Dental Students’ Notetaking: a Thematic, Material-based Interview Study

Background The transition from upper secondary to higher education and from higher education to professional practice require that students need to adapt to new literacy practices, academic and professional. The aim of this study was to map what characterizes dental students’ notetaking and secondarily what dental students express regarding their notetaking. Three undergraduate dental students participated in this material-based, semi-structured interview study, that was framed within a New Literacy Studies approach. To analyze the outcome of the interviews a thematic analysis was used. Eight themes that relate to what , how and for what purpose students write were discerned. These include a) what : T1-Professional vocabulary; T2-Core content; T3-Clinical example; b) how : T4-Multimodal accentuation; T5-Synthesis; and c) for what purpose : T6-Mnemonic strategies; T7-Academic purposes; and T8 professional purposes.


Abstract Background
The transition from upper secondary to higher education and from higher education to professional practice require that students need to adapt to new literacy practices, academic and professional. The aim of this study was to map what characterizes dental students' notetaking and secondarily what dental students express regarding their notetaking.

Methods
Three undergraduate dental students participated in this material-based, semi-structured interview study, that was framed within a New Literacy Studies approach. To analyze the outcome of the interviews a thematic analysis was used.

Results
Eight themes that relate to what, how and for what purpose students write were discerned. These

Conclusions
The digital development has changed the notetaking which has evolved from just synchronous to become both multimodal and asynchronous and is more of a writing practice. Students' writing practices seem to be motivated by their knowledge formation in relation to a subject matter. Results showed that students, half-way through their dental education, are aware of that notetaking is not only for passing exams but also for learning for their profession.

Background
Literacy is part of learning in higher education where students; are expected to read various types of texts, are expected to write various types of texts, and also talk about texts in various situations.
However, few students are familiar with literacy practices, e.g. the genres of texts they are expected to read and write related to a professional or academic language (1). Reading in Swedish dental education includes textbooks, national guidelines, research articles, PowerPoint-handouts, digital material (at the online-learning environment) such as learning tasks, course instructions and clinical instructions. Writing on the other hand includes notetaking, clinical documentation and tests (Lindberg et al. 2020, submitted). According to Lea and Stierer (2), this requires that students have to adapt and use new ways of knowing, including new ways of understanding, interpreting, and organizing knowledge. When entering higher education, most students encounter specific academic literacy practices, i.e. context-specific ways of reading and writing for academic purpose. Students' experiences of transfer from upper secondary school to academia was studied by Ask (3), who showed that it takes time to become acquainted with new ways of writing. In professional higher education, they also are expected to adapt to a professional literacy, which most often differs from the academic literacy. Also, this transfer has been found challenging in a study of nursing and engineering students (4). Consequently, professional higher education prepares not only for academic purposes of reading and writing but also for professional purposes of reading and writing (2). In this article, we specifically focus on students writing in one Swedish dental education during a specific course that comprises of four modules spread over four semesters, with start during the fifth semester.
Students' writing has mostly been explored as part of assessment situations, and students' academic texts for assignments and exams are seen "as tangible products of the processes of reading and writing" (5; p. 389) while less attention has been paid to the practices preceding assessment. Such approaches result in an understanding of less successful students' writing as deficit, and the problem is interpreted as the failing student's problem, not as part of the teaching practice (6,7). Thus, in professional higher education students have a double task: to learn how to read and write different types of academic texts in ways that are acceptable, i.e. what counts as a good written representation of knowing within a specific context (2), but also to read and write texts used and produced within and for the profession in context specific acceptable ways. Furthermore, they need to be able to alternate between these types of texts but also to judge when to use which types of texts.
Such findings have been summarized by Higgs (8) who argues that graduates in professional education are required to: a) have the abilities to access new information; b) judge the information applicability to their specific work setting; c) synthesize information from multiple sources (i.e. verbal, printed, and digital); d) produce reports and presentations utilizing multiple forms of media; and e) use information and communication technologies as part of their learning and future professional practice; as well as f) having the ability to critique new information and determine its relevance to a given situation, i.e. in their future profession (which this study is not able to answer). This is, to our knowledge the first material-based interview study regarding students' academic and professional literacy practices within higher education, where the interviews are based on the participants actual notes. There is a previous interview study by Berthén and colleagues (6) in which students' experiences of their notetaking was investigated. That study identified significant

Methods
To investigate the academic and professional literacy practices of students at an early stage of the dental education, this material-based interview study has two aims. The primary was to map what characterizes dental students' notetaking, and the secondary what dental students express regarding their notetaking. Our working hypothesis was that the main purpose of notetaking was to pass their course examinations.

Material
To analyze the student-aspect of notetaking, three students that volunteered were interviewed in an anonymous set-up, Hereby named Student 1, 2 or 3. The three students that were interviewed were registered in the module "Orofacial Pain and Jaw Function 2" which is part of the course "Clinical Odontology 2" (https://utbildning.ki.se/course-syllabus/2TL016/24160) during the third year of the Study Programme in Dentistry at the Department of Dental Medicine at Karolinska Institutet. The context of the study has previously been described in detail (Lindberg et al. 2020, submitted).
The interviews took place in October 2018 at the Department of Humanities and Social Sciences Education at Stockholm University by two of the researchers (VL, NCh). In order to secure anonymization of the interview setting the participants were instructed not to reveal any personal information during the interview that was video recorded. Further, the camera focused only on a table with the students' notes displayed and only the hands of the volunteers were visible when they wanted to show a specific part of their notes.

Theoretical Framework
This study is based firstly on students' notes, and secondly on material-based interviews with three of these students. Material-based interviews basically is theoretical recontextualization of think-aloud interviews, originating from cognitivistic traditions, into a New Literacy Studies (NLS) tradition. In her study of teachers' assessment of nursing students' written tests, Orrell (9) interviewed the teachers while they were reading and assessing students' responses. Mainly the interviews were based on teachers commenting students' responses aloud. The purpose of Orrell's study was to illuminate experienced teachers' cognitions during the action of assessment. However, the main idea in thinkaloud interviews -to capture the thoughts of the individual interviewees -is problematic for studies that foreground the social. The idea that it is possible to claim that you can capture people's thoughts through interviews has been criticized, firstly based on e.g. Vygotsky's (10) work. According to him, thinking and speech are related to each other, but they are not the same. Secondly, an interview is a specific kind of conversation: the conditions differ from other kinds of conversations, and interviews also have limitations (11)(12)(13). An interview is a joint construction between interviewer and interviewee: each party have their interpretations of the meaning of the questions posed, but also aspects like what questions are not posed, which answers the interviewer will or will not pose followup questions, and what answers the interviewer supports or doesn't support by various kinds of facial expressions, gestures, humming etc. Most of these aspects are unconscious but can be identified when analyzing interview situations. Based on this critique, interview studies have been methodologically developed in order to contextualize the interview situation (13,14). Since dental students' notetaking is considered a social practice, we prefer material-based as the concept that describes both the kind of interview we used, but also the theoretical basis for what we claim based on these interviews: the data that are co-constructed Analysis Thematic Analysis. Thematic analysis may be described as a method for identifying, analyzing and reporting patterns in a data. This method involves a rich description of data, a minimal organization of data, and supports interpretation concerning different aspects of the topic of study (15,16). Thematic analysis is here combined with New Literacy studies for the purpose of capturing patterned response or meaning within interview data that relates to students' notetaking. Prevalence is ensured by the refinement of analysis, in themes and potential sub-themes. A theme is determined by what it captures in relation to the research questions. The themes created relate to the data, i.e. the interview transcripts of three students' notetaking, and were generated by a thorough, inclusive and comprehensive coding process. Themes include data made sense of, i.e. interpreted, and not data paraphrased or described. Each theme has been described in detail and given a nuanced account.
Themes are ultimately related to the study's research questions. Patton (17) describes a thematic analytic process as progressing from a description in which data has been organized to reveal patterns of meaning, a summary, an interpretation that attempts to theorize the importance of the patterns, their general meanings and inferences.
Analytical procedure. The analytical procedure involved noticing patterns of meaning and issues of potential interest in the data. Analysis also involves a relational reading, described as a constant moving back and forth between the data set, the transcripts analyzed, and the analysis of data produced. The analytical steps performed in relation to three student interviews in their notetaking are hereby accounted for: 1.
The first step concerned familiarization with data which was achieved in the process of transcription of the interviews, that also involved a reading and re-reading of data, and the noting of ideas.

2.
In a second step, data for each student was coded in relation to interesting features, which here comprised of the following analytical questions: a) what do they write; b) how do they write; and c) for what purpose do they write? 3.
In a third step, collating codes into preliminary themes, by gathering of relevant data.

4.
In a fourth step, these themes were controlled in relation to the previously identified features and in relation to the entire data set. This additionally ensures that themes are internally coherent, consistent and distinctive. This controlling generated a thematic map of the analysis.

5.
A fifth step involved the definition of each theme and their naming. The themes (T1-

Results
Results from this study showed that students usually write different types of texts (Lindberg et al., 2020, submitted) for the development of a complete understanding of the subject matter. Students' writing is motivated by the development of knowledge and understanding of a subject matter, but also for study achievement and future professional development and support.
Based on the analytical questions from NLS and the procedure from the thematic analysis (Table 1) the following themes were discerned based upon the questions: what do students write, how do students write, and for what purpose do students write? Table 1 Overview of themes related to significant analytical questions (AQ) within New Literacy Studies (NLS Professional vocabulary, i.e. concepts and descriptions, involved the simplification or description of terminology or other phenomena in accordance with students' individual and everyday language. An example was that Student 3 added the verb 'movement' for further describing 'exaggerated protrusion of the mandibula'. The same student also added 'goes back and forth' to describe the terms 'protrusion' and 'retrusion'. All three students discerned core content, i.e. central, recurrent and accentuated (e.g. intonation) content by the teachers during lectures. An example from all three students was the word 'toxic', another was 'pain' and 'peripheral sensitization' that were accentuated by the teachers. Another example described by the three students was the repetition that patient anamnesis was a significant source of information for treatment.
Clinically relevant content was provided to students based on teachers' experiences, i.e. examples from their clinical practices. Teacher-examples were occasionally further supported by drawings on the whiteboard. Students copied these drawings into their own notes (Fig. 1).
How do students write?
Two themes were discerned in relation to how students write, and these were: T4) multimodal strategies; and T5) syntheses. Multimodal strategies that students used aimed to support memory, and to aid their understanding of the subject. Strategies comprised of various color coding; accentuation through different types of markings, such as squares, bolding and exclamation marks; arrows marking movement or leading to various descriptions; drawing own pictures, or adding pictures and images for further explanation of content in text; upper case letters; tags; visual symbols for instance marking female and male gender. For instance, Students 1 and 3 used black color as basic color for noting, while other colors signified different things (Fig. 2). Student 2, on the other hand used red color for marking words, concepts or other information that needs to be further controlled and thus clarified as an adequate explanation that was not provided in the lecture itself.
After the lecture, all three students either looked up in books, searched the internet or called a course-friend to ask. Student 3 also used yellow highlight to mark something important, while pink highlight to mark concepts and terminology. Student 3's synthesis comprised of a multimodal combination of PowerPoint-handouts from lectures, additional teacher information from lectures summarized in Word-documents, and students' individual complementary handwritten notes on tablets, referring to specific page on PowerPoint-handout ( Fig. 3). All three students often complemented the notes with a synthesis soon after the lectures, as a mnemonic strategy to increase the chance of remembering details from the lecture. The student synthesis was a structured summary of the subject, in terms of both general and detailed information.
These syntheses helped the students to reach a broader and deeper understanding of the subject.
Why do students write?
Three themes were identified for the question of why students write: T6) mnemonic strategies; T7) academic purposes; and T8) professional purposes (Fig. 1). Students notetaking as a mnemonic strategy, was presented by all three students as clarifications of vocabulary, examinations, diagnoses as well as procedures, to helping the three students to relate different information to each other.
Thus, the three students connected different parts of a subject to create a holistic understanding of the content.
Also, all three students used the notetaking and constructed syntheses to pass their exams and thus explicitly to achieve the learning objectives set for the educational programme. According to all three students, notetaking was an essential part of preparing for examinations. They emphasized that notetaking requires understanding of what is noted and understanding of how and why things are connected within a subject.
In terms of professional purposes, the three students interviewed expressed an awareness of the literacy related demands in the dentist profession. Thus, they all considered reading different types of texts and writing as part of a professional development and highly relevant as preparation for their future profession as dentists.

Discussion
This study shows that the technical advancement with the digital tools that were provided on the online learning environment as well as those tools, such as laptops and tablets, the students chose to bring to the lectures, resulted in evolved literacy practices. In relation to text-genres we found that students' notes related to three genres: a) the dental academic language needed for exams and presentation with teachers as the receiving part, i.e. anatomy, physiology and pathology/diagnoses related to textbooks and teachers' handouts, that also is the basis for their future professional terminology; b) professionally specific language in national and international guidelines for dentistry as well as diagnostic protocols to be used as tools for professional judgement and diagnosis; and c) professionally specific language to be used in clinical contexts with other dentists, caregivers and patients as receiving parties. Specific for this last genre is that these professional texts are to be written but they are often also used as a basis for oral communication with the mentioned receiving parties. In comparison to Dias and colleagues (4) the three literacy genres the dental students needed to appropriate, within the frame of the studied modules, seem to be more in agreement with the professional demands, than Dias and colleagues (4) found for nursing and engineering students. A point to be made, though, is that it is also expected that some of these dental students will have a future career in academia.
In relation to Berthén and colleagues (6)  Furthermore, they wrote complementary texts for mnemonic purposes and posed questions for clarification to the teachers during as well as after the lectures. They also summarized their notes afterwards including their own thoughts or questions to teachers. However, none of the interviewed students deliberately compared their notes with those of fellow students, but they expressed that they occasionally borrowed notes or asked another student if they found something unclear. All three students also copied teachers' PowerPoints to some extent, but copying was complemented with other strategies.
Studies on dropouts from higher education (cf. Hasselgren 2018) show that the response rate from less successful students, even in questionnaires, is quite low. Our assumption is that these students' notes represent firstly successful students' notes, and secondly that Swedish is their native language.
This can be seen as a methodological problem, since less successful students and students with Swedish as second language can be surmised to hesitate to share their notes.

Conclusion
This study showed that the digital development has changed the notetaking which has evolved from just synchronous to become both multimodal and asynchronous and is more of a writing practice.
Students' writing practices seem to be motivated by their knowledge formation in relation to a subject matter, but also in relation to their experiences during clinical training. Although our hypothesis was that the main purpose of notetaking and writing was to pass their course examinations, this study showed that students, half-way through their dental education, are aware of that literacy practices are not only for passing their exams but also for learning for their future profession. showing interest for participation. All participants gave their consent prior to inclusion.

Consent for publication
Not applicable Availability of data and materials The materials used and analyzed during the current study are available from the corresponding author on reasonable request

Competing interests
The authors have collected and analyzed the material alone and declare that they have no competing interests.

Funding
No funding.

Authors' contributions
All authors (VL, SLJ, MCh, NCh) contributed to the study conception and design. Material preparation, data collection and analysis were performed by MCh and SLJ. The first draft of the manuscript was written by VL and NCh and all authors commented on previous versions of the manuscript. All authors have read and approved the final version of the manuscript.  Photocopy of student 1 handwritten notetaking. Student 1 uses black color as basic color for notetaking, and three to four other colors in order to signify different things. The color was then used to group information about the same topic, for instance blue to clarify, green for professional purposes, and red to highlight important clinical aspects.