checking-in” with students, and an interactive style), (2) characteristics of the learning process (focus on the “big picture,” modeling and demonstrations, opportunities to apply new knowledge, high-quality feedback, focus, specificity and relevance, and peer interactions), and (3) learning environment (culture of the learning environment, technology). Common themes emerged across a wide variety of learning incidents. Although additional research is needed, the characteristics of effective learning experiences identified in this study may have implications for individual course design and for the dental school curriculum as a whole.[8]

Strauss et al., were of the view that learners gain additional value from community-based education when they are guided through a reflective process. They described the process by which structured reflection assignments and methods are incorporated in the University of North Carolina School of Dentistry's community-based Dentistry in Service to Communities program. The following strategies are described as ways to enrich community-based learning experiences for dental students: Photographic documentation, written narratives, critical incident reports, and mentored post-experiential small group discussions. Fieldwork and course-related examples are drawn from community-based dental experiences to illustrate how reflective teaching approaches can enhance student learning. A directed process of reflection is suggested as a way to increase the impact of the community learning experience.[9]

Mofidi et al., opined that dental schools are challenged to develop new learning methodologies and experiences to prepare better future for dental practitioners. They provided insights into the community-based experiences of dental students as documented in their critical incident essays and explore what learning outcomes and benefits students reported. Following two required community-based clinical rotations which took place in settings such as a public health clinic, special needs facility, hospital, or correctional institution, each student's reflection essay on a self-defined critical incident that occurred during the rotations was obtained. These were content-analyzed for recurring themes and categories. Students were confronted in their rotations with a wide range of situations not typically encountered in dental academic settings. Their essays showed that as a result of these rotations, students developed increased self-awareness, empathy, communication skills, and self-confidence. Critical incidents challenged assumptions and stereotypes, enhanced awareness of the complexities of dental care, and raised complex ethical dilemmas. This also illustrated a heightened sense of professional identity and enabled students to appreciate the role dentistry can play in impacting patients' lives. Hence, we concluded that community-based dental education that includes a process for reflection holds promise as an educational strategy to facilitate the personal and professional development of future dentists.[10]


  Conclusion Top


Dentistry as an important field of medical science has its applications in different phases of life. Dental research enables better opportunities in improving dental curriculum for the better understanding of the subject and its intricacies among students. It also helps improve the provision of oral care services to the population. CIT provides an in-depth understanding of the situation dealt with and helps advance services to the public.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Kothari CR. Research methodology: Methods and techniques. In: Text Book of Research Methodology. Revised 2nd ed.: New Age International (P) Limited, Publishers; 2004.  Back to cited text no. 1
    
2.
Morse JM, Field PA. Health professionals. In: Qualitative Research Methods. 2nd ed. SAGE Publications; 1995.  Back to cited text no. 2
    
3.
Meadows LM, Verdi AJ, Crabtree BF. Keeping up appearances: Using qualitative research to enhance knowledge of dental practice. J Dent Educ 2003;67:981-90.  Back to cited text no. 3
    
4.
Sofaer S. Qualitative research methods. Int J Qual Health Care 2002;14:329-36.  Back to cited text no. 4
    
5.
Patton MQ, Cochran M. A Guide to Using Qualitative Research Methodology; 2002. Available from: http://www.fieldresearch.msf.org/msf/bitstream/10144/84230/1/Qualitative%20research%20methodology.pdf. [Last accessed on 2015 Jul 25].  Back to cited text no. 5
    
6.
Allery LA, Owen PA, Robling MR. Why general practitioners and consultants change their clinical practice: A critical incident study. BMJ 1997;314:870-4.  Back to cited text no. 6
    
7.
FitzGerald K, Sue Seale N, Kerins CA, McElvaney R. The Critical Incident Technique: A Useful Tool for Conducting Qualitative Research – Critical Issues in Dental Education. Journal of Dental Education: American Dental Education Association; 2008.  Back to cited text no. 7
    
8.
Victoroff KZ, Hogan S. Students' perceptions of effective learning experiences in dental school: A qualitative study using a critical incident technique. J Dent Educ 2006;70:124-32.  Back to cited text no. 8
    
9.
Strauss R, Mofidi M, Sandler ES, Williamson R 3rd, McMurtry BA, Carl LS, et al. Reflective learning in community-based dental education. J Dent Educ 2003;67:1234-42.  Back to cited text no. 9
    
10.
Mofidi M, Strauss R, Pitner LL, Sandler ES. Dental students' reflections on their community-based experiences: The use of critical incidents. J Dent Educ 2003;67:515-23.  Back to cited text no. 10
    



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Qualitative Health Research. 2019; 29(7): 1065
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