Background

Self-efficacy is described as a psychological construct in the social learning theory (1). This idea was described by Albert Bandura as one's confidence in carrying out the behaviors necessary to get consistent results. Four sources of self-efficacy were proposed by Bandura's theory: verbal persuasion, mastery experiences, vicarious experiences, and physical sensations (2). To put it another way, self-efficacy is the certainty a person has about doing something exceptional and the courage to take action (3), both of which are necessary for practicing dentistry professionally. The contact between instructors and students leads to learning. It has to do with how learners' knowledge, abilities, and attitudes evolve through time in terms of behavior. The educational environment and other factors make learning more efficient (4). The intended curriculum is reflected in the learning environment (5). It could make a difference in how motivated children are and how well they do in school (6). The learning environment, instructors' attitudes toward teaching, the institutional behavioral culture, students' perceptions of the learning environment, the social context, and curriculum implementation are all part of the educational environment (7, 8). Successful academic and educational organizations in pre-clinical and clinical medical/dental courses are aided by the assessment of the curriculum and the learning experiences of the students. According to studies, academic discontent lowers student motivation and raises their anxieties
(9-11). Self-efficacy has a modest impact on (non-university) student accomplishment, according to a meta-analysis (12). On the other hand, in a stressful atmosphere, academic competence and personal skills may be diminished (13). Education at dentistry schools is influenced by a number of variables, including student background and socioeconomic position, treatment results assessed by patients, educational exams conducted by instructors according to a set timetable, academic aptitude, and individual abilities. Studies on the association between academic degrees, interest in the topic of study, contentment with learning, grade, gender, family education, economic position, and self-efficacy have been conducted in nursing and medical schools with varying degrees of success (2, 14). Few studies have examined dental students' self-efficacy or learning environment (10, 13, 15, 16), but to the best of our knowledge, no research has examined the connection between these two factors in dental schools.

Objectives

This study examines the status of self-efficacy and educational ambiance among clinical dental students at Tehran University of Medical Sciences (TUMS) in 2018, as well as the relationship between self-efficacy and educational atmosphere.

Methods

The current cross-sectional descriptive-analytical research was carried out in 2018 at Tehran University of Medical Sciences' School of Dentistry. All third through sixth year clinical dentistry students were included in the study's participants. It was optional to take part in the research. The study protocol (IR.TUMS.DENTISTRY.REC.1397.114) was approved by the School of Dentistry Ethics Committee.

Sampling And Data Collection: With an alpha of 0.05, a beta of 0.20, an R2 of 0.1, and 16 variables without any controlled variables, 187 individuals were needed. A total of 190 clinical dentistry students (or 87% of the 216 who wanted to participate in the research) agreed to take part and complete the questionnaire. Participants' informed written permission was collected after a brief description of the research design. The Sherer
Self-efficacy Scale (17) and the Dundee Ready Education Environment Measure (DREEM) (18) were then used to gauge the students' sentiments regarding their self-efficacy and the learning environment, followed by a brief questionnaire providing basic information that was completed anonymously.

Data Collection Tool: The data collection instrument had three components. The first section consisted of a general information questionnaire that included background characteristics (gender, marital status (single or married)), place of residence (with family, dorm, personal house), parents' education (classified as university education or not), and self-reported socioeconomic status (good, moderate, poor). Besides, the questionnaire included educational variables (academic year of study, acceptance rate, grade point average, grade point for the previous semester,
post-dental school employment experience, and
self-perceived efficacy (good, moderate, or poor)).On the national university entrance exam, a quota system is used to select students from privileged areas (province capitals and large cities: quota 1), underprivileged areas (small cities: quota 2), remote areas (quota 3), children of faculty members (quota 4) and disabled and volunteer veterans (quota 5) allowing for preferential treatment. All nominal variables with many states were transformed to those with just two. For instance, the five categories of quotas-1 to 5-were changed into 1 to 3 and 4 to 5. The explanation was that although 1-3 quotas were all accepted to the university through examination without any special benefit, 4-5 quotas were admitted via additional incentive. Therefore, there was no need for dummy variables. The second section included 17 items on a five-point Likert scale from the validated Persian version of the Sherer Self-Efficacy Scale. A sample question for measuring self-efficacy is, "When I make plans, I am confident I can make them work." To get the overall score for self-efficacy, 8 questions were rated in reverse. The overall self-efficacy score goes from 17
(the lowest level) to 85 (the highest level). The Sherer Self-Efficacy Scale has already been verified (Cronbach's alpha coefficient=0.86) and its reliability has been acknowledged (19). Professors of dentistry and medical education verified the questionnaires' content validity for the current research.

The DREEM questionnaire, which consists of 50 items on a five-point Likert scale and has been verified and deemed trustworthy in Persian (Cronbach's alpha coefficient = 0.91) (20) as the third component, was used to assess the study's educational environment. This survey examines five crucial areas: students' perceptions of learning (PoL), perceptions of teaching (PoT), academic self-perception (ASP), perception of the environment (PoA), and social self-perception (SSP). A PoL question might be, "I am encouraged to participate during teaching sessions." The PoT question "The course teachers are knowledgeable." is an example. The extra file contains the whole questionnaire. To get the overall educational environment score, 8 questions were rated in reverse. The overall score for the educational environment goes from 50 (worst educational environment) to 250 (best educational environment). The overall rating of the educational environment was divided into five categories: non-desirable (0-50),
semi-desirable (51-100), desirable (101-150), very desirable (151-200), and highly desirable (201-250). The PoL domain has twelve questions with a maximum score of 60. With a maximum score of 55, 11 questions are used to assess the PoT domain. The ASP domain is evaluated with eight questions, with a possible score of 40. The PoA domain is evaluated using 12 questions with a maximum score of 60, while the SSP domain is evaluated using 7 questions with a maximum score of 35.

Statistical Analyses: For statistical analysis, IBM SPSS version 20 (Armonk, NY: IBM Cop.) was utilized.

Kolmogorov-Smirnov was employed to verify the normality of the data distribution.

ANOVA was used to evaluate the statistical difference between three or more independent groups, and the T-test was used to compare the means of two groups.

Multiple regression analysis was utilized because dependent variables had a normal distribution depending on the values of the independent variables. Univariate linear regression analysis was used to predict the values of the dependent variables (scores of overall educational environment and its dimensions in addition to overall self-efficacy) based on the independent factors. The linear connection between the quantitative variables was assessed using Pearson correlation.

P-values<0.1 were regarded as statistically significant.

Regarding the exploratory nature of the present article and the number of participants, the p-value was set as 0.1 at the discretion of the statistical analysis expert.

Results

About half of the clinical dental students who participated in this study were female (52.6%), single (87.4%), resided in a residence (50%) and had a decent self-reported economic status (50%). The fathers of 80.5% of the pupils were college graduates. 51.1% of the students had a grade point average in the range of 16 to 16.9 out of 20.

85.5% of the students admitted to quota 2 had no prior job experience, while the acceptance rate for those students was 38.9%. Self-perceived efficacy was rated as excellent by 42.1% of students and moderate by 53.2% of students. Self-efficacy had a mean score of 57.9
(SD = 6.3), while the overall educational climate had a mean score of 158.1 (SD = 15.4).

According to demographic and educational data, Table 1 displays the mean self-efficacy and educational environment ratings. Dental students in lower years (p=0.04), those with a higher-grade point average (p=0.015), and those with greater self-perceived effectiveness (p=0.001) had higher self-efficacy scores on average. The mean score for the overall educational environment was also higher for dental students in lower years (p=0.039) and for those with a better grade point average (p=0.036).

Only grade point average and admission quota among all demographic and educational characteristics, according to a linear regression analysis, predicted
self-efficacy (Table 2). For each point raised in the grade point average and each admission quota, the mean self-efficacy score dropped by 0.839 points and 0.641 points, respectively.

Among all demographic and educational variables, linear regression analysis revealed that only gender (Beta=-3.97, p=0.076) and academic year (Beta=-0.1887, p=0.061) predicted the total educational ambiance score (Table 2).

Bivariate analysis revealed no significant differences in the mean scores of most educational milieu domains based on background and educational variables, with the exception of PoL, where male (p=0.02) and married (p=0.023) subjects had a higher mean score (Table 3). Regarding PoA, pupils with a moderate socioeconomic status achieved a higher mean score (p-value = 0.033). In addition, the subjects with higher self-perceived efficacy had higher
self-efficacy (p 0.0001), ASP (p = 0.006), PoA
(p = 0.013), and SSP (p = 0.017) scores.

Table 1. Mean Score and Standard Deviation of Self-Efficacy^* and Educational Atmosphere^** According to Demographic/Educational Information Among Clinical Dental Students (N=190), 2018

*: According to the Sherer questionnaire (20); **:  According to the DREEM questionnaire (22); ***:  Quota 1= lived in a big city at the time of entrance to the university, Quota 2 lived in a small city at the time of entrance to the university, Quota 3=live in a very small city or remote area at the time of entrance to the university, Quota 4= child of a faculty member, Quota 5= veterans; ****: According to results of t-test for comparing two groups and ANOVA for three or more groups.

After adjusting for the impacts of all other independent factors, female dentistry students had a total educational environment score that was 4 points lower, and switching to a higher academic year caused that score to drop by around two points.

All other categories and the overall educational environment positively linked with the student's self-efficacy, with the exception of PoT (p=0.302). Students' perception of the environment had the strongest positive correlation (highest Pearson coefficient, rho=0.351), followed by their perception of their academic performance (rho=0.291) (Table 4).

Table 2. Results of Linear Regression Analysis for Self-Efficacy* and Total Educational Atmosphere** According to Demographic/Educational Information Among Clinical Dental Students (N=190), 2018

*: According to the Sherer questionnaire (20); **: According to the DREEM questionnaire (22); ***:B was the unstandardized coefficient;;****:P-values less than 0.1 were significant; *****: all groups of acceptance quotas were divided into two main groups (1 to 3 named 1 and 4 to 5 named 2).

Table 3. Results of Linear Regression Analysis for five domains of educational Atmosphere* according to demographic/educational information among clinical dental students (N=190), 2018

*: According to the DREEM Questionnaire (22), **: B was the Unstandardized Coefficient; ***: P-values less than 0.1 Were Significant. PoL: Students’. Perception of Learning; PoT: Students’ Perception of Teaching; ASP: Students’ Academic Self-Perception; PoA: Students’ Perception of Atmosphere; SSP: Students’ Social Self-Perception.

Table 4. Mean Score (and Standard Deviation) of Educational Atmosphere and its Domains, and Results of Correlation Analysis (Pearson Correlation) of Educational Atmosphere and its Domains with Self-Efficacy Among Clinical Dental Students (N=190), 2018

*: Pearson correlation coefficient

PoL: students’ Perception of Learning; PoT: students’ Perception of Teaching; ASP: students’ Academic Self-Perception; PoA: students’ Perception of Atmosphere; SSP: students’ Social Self-Perception.

Discussion

This research discovered that dentistry students had a highly desired (151-200) degree of self-efficacy and educational environment. According to the research, dental students' self-efficacy was significantly influenced by the teaching environment. According to our knowledge, this is the first research to examine how the educational environment affects dentistry students' self-efficacy using two widely used instruments, the DREEM and Sherer self-efficacy measures. The two tools have been utilized in various contexts in the past, such as with medical students (11). According to our main analysis, the mean self-efficacy score was greater for junior dental students and those with better grade point averages.

Self-efficacy was shown to be inversely connected with acceptance rate and grade point average in advanced analysis, which may be related to these students' initial individual skills and stronger
self-efficacy at the time of university entrance.

With the exception of students' Perception of Teaching (PoT), advanced analyses in a well-fitted sample size demonstrated a substantial strong association between self-efficacy and the overall score of the educational environment and most of its dimensions. The Perception of Atmosphere (PoA) average score for the students was greater than in previous research (18, 21, 22), although it was comparable to a local report (23). Additionally, it was greater than the PoA score stated as the average for medical students at a recently founded local institution (24). This distinction between dentistry school clinics and hospitals may be the result of their different physical environments. The premise that the educational environment has a significant impact on self-efficacy is supported by the substantial correlation between the PoA and self-efficacy. Our results demonstrated a relationship between self-efficacy and the educational environment. On the other hand, students who felt more confident in their own abilities were more likely to achieve better grade point averages. Self-efficacy beliefs have an impact on students' mental health, and perceived self-efficacy has a direct impact on academic accomplishment (25). The students' motivation for accomplishment is significantly influenced by cognitive self-efficacy (26). International rankings in academic and research accomplishments are a point of competition for educational institutions all around the globe. Evaluation of the variables influencing self-efficacy in educational contexts may help with lesson design.

Boys outperformed girls in terms of overall educational climate and perception of learning (PoL), which is likely related to the differences in personality traits between male and female pupils. As a general rule, girls are exacting and stern, while guys tend to have more expansive viewpoints. The findings of a research by Sunkad et al. (2015) on 914 medical, dentistry, nursing, physiotherapy, and health students of KLE University of India were identical to the males' more favorable impression. In line with the findings of the current investigation, this study revealed that male students had a more favorable PoA than female students (21). Boys have a learning style that is independent of the educational environment, but girls have a learning style that is tied to it (27). Similar to the findings of studies on dental students in Saudi Arabia (18, 28) and Australia (26), senior students in the present study had reduced self-efficacy and educational ambiance scores. In advanced linear regression analysis, however, the relationship between self-efficacy and performance was no longer significant. As students advance to higher academic years, their experience increases, and they become involved with more real-world cases and administrative, social, and communication conditions, which may result in a decrease in the senior students' rating of the total educational atmosphere. Self-efficacy is related to both self-oriented and other-oriented perfectionism, as previously reported. Higher levels of socially prescribed perfectionism correlate with high
self-efficacy (29). In this study, students with a lower grade point average had higher self-efficacy, indicating self-directed perfectionism. This study presents an innovative method for analyzing the effect of the educational environment on the self-efficacy of clinical dental students.

In addition, the Persian versions of the utilized instruments were validated before their English counterparts. This study was limited by the large number of educational assignments given to students in clinical departments. In order to guarantee the veracity of the responses, the questionnaires were collected within two days. Thus, the pupils were able to respond to the queries calmly and without anxiety. Together with meticulous planning, identifying the strengths and limitations of clinical dental education can enhance the education and training of competent dentists.

Limitation: Despite applying the p-value of 0.1, this research has valuable implications, given that this was among the first studies in an Iranian population with its certain characteristics and the educational curriculum used in it.

Conclusion

This study revealed a correlation between dental student self-efficacy, educational ambiance, and its domains. TUMS dental students reported a moderate to high level of self-efficacy and a very desirable (151-200) level of educational ambiance. The study confirmed the considerable positive effect of the educational environment on the self-efficacy of dental students. The results can assist faculty members in designing optimal educational programs to enhance the quality of education and produce students who are empowered and responsive to the requirements of the community.